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U.S.'s continued lag in maternal mortality needs policy fix

The country's fix for poor maternal mortality rates could lie in policy decisions proven effective in similarly developed nations.

When it comes to maternal mortality, the U.S. can find a way forward if it looks to its peers across the globe, contends a new report from the Commonwealth Fund.

The report says that the U.S. still has the highest maternal mortality rate in the developed world, with 22 maternal deaths per 100,000 live births.

Maternal mortality for any U.S. demographic, including white people, is higher than it is for anyone in Chile, the nation that has the next-highest maternal mortality rate. Per the report, Black birthing people in the U.S. are more than twice as likely to die from childbirth or childbirth-related causes than their white counterparts.

Highest maternal mortality rate among Organisation for Economic Cooperation and Development (OECD) nations is not a title the U.S. should want, and it's not one it has to have, according to Munira Gunja, M.P.H., senior researcher in the International Program in Health Policy and Practice Innovations at the Commonwealth Fund and the report's lead author.

"Other countries have been able to achieve almost zero to no maternal deaths each year, and they have solutions on the ground that we just don't have in place in the U.S.," Gunja said in a phone call discussing the report. "We know that there are ways to really reduce this preventable problem that we have."

This report from the Commonwealth Fund is a step in the right direction, Gunja indicated, because it provides data about maternal health in nations that are peers to the U.S., giving the closest the industry can come to an apples-to-apples comparison.

But of course, it's not a true 1-to-1 comparison, Gunja added, because U.S. health policy is so distinctly different from other similarly developed nations. Without a universal healthcare system, the U.S. might continue to trail in terms of maternal health.

U.S. maternal health dwarfed by peer nations

In some cases, the U.S. maternal mortality rate is triple that of other OECD nations. In fact, Norway boasts a 0 deaths per 100,000 live births maternal mortality rate, and in Switzerland, it's as low as 1.2 deaths.

That's a far cry from the 22 maternal deaths per 100,000 live births in the U.S. or the 49.5 deaths among Black people.

In the U.S., most of these deaths (65%) happen during the postpartum period. According to the Commonwealth Fund, issues like severe bleeding, high blood pressure and infection most commonly contribute to maternal mortality early on. Cardiomyopathy is the biggest contributor of late maternal deaths.

The higher maternal mortality rate at any point during pregnancy, childbirth or the postpartum period is indicative of serious lapses in the U.S. healthcare system, Gunja and her co-authors contended.

Limited coverage leads to maternity care lapses

Maternal mortality is more common in the U.S. likely because pregnant people in the U.S. face more barriers to the wraparound prenatal, childbirth and postpartum care that is necessary to promote good outcomes.

Most prominently, poor access to comprehensive health insurance coverage affects care access, Gunja explained.

"In every other country, every woman is guaranteed health insurance. We don't have that here, so there's still roughly 8 million women without any health insurance coverage," she stated. "Right off the bat, we're not even allowing people a chance to get basic preventative care and treatment and screenings. And then we fast forward to when they actually get pregnant, and they've already been left behind compared to other women."

That problem is worse for populations of color and low-income people, Gunja added, and that's part of what leads the U.S. to have the worst maternal health disparities in the developed world.

"Even though disparities may exist in all countries, the disparities are much wider and higher," Gunja said. "What contributes to that is going back to having health insurance at baseline. We need to make sure everyone's covered and that they can at least have access to basic preventative and primary care services without that fear of a high out-of-pocket bill and co-payments."

Poor insurance coverage continues to affect access to quality pregnancy and postpartum care.

And although Medicaid is legally required to cover pregnant people 60 days postpartum and 47 states plus Washington D.C. have extended Medicaid coverage postpartum, that coverage is not always comprehensive. Paired with typical barriers that affect patient access to care, pregnant people face an uphill battle in accessing maternal and postpartum care.

That is not as much of a problem in peer nations, Gunja said.

"In other countries, there are home visits being made by a physician or midwife or public health nurse," she pointed out.

The U.S. is the only OECD nation that does not guarantee access to home visits from some type of maternity care provider, although home visits are covered by some state Medicaid programs and private insurers.

"In the U.S., women are expected to go to the doctor," Gunja stated, as opposed to the doctor meeting you. "This in itself is a huge barrier If you don't have childcare for your baby, or if you don't have the right transportation to get to the doctor."

And that is not to mention the dearth of providers available to treat pregnant people in the U.S. In addition to documented maternity care deserts across the nation, Gunja and colleagues flagged differences in the types of providers available to treat patients. The analysis particularly zeroed in on midwives, who studies show could potentially avert 41% of maternal deaths, 39% of neonatal deaths and 26% of stillbirths around the world.

But the U.S. has the lowest supply of midwives among OECD nations, with only 16 midwives per 1,000 live births.

"We just don't have enough of them in this country. They're reimbursed at really low rates, so they're hard to come by," Gunja explained. "Without a comprehensive maternal care workforce, we shouldn't be surprised that women aren't able to get the care that they need."

Policy barriers to good maternal outcomes

The U.S. has other policy levers that could improve maternal health outcomes.

"In the U.S., we're the only country without a federally paid leave system," Gunja pointed out. "Women who may not be physically ready to go back into the workforce need a paycheck. Then they go back to work and are not taking care of their bodies."

According to the Commonwealth Fund's assessment, every other OECD nation provides at least 14 weeks of paid leave following childbirth. In Norway, it's as much as 86 weeks.

"We just aren't providing any support for so many women, but especially lower-income women and women of color in this country," Gunja noted.

Gunja said there is a path forward for the U.S. -- to just take a look at its peer nations. And indeed, the country is making some headway in decreasing maternal deaths.

But by examining the policies that have a proven track record, the U.S. can make greater progress.

"We know that there are solutions that we can implement because other countries have proven to be able to do it," she concluded. "Some states have taken steps in the right direction with paid leave policies and with more postpartum support, a federal policy can go a long way to make sure that every single woman has access to the same services, and we can reduce inequities in the system."

Sara Heath has been covering news related to patient engagement and health equity since 2015.

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