Among 11 developed countries, the United States has the highest maternal mortality rate, a relative undersupply of maternity care providers, and no guaranteed access to provider home visits or paid parental leave in the postpartum period, a recent report from The Commonwealth Fund concluded.
Among 11 developed countries, the United States has the highest maternal mortality rate, a relative undersupply of maternity care providers, and is the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period, a recent report from The Commonwealth Fund concluded. Compared with any other wealthy nation, the United States also spends the highest percentage of its gross domestic product on health care.
Maternal deaths have been increasing in the United States since 2000, and although 700 pregnancy-related deaths occur each year, two-thirds of these deaths are considered to be preventable.
In an issue brief, researchers assessed maternal mortality, maternal care workforce composition, and access to postpartum care in 10 high-income nations and compared findings with the United States. Data from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom were gleaned from 2020 health statistics compiled by the Organization for Economic Co-operation and Development. US data were taken from the CDC’s Pregnancy Mortality Surveillance System.
According to the World Health Organization (WHO), maternal mortality is defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”
Overall pregnancy-related mortality in the United States occurs at an average rate of 17.2 deaths per 100,000 live births. Leading causes of death include cardiovascular conditions, hemorrhage, and infection. However, in the Netherlands, Norway, and New Zealand, that rate drops to 3 or fewer women per 100,000.
More than 50% of pregnancy-related deaths in the United States occur after the birth of the child, or post partum. Any death within 1 year of the end of pregnancy due to a pregnancy complication or a death during pregnancy is classified as a pregnancy-related death. Deaths that occur within 1 week post partum (19% of all maternal deaths) are largely attributed to severe bleeding, high blood pressure, and infection.
When it comes to care providers, the United States and Canada “have the lowest overall supply of midwives and obstetrician-gynecologists (OB-GYNs) — 12 and 15 providers per 1000 live births, respectively,” whereas all other countries have a supply that is between 2 and 6 times greater.
Midwives differ from OB-GYNs in that they help manage a normal pregnancy, assist with childbirth, and provide care during the postpartum period. In contrast, OB-GYNs are physicians trained to identify issues and intervene should abnormal conditions arise. OB-GYNs typically only provide care in hospital-based settings.
The role of midwives has been found to be comparable or preferable to physician-led care in terms of mother and baby outcomes and more efficient use of health care resources. WHO recommends midwives as an evidence-based approach to reducing maternal mortality.
According to the American College of Nurse Midwives, the “US maternity workforce is upside down relative to patient needs.” Although OB-GYNs outnumber midwives in the United States and Canada, in most other countries the inverse is true.
“Midwives provide most prenatal care and deliveries in the U.K. and the Netherlands— countries considered to have among the strongest primary care systems in Europe. Dutch midwives also deliver home births, which represent 13% of all births, the highest rate of any developed countries,” the report reads.
Midwife services are not uniformly covered by private insurance plans in the United States, whereas both midwifery and obstetrician care services are covered by universal health insurance in some other countries.
Under the Affordable Care Act (ACA), Medicaid programs are required to cover midwifery care, but “the supply of providers is often so low that beneficiaries are often unable to access these services.” State licensure laws, restrictive scope-of-practice laws, and rules requiring physician supervision of midwives may all contribute to the low supply of midwives in the United States. Medicaid also currently covers 43% of all deliveries in the United States but only extends coverage for a maximum of 60 days post partum.
Furthermore, in some states, appeals courts have ruled to end Medicaid funding to Planned Parenthood clinics, which provide a number of health services to low-income women, including pregnancy services such as postpartum care.
Postpartum care, including home visits by midwives, also improves mental health and breastfeeding outcomes among new mothers and is associated with reduced health care costs. Some Medicaid beneficiaries can receive these services in the United States, but all other countries included in the report guarantee at least 1 visit within 1 week of birth.
A recent cross-sectional analysis of nearly 600,000 commercially insured childbearing individuals found that the prevalence of suicidal ideation and intentional self-harm (suicidality) occurring in the year preceding or following birth increased substantially from 2006 to 2017.1
In 2006, suicidality prevalence was estimated at 0.2% per 100 individuals and rose to 0.6% per 100 individuals in 2017, whereas diagnoses of suicidality with comorbid depression or anxiety increased from 1.2% in 2006 to 2.6% in 2017 (per 100 individuals for both). Over the course of the study period, younger, non-Hispanic Black, and lower-income individuals experienced larger increases in suicidality.
“Policy makers, health plans, and clinicians should ensure access to universal suicidality screening and appropriate treatment for pregnant and postpartum individuals and seek health system and policy avenues to mitigate this growing public health crisis, particularly for high-risk groups,” the authors of that analysis wrote.
In the United States, non-Hispanic Black women are more than 3 times more likely to have a maternal death than White women. Non-Hispanic Black women are also significantly more likely to have a severe maternal morbidity event at the time of delivery.
Importantly, these numbers reflect official tallies of maternal morbidity in the United States and do not account for undocumented pregnant women, many of whom postpone prenatal care and give birth at home in response to recent immigration enforcement policies.
When it comes to paid maternity leave, the Commonwealth Fund report found the United States was the only high-income country that does not guarantee paid leave to mothers after childbirth. All other 10 countries guarantee at least a 14-week paid leave time from work while several provide more than a year of maternity leave.
Despite these bleak trends, some gains have been made to improve maternal morbidity and mortality in the United States. The passing of the ACA helped women gain access to maternity care in that it mandated coverage for free preventive services, expanded Medicaid eligibility, offered premium subsidies for low-income women, and provided coverage for young women.
But the authors noted that more changes need to be enacted to reverse these trends which disproportionately affect women of color. Solutions include strengthening postpartum care, guaranteeing paid maternity leave, and working to close the racial disparity gap in this population.
“Addressing systemic racism so that Black and Indigenous people are not at risk when they are pregnant is critical to reducing U.S. maternal mortality, while offering paid maternity leave to all birthing people would contribute to their health and the health of their babies, as well as strengthen the financial security of families,” wrote Laurie Zephyrin, MD, and Roosa Tikkanen of The Commonwealth Fund in STAT News.
“The U.S. is clearly willing to invest in health care, yet it does not invest enough in its birthing people…When it comes to maternal health care, it is time we started investing wisely to ensure that no one dies a preventable death while bringing life into the world.”
1. Admon LK, Dalton VK, Kolenic GE, et al. Trends in suicidality 1 year before and after birth among commercially insured childbearing individuals in the United States, 2006-2017. JAMA Psychiatry. Published online November 18, 2020. doi:10.1001/jamapsychiatry.2020.3550