The U.S. spends more on health care than any other wealthy nation. Yet, more people here die from complications of pregnancy and childbirth than in any of those countries.
The numbers are stark: Birthing people die in 17 of every 100,000 births in the U.S., compared to just three or fewer in the Netherlands, Norway, and New Zealand. Those who die in this country are, more often than not, Black people, the delivery room being one more place where systemic racism takes its toll on Black families.
Patrick Skerrett / STAT
Source: The Commonwealth Fund
It doesn’t have to be this way, and it isn’t in countries similar to ours. What are we doing wrong? Why is it harder to have a safe, healthy birth in the U.S. than in other high-income countries?
The short answer is that other countries prioritize birthing people in ways we do not.
While people in other high-income nations have the security of universal coverage, residents of the U.S. aren’t guaranteed to have health insurance throughout their lives, even during pregnancy, childbirth, and the postpartum period, which is when more than half of maternal deaths in the U.S. occur. And even when insurance coverage is available here, it can fall far short of what is needed.
Medicaid currently pays for 43% of all deliveries in the U.S., but that coverage extends only for a maximum of 60 days after giving birth. In some countries, pregnant people pay nothing out of pocket toward maternity care services, while in the U.S. families can face extraordinarily high costs for childbirth.
The U.S. also offers less of the mental health and social support that people need after giving birth. Here, a single physician visit several weeks postpartum is the norm. In contrast, other countries guarantee supportive home visits from a nurse during the first week after giving birth.
As result of systemic racism, our health care system does not guarantee good outcomes for Black and Indigenous people. They are not only more likely to die as a result of pregnancy or childbirth than white people, but are more likely to have near misses, suffering complications so serious that they could have died.
Our health system also has a shortage of maternal health providers overall, both OB-GYNs and midwives. The U.S. suffers especially from an undersupply of midwifery care, which evidence shows improves birth outcomes. In several other countries, midwives are at the center of delivering maternity care, with OB-GYNs engaged in caring for high-risk or complicated pregnancies. In the U.S., OB-GYNs substantially outnumber midwives, and midwifery services are not always covered by insurance, or available in every region of the country, or accessed easily by people of color and those with lower incomes.
Another difference is that the U.S. is the only industrialized country to not guarantee paid maternity leave from work. Research shows that birthing people who receive paid leave have better outcomes than those who do not. People of color are less likely to have access to paid leave than white people — further exacerbating disparities in outcomes.
We must do better in a number of ways, especially because most maternal deaths are entirely preventable. Assuring continuous health insurance throughout life — but especially during pregnancy and the postpartum period — is essential. It is encouraging that many states have expanded Medicaid coverage under the Affordable Care Act, which improves access to maternity care starting from preconception to postpartum care. Assuring the Medicaid program is fully expanded in all states, and that those who are eligible for Medicaid only due to pregnancy are eligible for a full year after they give birth would further protect nearly half of all birthing people in the U.S.
Increasing the supply of midwives, including midwives from racially and ethnically diverse communities, would also help. Currently, a patchwork of state laws and regulations provide barriers to midwifery care that could be alleviated by opening up the profession and expanding access to it. Evidence from Florida shows that open-door access to midwife-led birthing clinics can improve outcomes for both Black birthing people and their babies. In the wake of Covid-19, the demand for midwifery care has increased, and several states have issued emergency orders to expand access to midwifery care.
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.
The U.S. is clearly willing to invest in health care, yet it does not invest enough in its birthing people. The good news is that we can learn from other nations who are succeeding at this.
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.
Laurie Zephyrin is an OB-GYN and vice president for delivery system reform at The Commonwealth Fund. Roosa Tikkanen is a senior research associate for the Commonwealth Fund’s International Program in Health Policy and Practice Innovations.
