Women in the U.S. More Likely to Die in Pregnancy, Childbirth, and Postpartum Than Women in Other High-Income Nations

Among high-income countries, the United States has the highest maternal mortality rates, reflecting deaths from complications of pregnancy and childbirth, a new international comparison from the Commonwealth Fund shows. And even more troubling trends stemming a serious shortage of maternal health providers — particularly midwives — may lie ahead.

The report, Maternal Mortality and Maternity Care in the U.S. Compared to 10 Other Developed Countries, compares the U.S. to Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.

Key findings include:

• Pregnancy and childbirth are more dangerous for women in the U.S. U.S. women have the highest death rate from complications of pregnancy and childbirth – 17 deaths per 100,000 live births – a maternal mortality rate that is more than double the rates of most other high-income countries. In the Netherlands, Norway, and New Zealand, for example, there are three maternal deaths or fewer per 100,000 live births.
• The U.S. has a shortage of maternity care providers, and a far lower supply of midwives than other high-income countries: The U.S. and Canada have the lowest overall supply of midwives and ob-gyns, with 12 and 15 providers per 1,000 live births, respectively. All other countries have a proportion two to six times greater. And in many of these countries, midwives, which are proven to improve birth outcomes, play a central role in maternity care provision. Unlike in the other countries surveyed, ob-gyns in the U.S. and Canada far outnumber midwives.
• More than half (52%) of maternal deaths in the U.S. occur after birth. The majority of postpartum deaths happen between one week after birth and up to one year after childbirth, a period also known as the “fourth trimester.”
• Access to home visits after childbirth is guaranteed to women in other countries, but not in the U.S. All countries, apart from the U.S., guarantee at least one visit by a midwife or nurse within one week of childbirth. Evidence suggests that home visits are associated with improved mental health and breastfeeding outcomes, as well as reduced health care costs.
• The U.S. is the only high-income country that does not guarantee paid maternity leave to mothers after childbirth. All countries in the study, apart from the U.S., mandate at least 14 weeks of paid leave from work, with most mandating more than six months.

IMPLICATIONS

The U.S., the authors say, has much to gain from studying the health systems in countries that have good access to preventive care and primary care. In these nations, universal coverage begins at birth; pregnant women and new mothers are often exempt from out-of-pocket costs; and care is often being led by midwives. The researchers say there are a number of policy options for lowering the high U.S. maternal death rate:

• Increasing the supply of midwives: While the Affordable Care Act (ACA) mandated that Medicaid pay for midwifery services, the authors believe there is more work to be done in the U.S. to enhance access and affordability of midwife-led care. In the U.S., several barriers affect the supply of midwives, including restrictive scope-of-practice laws and physician supervision requirements over midwife care, which vary widely from state to state.
• Expanding access to and affordability of maternity care. Universal, comprehensive maternity care coverage, including access to midwife care, and exemptions from cost sharing are the norm in other high-income countries. Although the ACA strengthened maternity care coverage, access varies depending on insurance type and geographic location, and out-of-pocket costs vary significantly.
• Strengthening postpartum care. Since more than half of maternal deaths occur after birth, the authors assert that strengthening postpartum care should be a priority. Expanding eligibility for Medicaid, which pays for 43 percent of U.S. deliveries, can lead to more stable postpartum coverage. The authors also recommend extending Medicaid coverage from only six weeks postpartum to a year after childbirth.
• Addressing racial disparities. The high U.S. maternal mortality rate can also be attributed to the country’s wide racial and ethnic gaps. In 2018, the death rate for Black mothers was more than two times that for white mothers. COVID-19 may be exacerbating such disparities, because of the pandemic’s disproportionate health, economic, and mental health burdens on Black people.
• Offering paid maternity leave. The U.S. is the only country that does not legally guarantee all new mothers paid leave. Studies show not only that paid leave contributes to the health of mother and baby and families’ financial security, but that women receiving paid leave require fewer health care services than women with unpaid leave only.