International comparisons show that the United States lags other high-income nations on core maternal health measures like the size and composition of the perinatal workforce (i.e., clinical and nonclinical professionals that provide pregnancy, labor, and postpartum care), access to comprehensive postpartum support, and maternal mortality. In 2023, the U.S. maternal mortality rate was 17 deaths per 100,000 live births, compared to 12, 7, and 4 deaths per 100,000 live births in Canada, France, and Germany, respectively.
Healthy People 2030, an initiative led by the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health Promotion, has set objectives to improve the nation’s health and well-being and created an indicator for reducing maternal deaths. The U.S. has made no progress in this area since its 2018 baseline of 17.4 deaths per 100,000 live births.
This lack of improvement is tragic, given that most (87%) pregnancy-related deaths are preventable. Known strategies to reduce adverse maternal outcomes and strengthen well-being include a robust and diverse perinatal workforce; chronic condition management before, during, and after pregnancy; midwifery and community-based care models; and comprehensive postpartum care.
Furthermore, adverse maternal outcomes like maternal mortality disproportionately affect people and families that are American Indian/Alaska Native (AIAN), Black, and Native Hawaiian and Pacific Islander (NHPI) and those residing in rural areas and in the U.S. South. People in these groups are more likely to face barriers to high-quality, comprehensive maternal care, as well as health care overall. For instance, people who are AIAN, Black, or NHPI are more likely to be uninsured than white people, and people in rural areas are more likely to live in maternity care deserts. Community-based care (e.g., care provided by midwives and at birthing centers) is effective at reducing unwanted health outcomes, including among underserved people, but it is not well supported by current payment models, with reimbursement rates sometimes too low to cover the actual costs of care.
The Commonwealth Fund’s Achieving Equitable Outcomes program aims to improve maternal health and advance equity, particularly for communities that have been historically underserved by the health care system. We are focused on strengthening continuity of care, advancing culturally responsive models of care, and improving care transitions across the perinatal period. Two areas where we believe progress is possible are stronger postpartum care standards and expanded access to community birthing. These are practical, evidence-based opportunities to improve care quality, strengthen care experiences, and support better outcomes for birthing people, mothers, and babies nationwide.
Postpartum Care Standards
The year following childbirth is the period of greatest risk for maternal morbidity and mortality. Two-thirds of maternal deaths occur during this period, yet postpartum care in the U.S. remains fragmented, inconsistent, and inefficient.
As of May 2026, 49 states and Washington, D.C., have taken an important step by implementing Medicaid coverage to a full year postpartum (leaving Arkansas as the sole state without it), but coverage alone is not enough. In addition, these gains may be at risk if Medicaid cuts or new administrative barriers under H.R.1 lead to coverage losses or disruptions in care.
Too often, postpartum care is limited to a single visit approximately six weeks after childbirth; up to four in 10 women do not receive any postpartum care, and many more lack access to ongoing support for chronic condition management, mental health concerns, lactation support, or recovery from birth-related complications. Poor transitions between obstetric and primary care or specialty care can result in gaps that fail to adequately address the clinical, behavioral, and social needs that emerge in the months after childbirth. Evidence shows that holistic, continuous postpartum care improves outcomes, yet standards and benefits vary widely across states and health care plans, limiting equitable access to needed care.
Strengthening postpartum care standards offers a critical opportunity to improve maternal health outcomes. Aligning payment, coverage, and care delivery to support continuous, comprehensive postpartum care — delivered in ways that are responsive to patients’ needs and circumstances — can reduce preventable maternal and infant morbidity and mortality and help reduce persistent disparities in maternal health.
Community Birthing
Community birthing offers an evidence-based approach to improving maternal health outcomes and addressing inequities in maternal health. Community birthing relies on a team of midwives, doulas, and community health workers; takes place in birth centers; and provides low-intervention, culturally responsive care. It can support safer births and stronger postpartum transitions. Yet access remains limited due to wide variability across states in midwifery reimbursement and scope of practice, as well as inadequate reimbursement for birth center services and barriers for birth centers to contract with Medicaid managed care organization networks.
Innovative financing and policy approaches are necessary to build, sustain, and scale community birthing. Public–private partnerships can help launch new birth centers or stabilize existing centers and support workforce development. Policy reforms that modernize Medicaid payment and remove regulatory barriers can further strengthen all aspects of community birthing and expand equitable access to high-quality, patient-centered maternal care.
