The United States may be one of the wealthiest countries in the world, but when it comes to maternal health, it’s falling short. The number of American women who die from pregnancy-related complications has been on the rise in recent years — around 23 deaths per 100,000 live births in 2020 — even as worldwide maternal mortality rates have dropped. And while pregnancy-related deaths are still relatively rare, they should be even rarer: the majority of these deaths are preventable, research has found.
The COVID-19 pandemic has only worsened the state of maternal health in the U.S. In the first year of the pandemic, the rate of women who died from pregnancy-related complications increased 33 percent overall, with Black and Hispanic women dying at higher rates than white women, according to a study published by JAMA Network. The Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics reports that in 2020, the maternal mortality rate for non-Hispanic Black women was around 55 deaths per 100,000 live births, 2.9 times the rate for non-Hispanic white women.
As of June 2022, even more women are at risk. The U.S. Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade, eliminating a woman’s Constitutional right to choose to have an abortion. Women’s health experts say severe restrictions and bans on abortion will have devastating impacts on maternal health; prior to the Dobbs decision, many of the states that had the most restrictions on abortions were among the states with the highest maternal mortality rates. One study estimates that if a nationwide abortion ban were enacted, pregnancy-related deaths would increase 21 percent.
“We need better health care in general, and we need to really invest in the health of moms, even after they give birth,” says Bethany Kotlar, Associate Director of the Maternal Health Task Force at Harvard Chan School’s Center of Excellence in Maternal and Child Health (MCH).
Here, a few of the many complex factors contributing to the current state of maternal health in the U.S., plus what you can do to take action.
1. Access to high-quality, affordable health care is very limited
While the Affordable Care Act (ACA) has expanded health coverage for many Americans since it was enacted in 2010, more than 31.2 million Americans under the age of 65 are still uninsured, according to a 2022 National Center for Health Statistics report on health insurance coverage as of 2020.
Marketplace coverage may have its downsides when compared to private health insurance, such as fewer insurer choices. And, as Kotlar notes, Medicaid participants may have more limited health care access, since providers have some leeway over whether they accept Medicaid patients or not.
This is in stark contrast to the countries with the lowest maternal mortality rates globally, where there is universal health care. Universal health care, which is often funded by the government, ensures every person has access to free or low-cost health care. In 2018, a year the U.S. had 17.4 pregnancy-related deaths per 100,000 live births, countries with universal health care experienced significantly lower maternal mortality rates: Germany had 3.2 pregnancy-related deaths per 100,000 live births, the Netherlands 3 and Norway 1.8, to name a few examples.
Universal health care would guarantee everyone the same level of quality care the privately insured receive, including pregnant and postpartum women, as well as those who are trying to conceive.
While some uninsured women can qualify for pregnancy-related Medicaid coverage (more on this below), health insurance is essential before a woman becomes pregnant, too. To increase the chances of having a healthy pregnancy, women should have good preconception health care, which includes receiving standard tests like Pap smears, screenings for conditions that might interfere with fertility or pregnancy, and treatment for any chronic conditions or medical problems.
“We have uninsured people, underinsured people and low-quality health care for people who have Medicaid,” says Kotlar. This grab bag of insurance circumstances means pregnant and postpartum people with the best insurance generally receive the best care, while others can fall through the cracks.
2. In 12 states, pregnancy-related Medicaid coverage expires 60 days after birth
Health insurance is critical before, during and after pregnancy, and Medicaid, the public health insurance program for people with low incomes, plays an important role in our country’s prenatal care. According to the CDC, 42.1 percent of U.S. births were covered by Medicaid in 2019.
But, as Kotlar notes, too many women can fall through the cracks in our current system.
Currently, uninsured women who become pregnant and have incomes up to 138 percent of the federal poverty level (and in some states, more than that) can qualify for pregnancy-related Medicaid, which covers prenatal appointments, labor and delivery, and 60 days of postpartum care.
However, pregnancy-related Medicaid coverage is only guaranteed for 60 days after delivery. After that, women in the 38 states that have adopted the Medicaid expansion under the ACA have a continued pathway to at least some coverage under standard Medicaid. However, in the 12 states that have not adopted the Medicaid expansion, many moms lose their coverage because their income isn’t low enough to qualify for standard Medicaid coverage.
