The following post is by the editorial board of The Washington Post:
Over the past two decades, most countries have made great strides in maternal health, bettering outcomes for mothers and children. The most glaring exception to this trend is, disappointingly, the United States.
In 2021, the most recent year for which data is available, the United States’ maternal mortality rate was 32.9 deaths per 100,000 live births— a stark increase from preceding years. Some of that was no doubt linked to the coronavirus, which posed particular risks for pregnancy. Yet even before the pandemic, the United States saw significantly worse outcomes relative to peer countries — and that pattern shows no signs of changing. A paper published in JAMA in July found that more than twice the number of people in the United States are dying of pregnancy-related causes than 20 years ago.
The dismal figures, coupled with the tragic death of Olympic sprinter Tori Bowie during childbirth in June, have cast a much-needed spotlight on this brewing crisis. But — because maternal health intersects with myriad other socioeconomic factors and varies dramatically by location — there is no single solution. Still, it’s time for federal, state and local institutions to start thinking creatively about how to better serve mothers.
Most interventions to improve maternal health focus on prenatal care and delivery. To be sure, these are critical periods in pregnancy. The majority of pregnancy-related deaths, however, occur postpartum.
For many American mothers, postpartum care does not functionally exist — a pattern Jessica L. Cohen, an associate professor of global health at Harvard University and an affiliated researcher with the Abdul Latif Jameel Poverty Action Lab (J-PAL), describes as a “chasm of accountability.”
This begins soon after delivery: The average hospital stay after childbirth is about two days, lower than in places such as Japan and much of Europe. The rush to get birthing parents out of the hospital can make it harder to identify conditions such as postpartum preeclampsia, regarded as a “silent killer.”
Subsequently, an estimated 40 percent of women do not attend a postpartum visit with health-care providers, and the visits that do take place are generally brief. The American College of Obstetricians and Gynecologists recommends a more continuous model of care, with targeted, regular appointments with professionals.
Some of this is, of course, contingent on better family leave policies: Incredibly, a 2012 study found that 23 percent of new mothers in the workforce returned to work within 10 days of delivery. Pregnancy-related Medicaid and Children’s Health Insurance Program coverage can also be expanded to cover more of the postpartum period. The American Rescue Plan offered states the option of extending Medicaid from 60 days after pregnancy to 12 months; 36 states have taken up this option.
Mental health should be central to this approach. Data from the Centers for Disease Control and Prevention suggests that nearly 23 percent of pregnancy-related deaths were linked to mental health. Regular screenings can help more women receive the support they need. A new Food and Drug Administration-approved drug to treat postpartum depression could help, too.
There is another phase to pregnancy that is often overlooked: pre-pregnancy. Many risk factors — such as substance-use disorders or physical comorbidities — can be identified and addressed early. Unintended pregnancies are linked with poorer maternal and child outcomes, so family planning can be a key tool — though restricted abortion access after the Supreme Court’s Dobbs decision has made this more difficult.
According to the CDC’s 2021 data, the maternal mortality rate for Black women was 2.6 times higher than that for White women. Also, American Indian and Alaska Native women are twice as likely to die from pregnancy-related causes than White women.
Some of this discrepancy has to do with the interlocking challenges facing Black women and other women of color — a type of “chronic stress” that University of Michigan professor Arline Geronimus called “weathering.” And it’s true that differences in maternal health outcomes will persist as long as disparities in housing, income, physical safety, health and treatment do.
Yet there is more that can be done in the near term to promote better outcomes. Maternity ward closures during the pandemic were disproportionately concentrated in Black and Hispanic communities. This exacerbated preexisting trends: In the District, for instance, low-income communities in Wards 7 and 8 went without easy access to maternity care centers for years. In addition, hospitals that serve a higher proportion of minority patients tend to be understaffed and under-resourced, resulting in less comprehensive care.
Maternity wards often generate lower profits compared with other health services, and Medicaid reimbursements for births — which pay for more than 40 percent of deliveries nationally — are generally low. Governments could address this market failure by making Medicaid payment rates more competitive and providing grants or incentives to maternity centers that operate in low-income areas. Many minority and low-income women also mistrust the health system; investing in diversifying the medical profession could help build bridges with wary communities.
The United States can also learn from countries — both high- and low-income — that have vastly improved their maternal health outcomes. Most European countries, for example, fare far better on maternal health outcomes by relying more on midwives than obstetrician-gynecologists, allowing doctors to focus their care on women who need it most.
Home visits have also been key to many nations’ strategies, and a number of developing countries rely on community health workers. The United States does have home-visiting programs, most notably the Nurse-Family Partnership (NFP), which connects nurses to low-income mothers expecting their first child. While the initiative has previously been linked to positive maternal and child indicators over longer time horizons, a recent randomized evaluation in South Carolina, led by Harvard associate professor and J-PAL affiliate Margaret A. McConnell, found it did not have a significant effect on birth outcomes. Another study in South Carolina, led by University of Maryland assistant professor Rebecca A. Gourevitch, likewise found no significant effect on prenatal care.
The NFP, like most home-visit programs, is locally administrated. Its success typically rides on the resources available in the community — a concern amid nationwide shortages in maternity care, mental health services and other support systems. Moreover, initiatives staffed by nurses might struggle to reach people who are disconnected from or uncomfortable with the health-care system.
In time, technology can help address some of these gaps. Organizations are already experimenting with telehealth, apps and digital services that link expecting families with the services they need. These can be particularly useful at identifying warning signs and matching people to specialists or health-care providers with an understanding of their language and culture.
Pregnancy can be an anxious time — and a joyful one. With smart policies and investments, the United States can rebalance the scales so more families can focus on what really matters: ushering new babies into safe, healthy, welcoming homes.
