U.S. Healthcare System Failing New Mothers

Why did you undertake this report?

On the international side of the Commonwealth Fund, our mission is really to promote a high-functioning health system for all people in the United States. We also seek to understand what models other countries have implemented to make their health systems so much more effective and higher performing than the U.S. system. The reason we pay so much attention to maternal deaths is because we have this unacceptably high maternal death rate. Some other countries—like Norway—have been able to almost eliminate all maternal deaths. [Norway’s maternal mortality rate for 2021 was two deaths for every 100,000 live births; the number in the United States was closer to 22 deaths per 100,000 live births that year. The high-income country with the next highest rate was Chile, at 14 per 100,000; most other countries were at eight or fewer]. So, we did this work to understand how we may be able to change this high rate when we know that there are some solutions that could change this and reverse the trend.

Why does the United States have such high maternal mortality compared to other countries?

It starts with a universal healthcare system. We are the only high-income country where about 8% of the population is uninsured. All these other countries guarantee that every resident will have health insurance. So, from the start, we are leaving some women out of the system for years before they may get pregnant. If you don’t have access to health insurance or drug coverage, that already puts them behind from a health standpoint. And then, of course, when a woman gets pregnant, there are gaps in care, and they just don’t have access to the same kind of support that women get in other countries.

We also see these huge disparities among Black and white women, and there’s a lot of reasons for that. There’s a lot of racism in the healthcare industry, as we know, and Black women don’t always get the same care as other women. But we also know that Black women can be at a greater health disadvantage going into pregnancy than white women or women of other races and ethnicities.

What can employers do about this?

It’s important for employers to make sure that, when they are hiring someone, that they are offering comprehensive health insurance that doesn’t create any financial barriers to accessing care. We know that over a third of people in America are likely to skip needed health services because of the cost. And we know that nearly a quarter of Americans are considered underinsured. This means that they have health insurance coverage, but the cost of it is so high that getting care becomes unaffordable. So, giving health insurance is a good first step, but we need to make sure that people can actually use health insurance and not end up with medical debt. Employers need to make sure that their people are able to go to the doctor, particularly for preventative services. Primary care— preventive care—can be used to address any chronic conditions or health issues they have before pregnancy, which can improve outcomes during pregnancy and after giving birth.

According to the report, nearly 65% of maternal deaths happen after childbirth, from causes including bleeding, high blood pressure, and infection in the first week and heart disease weeks to months afterward. What can employers do to help during this critical time?

This means a year after giving birth, we need to make sure that health benefits include comprehensive postpartum support. To ensure that employers are providing paid leave policies and that health plans can allow women to access midwives, for example. This can help ensure that their mental health is being managed, as well, because suicide rates are also high postpartum. So, making sure to have health and mental health benefits that will actually help women during this period is critical.

The report also mentions the importance of paid maternity leave. The United States is the only industrialized country without mandated leave, correct?

Yes, paid leave is such an important component from the healthcare policy side. In the United States, we have this expectation that women are going to go right back into the workforce. And we see that that’s not the case in other countries. Other countries allow women to take care of themselves, their bodies, and their babies longer after giving birth. (See Sidebar: Paid Maternity Leave Across the Globe)

Are other countries doing things that help keep women and babies healthy after birth that we could duplicate?

The expectation in the United States is for women not to go to their doctor after giving birth until their six-week postpartum appointments. In other countries there are also fewer barriers to getting care, whereas in the United States we really have set up barriers to making sure that women are able to take care of themselves. Something that is being done in Chile, for instance, is a conditional cash transfer program that encourages women and children are getting the right care that they need. Cash transfers are given as a financial incentive for families when they are going to postpartum visits and wellness checkups for their kids, sometimes up to age 18. And it really is a huge benefit, one that has been implemented in countries all around the world now, because it’s such a successful program.

Midwives can improve health outcomes of birthing women and their children. But, according to the report, the United States has the lowest number of midwives among high-income countries, correct?

One thing we know is that we just don’t have enough midwives, in general, in the country. So, we need to increase the number of midwives. And then we need to make sure that everyone is actually able to access midwives through their health insurance benefits. But in the United States, we are facing this huge internal shortage crisis. We have to do something immediately to increase the supply of the OB-GYN workforce. [The Commonwealth Fund report says the United States has 16 midwives and 13 OB-GYNs per 1,000 live births. With the exception of South Korea, all other high-income countries have two to six times more providers.]

Why are midwives so important, particularly for postnatal care?

They create a relationship with the parents and make sure that the healthcare is in place that they need. Midwives can help women get mental healthcare that is needed and ensure new mothers are getting lactation support. They are able to be there to answer any sort of general questions they have. We know from any women in our lives that have had children how frightening the postpartum period can be, how many questions we have. And having a midwife there means you can have an expert coming to you, who, hopefully, can really help you.

Are midwives covered under private insurance plans?

In some states or some municipalities, they may provide postpartum care by midwife. But it really requires the patient to understand what their benefits are, either on their health insurance plan or other state program. That’s also something employers can do for parents. They can look at their health insurance plans and ensure that OB-GYNs and midwives are fully covered and there’s plenty on the plans.

Or at least get as many as they can on the plans to create as much access as possible.

What can employers do to improve the chances that women are getting the care they need during and after pregnancy?

Something an employer can do is use their insurance data. If they know that someone is pregnant or nearing the end of their pregnancy, they could send out information [to the pregnant person]. They can provide information through their health insurance about what their options are and what their healthcare coverage is. The stress of parenthood is now being considered a public health crisis. And so, employers need to understand this and try to help alleviate families’ stress. And, certainly, one way to do that is through offering better health insurance benefits, because that is going to be a big factor during that time.

In the end, it all comes down to supporting women. That means before, during, and after pregnancy. Employers can make sure that women have comprehensive, affordable health insurance before they get pregnant and then after pregnancy. Some employers are doing this in multiple ways including home visits and paid-leave policies. But it is critical postpartum because women are too vulnerable during this time to be left behind.

Four to six weeks, which is the leave that most women take after having a baby in the United States, is almost nothing in a lot of these countries. [The minimum standard from the International Labor Organization is 14 weeks.] And it’s not just about maternity care. Some countries have gotten incredibly creative with their paid leave policies so that the fathers and even the grandparents—any caretaker—can use their leave for maternity purposes. The United States has a lot to learn. You can really enhance the well-being of the mother, father, and child by giving comprehensive health insurance and creating long paid-leave policies.