For years, women’s health advocates have been sounding the alarm on the high rate of maternal mortality in the US, particularly for Black women. In 2018, the rate of maternal mortality in the US was 17.4 maternal deaths per 100,000 live births, a much higher rate than other wealthy developed countries. Black women in the US are twice as likely to die giving birth as white women; even Black celebrities have experienced dangerous complications during birth.
What makes the US so different from other wealthy countries when it comes to maternal health? A new report from the Commonwealth Fund compares maternal care workforce composition and access to postpartum care and social protections in the U.S. with 10 other high-income countries, to better understand differences in maternal mortality.
The report finds that the US is an extreme outlier in rates of maternal mortality. For every 100,000 live births in the US, 17.4 women die. That’s twice the rate of the next-highest country, France (8.7 deaths per 100,000 births) and ten times the rate of New Zealand (1.4 deaths per 100,000 live births).
Where are the midwives?
What makes the US so different from the other developed countries studied? The Commonwealth Fund report points out that in almost every other wealthy country, midwives outnumber ob-gyns. For example, Sweden has 66 midwives for every 1000 live births, while the US has just 4.
The lack of midwifery care in the US contributes to a dire shortage of maternal health professionals. While Sweden and the US have the same ratio of ob-gyns per live births, the paucity of midwives in the US means that fewer mothers can access care. Most other countries have at least 35 maternal health professionals per 1000 live births; the US has only 15.
Midwifery care is one of the “reliably high-quality forms of maternal and newborn care” outlined in a recent report from the National Partnership for Women & Families. The report cites research demonstrating that midwifery care is associated with fewer episiotomies, more vaginal birth after cesarean, and better psychological experience for patients compared to physician care alone, and may reduce hospitalization during pregnancy.
Why is the US so short on midwives? Not all private insurers cover midwife care, and Medicaid only universally covers care from Certified Nurse Midwives (midwives with a nursing degree as well as midwife training), not Certified Midwives without nursing degrees. Additionally, laws restricting the scope of practice for midwives and rules requiring physician supervision of midwives make it more difficult for midwives to practice.
The NPWF recommends enacting legislation like the Maximizing Optimal Maternity Services (Midwives for MOMS) Act, which would increase the supply of midwives with nationally recognized credentials; increasing public insurance coverage of certified midwives; ensuring pay equity for midwives that do the same work as physicians; and amending restrictions at the state level so enable midwives can “practice at the top of their license.”
The need for post-partum care
While we might think of maternal deaths as those that happen during labor, a significant proportion of deaths happen in the days and weeks after the birth. According to the Commonwealth Fund report, 19 percent of all maternal deaths occur between one and six days postpartum, and 21 percent of all maternal deaths are between one and six weeks postpartum. In comparison, 17 percent of deaths occur during birth.
Postpartum care in the US lags behind that of other developed countries. All other countries in the Commonwealth Fund report mandate two weeks of paid maternity leave; the US has no paid maternity leave requirements, which puts undue stress on mothers that could negatively impact health.
Insurance coverage of postpartum care is also lacking in the US. Medicaid programs in some states cover home visits after birth, but this is not universal. Having multiple health contacts within the first six weeks can help providers recognize urgent health problems, but most US women only have one physician visit during this period, and some not even one.
“Many women will have access to prenatal care and coverage until the six week visit and then, boom — they’re dropped off,”
Dr. Laura Riley, Obstetrician and Gynecologist-in-Chief, Weill Cornell Medical Center
Although 12 percent of maternal deaths take place more than six weeks after birth, Medicaid coverage in most states only covers postpartum visits within six weeks after birth. “Many women will have access to prenatal care and coverage until the six week visit and then, boom — they’re dropped off,” said Dr. Laura Riley, Obstetrician and Gynecologist-in-Chief at New York-Presbyterian/ Weill Cornell Medical Center, at the Atlantic Pulse Conference last year. “We can’t drop people off at six weeks,”she said.