To help improve coverage for low-income women who may no longer qualify for Medicaid after they give birth, the Biden administration gave states an option to extend pregnancy-related Medicaid coverage up to a full year postpartum through the American Rescue Plan. The extension could last for five years starting in April 2022. So far, according to a Kaiser Family Foundation analysis, 36 states plus Washington, D.C. have taken advantage of this program, or are in the process of doing so — 33 with no limits to coverage, and three with some limits. But women living in states that have not implemented extended Medicaid postpartum coverage risk losing it 60 days after birth if they don’t qualify through another pathway.
This is a problem for many reasons, but particularly because about one-third of maternal deaths occur sometime in the 12 months after a baby is born, according to the CDC. Hispanic and Black women, who are twice as likely as non-Hispanic white women to have their births covered by Medicaid, are especially at risk of losing coverage at this critical time.
3. The maternal mortality rate is tragically high, with Black, American Indian and Alaska Native mothers especially at risk
There are around 750 to 860 pregnancy-related deaths in the U.S. every year, according to the CDC. According to a report released in 2019, the U.S. ranks roughly 55th in the world (with 17 deaths per 100,000 live births) based on figures from 2000 to 2017. Pregnant women in this country are more than twice as likely to die from pregnancy- or delivery-related complications than women in other high-income countries.
Leading causes of maternal mortality in the U.S. include hemorrhage, cardiomyopathy, infection and other heart conditions. Substance abuse, opioid addiction and domestic violence also play a role.
Tragically, most maternal deaths are preventable.
American Indian and Alaska Native women are two to three times more likely to die of pregnancy-related complications than white women. For Black women, maternal mortality is three to four times that of white women — a rate that increased during the first year of the COVID-19 pandemic.
As for why moms of color are more at risk, the reasons are complicated. Some pregnancy-related complications, such as postpartum hemorrhage, gestational diabetes and preeclampsia, disproportionately affect Black women.
Women of color may also have higher stress levels and income inequality, and may have a harder time getting to and from prenatal appointments. In May and June 2022, What to Expect surveyed more than 1,400 U.S. women who were either pregnant or had a baby 0 to 12 months old. The survey found that Black moms-to-be were more likely than Caucasian moms-to-be to rely on someone else to get to appointments — they are five times more likely to take a taxi or ride share to their prenatal appointments, for example, as well as more likely to rely on someone else to drive them.
Black mothers in our survey were significantly more likely to have delayed first appointments (12 percent had their first visit at 13 weeks or later, compared to 6 percent of Caucasian mothers) and later first ultrasounds, too. What’s more, while almost one third of moms who responded (32 percent) said their pregnancy was considered to be “high risk,” the rate was higher for Black moms (39 percent). And Black moms were also more likely to have their labor induced because of a health issue with their baby and more likely to need an emergency C-section.
Racism plays a role, too: In one Amnesty International report, “discrimination and inappropriate treatment” from medical professionals was listed as one of the key contributors to higher rates of death for Black moms. And as the Congressional Black Maternal Health Caucus notes, a Black woman with a college degree is more likely to die from pregnancy-related complications than a white woman with a high school diploma.
“The wider system is not set up to make sure that… people of color, people who are low-income, immigrants, are making it through that system with high-quality health care,” says Kotlar
4. Millions of women live in maternity care deserts
The term “maternity care deserts” was coined by March of Dimes to describe a county where access to maternity care is limited or absent. In the U.S., 7 million women live in counties with limited care, and 2.2 million live in “total” maternity care deserts, meaning their counties have no maternity care options at all.
Maternity care deserts have a higher poverty rate and lower median household income than counties with adequate access to maternity care, March of Dimes has found.
One reason why these deserts develop, Kotlar says, is because we have a for-profit medical system in the U.S., and running maternity wards is expensive.
And because women who live in these areas have to travel great distances for care, as well as manage limited appointment availability, they often have no choice but to limit their prenatal visits. As a result, any pregnancy complications that might arise aren’t treated as quickly or at all, and the health of both mother and baby can suffer.
