Every year, a group of Oregon health care professionals gathers for a grim exercise — reviewing every case in which a mother died during or soon after pregnancy. This past February, they reported a troubling finding: Mental health conditions and substance use were causing more of those deaths than any other factor.

Most of the deaths were suicides or overdoses. Some of the women were homeless. Many faced discrimination or fell through cracks in the health care system due to the complexity of their needs.

“These are tragic cases,” said Dr. Mark Tomlinson, a maternal-fetal specialist who chairs the Maternal Mortality and Morbidity Review Committee, created by the state Legislature in 2018. “Sometimes seeing opportunities that could have been done differently, that could have prevented th

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