Our Crisis in Maternal Healthcare Is Uniquely American

Maternal healthcare in the U.S. is largely not accessible, equitable, affordable or person-centered.

When maternal health suffers, so does newborn health and future child health. (MoMo Productions / Getty Images)

The state of maternity care in the U.S. is disheartening.

Each year, up to 60,000 U.S. women experience severe complications from pregnancy and childbirth. More than 1,200 U.S. women died during pregnancy or shortly after childhood birth in 2021. Death rates among Black women were more than double that of white women.

Death rates decreased in 2022, due to what the U.S. Government Accountability Office attributes to a decrease in COVID-19 complications. But maternal health outcomes are still alarming.

Compared to the 10 most high-resource countries—such as Germany, Australia and France—the U.S. ranks last in maternal death rate, maternal care workforce rate and paid parental leave allowances. Compared to all countries, the U.S. ranks 55th in maternal death rate.

In the U.S., there is a lack of universal maternal healthcare coverage and a workforce shortage of maternity care providers, such as ob-gyn physicians with a misdistribution in rural and poorer areas. This gap in access is a particular concern for Medicaid programs which cover nearly half of U.S. births and nearly two-thirds of births among Black women.

Adding insult to injury, U.S. healthcare spending far exceeds any other country.

This spending tends to not be distributed equitably across all populations, leading to vast racial and ethnic disparities in the ability to access and afford quality perinatal care. Maternity care spending also tends to focus on addressing complications as they occur, rather than more cost-effective preventative and primary care.  

Emulating healthcare policies and practices from the most successful peer European high-resource countries is a challenge given the vast chasm in how maternal healthcare is set up between those countries and the U.S.

  • While access to maternity care coverage in the U.S. depends on the state of residence and type of insurance, with out-of-pocket costs varying significantly, universal coverage is the norm in other high-income countries.
  • The U.S. also is the only high-income country that does not guarantee paid leave to mothers after childbirth.

While the healthcare structures in other high-income countries may not be applicable to the U.S., there is much to learn from the highest-performing states when it comes to maternal health outcomes.

Several factors contribute to the stark differences between states with the lowest maternal mortality rates (California, Massachusetts and Colorado) and states with the highest rates (Arkansas, Alabama and Louisiana).

Rates of obesity, diabetes/prediabetes and cardiovascular conditions—such as high blood pressure—trend higher in the lower-performing maternal outcomes states compared to higher-performing states. Cardiovascular conditions are the leading cause of pregnancy-related complications and are responsible for over one-third of maternal deaths.

States also differ widely in access to maternal care.

Maternal and perinatal care should not depend on the state where a mother lives.

I live in Texas, the state that ranks last in access to high-quality maternal care. Texas has the lowest rate of childbearing age women who have insurance and who have a primary care doctor.

When looking at several of the worst performing states in maternal care outcomes, they tend to have the fewest ob-gyns as well as number of primary care clinicians per capita. They also tend to have fewer numbers of insured women. Having coverage in the early stages of pregnancy is particularly important so chronic conditions like diabetes can be better managed to reduce complications like preeclampsia.

Some states are improving the quality of maternal care by reforming Medicaid payment structures that reduce payment for medically unnecessary C-sections and use financial incentives to promote maternal wellness outcomes using team-based maternal care using midwives and doulas.

Using this approach, California’s Medicaid program (Medi-Cal) was able to reduce rates of low-risk first-birth C-sections and lower rates of other major complications since having a C-section increases risk of other major complications such as hysterectomy and uterine rupture in subsequent pregnancies.

California’s program was also able to lower overall maternal care costs as c-sections are roughly $20,000 more expensive than vaginal births in California.

Minnesota, Oregon, New Jersey and Indiana have enacted legislation to cover doula services in low-income communities through Medicaid. Having doula services is associated with improved birth outcomes and experience.

Several states have expanded Medicaid eligibility for postpartum coverage from 60 days to up to one year after birth using a provision in the American Rescue Plan Act that took effect on April 1, 2022.

Texas has proposed a more limited version of the expansion to only cover six months—despite efforts by the Texas Medical Association to provide Texans with the full 12 months of insurance eligibility they say is needed to provide comprehensive postpartum support.

Currently, 11 states—California, Colorado, Connecticut, Delaware, Massachusetts, Maryland, New Jersey, New York, Oregon, Rhode Island, Washington, as well as D.C.—have introduced some form of paid leave. Paid leave is associated with a reduction in low birthweight and preterm births and higher rates of breastfeeding initiation and duration, which has long-lasting health benefits for mothers and babies.

Maternal healthcare in the U.S. is largely not accessible, equitable, affordable or person-centered. When maternal health suffers, so does newborn health and future child health.

While several states have prioritized maternal and child health through their policies, far too many are standing idle despite many birth complications including maternal death being largely preventable. Maternal and perinatal care should not depend on the state where a mother lives.

For this Mother’s Day, policymakers, administrators, medical practitioners and healthcare providers need to demonstrate to mothers in the U.S. that they are a priority and advocate for legislation that promotes comprehensive maternal healthcare.

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Jeffrey D. Shahidullah, Ph.D., is an assistant professor of psychiatry and behavioral sciences at The University of Texas at Austin Dell Medical School and a public voices fellow with The OpEd Project. @JeffShahidullah.