American women are far more likely to die from pregnancy-related causes than women in other wealthy countries -- and a national shortage of maternity care providers bodes ill for the future.
Those are some of the findings from a new report on maternal mortality by the nonprofit Commonwealth Fund, which compared the United States with 10 other high-income nations.
It found what the researchers called "unacceptable" numbers.
In 2018, the U.S. maternal mortality rate stood at 17 for every 100,000 births -- more than double the rate of most other countries. Those figures capture deaths during pregnancy and within 42 days of the end of pregnancy.
But many women die later in the so-called "fourth trimester," or the year after giving birth.
And of all pregnancy-related deaths in the United States, 52% happened after childbirth, the report found. When women died within a week of childbirth, it was often related to severe bleeding, infections or high blood pressure. Later in the postpartum period, the leading cause of death was cardiomyopathy, a weakening of the heart muscle.
"Even though the U.S. spends more on health care than anywhere else in the world, it has higher rates of these preventable deaths," said report co-author Roosa Tikkanen, a senior research associate at the Commonwealth Fund.
The United States has long held that dubious distinction. And maternal mortality is yet another area where racial disparities are stark: Black women have more than double the death rate of white women in the United States.
The new report adds a layer, Tikkanen said -- looking at differences in countries' health care systems that may illuminate why the United States fares so poorly.
One key difference is the supply of maternal care providers, including obstetricians/gynecologists and midwives.
Nearly all other wealthy nations, except for Canada, have far more providers relative to population. In the United States, there are 15 providers for every 1,000 births, while Sweden has 78 per 1,000, according to the report.
In many European countries, as well as Australia and New Zealand, midwives make up the bulk of the maternal care workforce.
It's not clear whether midwives are a driving reason for lower maternal mortality in those countries, according to Tikkanen. But in most countries, she said, maternal care is well-integrated into primary care, with midwives being a crucial part of that. So women in other wealthy countries typically have greater continuity of care before, during and after pregnancy.
Dr. Rahul Gupta is chief medical officer for the nonprofit March of Dimes, which has long made reducing maternal mortality a priority.
He said the new report highlights why the United States is an "outlier" among wealthy nations.
"In countries that are doing well," Gupta said, "there is a system of life-course care centered on the individual. Here, we're centered around the health care system."
When, for example, a woman dies of cardiomyopathy after giving birth, he said, that may involve gaps in health care not only after childbirth, but during and before pregnancy.
Gupta noted that midwives are important providers whose ranks are low in the United States: According to the report, there are just four midwives for every 1,000 births in the United States, versus, for instance, 43 per 1,000 in the United Kingdom and 68 per 1,000 in Australia.
But numbers are not the whole story, Gupta added. "We also need culturally competent midwife care -- providers who understand the lived experiences of the people they're serving," he said.
It's not only midwife care that separates the United States from other rich nations. The report underscores several differences:
- Along with universal health care in other countries, pregnant women and new moms are often exempt from out-of-pocket costs.
- Women in those countries are guaranteed home visits from a nurse or midwife soon after delivering. In the United States, that's covered sporadically, by some health plans and some state Medicaid programs.
- The United States remains the only country that does not mandate paid maternity leave.
According to the Commonwealth researchers, the Affordable Care Act has made a difference. It expanded Medicaid in many states, and required the program to cover midwife care, for instance.
But broader change is needed, they added.
Gupta agreed. "The issue isn't that we don't know what works," he said. "We do know what works, based on other countries. So what now? I think we need a coming together of minds across the country. We have to agree that what we have isn't working."More information
For more on preventing pregnancy-related deaths, visit the March of Dimes.
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