In 2020, about 1 in 16 infants was born to a woman who had late or no prenatal care. Infants of mothers who don’t receive prenatal care are three times more likely to have low birth weights and five times more likely to die than those born to mothers who receive adequate care during their pregnancies.
5. Paid parental leave isn’t guaranteed by federal law
The U.S. is the only high-income country that does not guarantee paid leave for parents. Many parents are forced to return to work immediately or shortly after welcoming a child in order to provide for their families.
Some pregnant women receive 12 weeks of unpaid, job-protected leave through their employer, thanks to the Family and Medical Leave Act (FMLA). But the law only applies to companies with 50 or more employees, and employees must have worked at a company for at least a year or a certain number of hours to be eligible.
Others have access to state-funded paid family leave, but right now, it’s only in seven states plus Washington, D.C. (California, New Jersey, Massachusetts, Rhode Island, New York, Washington and Connecticut). Even among these states, the benefits vary. Some offer 12 weeks of paid leave; others, six. The percentage of your salary that you are guaranteed during leave varies, too.
Meanwhile, “a lot of other developed countries have a year of maternity or paternity leave, and it’s paid,” Kotlar notes. “We’re really lacking in this area.” Governments in Australia, Canada, Chile, Costa Rica, Israel, Japan, Korea, Mexico, New Zealand, Turkey and most of Europe mandate some form of paid leave for new parents, for example.
Juggling work and the demands of newborn care can mean that new moms don’t have time to care for themselves — they may be less likely to go to their postpartum checkup, for example.
“If [mothers] have to go back to work pretty much immediately, or a couple of weeks after birth, they don’t have time to monitor their bodies to see if any risk factors come up,” Kotlar says.
6. Most new moms have just one postpartum doctor’s visit
In their latest guidelines, the American College of Obstetricians and Gynecologists (ACOG) recommends that women see their OB/GYNs or midwives within three weeks of giving birth, along with regular check-ins throughout the postpartum period and a more comprehensive visit by 12 weeks. But many women in the U.S. still have their first and only visit around six weeks, which is commonly known as the six-week checkup.
During this appointment, new moms are screened for postpartum depression, receive a pelvic exam and are given guidance on when they may resume normal activities, like exercise and sex. The uterus is also checked to make sure it is contracting back down to its pre-pregnancy size.
Meanwhile, by the typical six-week checkup, a newborn has generally had two well-child visits as well as an official checkup in the hospital. Infants continue to be examined at regular intervals over the course of that first year during well-baby visits — their mothers will not.
“We’re really not investing the time and energy as a country into helping people recover postpartum,” says Kotlar, adding that in many other developed countries, there are home visiting programs that frequently check up on moms during the postpartum period.
What do those home visits look like?
- In Germany, if needed, a midwife will visit a new mom every day for up to 10 days after delivery, along with additional checkups until eight weeks postpartum.
- In Sweden, a midwife or nurse visits in the first postpartum week and continues to check in weekly or biweekly until eight weeks postpartum.
- In the United Kingdom and Switzerland, a midwife or nurse visits the home — sometimes daily — until 10 days postpartum.
- Australia, Canada, France, the Netherlands, New Zealand and Norway also have some form of home visits, even if just within the first 24 to 48 hours after discharge.
These frequent check-ups are important, since “postpartum moms have continued health needs as well,” Kotlar says. “And ignoring those can lead to horrible outcomes.”
What you can do to help
Despite these bleak statistics, parents and parents-to-be are not powerless, and there are things you can do to help improve the state of maternal health in the U.S.
Congress is currently working to pass the Black Maternal Health Momnibus Act of 2021, a comprehensive collection of 12 bills designed to tackle the maternal health care crisis in the U.S. So far, only one of the 12 bills has passed, but you can advocate for the legislation by contacting your elected representatives and by supporting organizations that are working to expand access to obstetric care and doula services, as well as midwives and nurse practitioners.
And during What to Expect’s annual #BumpDay, happening this year on July 20, take action by visiting WhatToExpectProject.org to send an email to your elected officials urging them to support the Helping MOMS Act, which aims to increase access to lifesaving postpartum care.