By now you’ve likely heard that the U.S. leads all wealthy nations in terms of maternal mortality rates. This statistic is hard to swallow, especially since two in three such complications are preventable. Given that the U.S. is the wealthiest country in the world, these outcomes are clearly not acceptable. We spend more per person on health than comparable OECD countries, and we also spend a higher proportion of GDP on healthcare than other high-income countries.
Indeed, in a recent analysis of 71 performance measures, the U.S. came in last out of 11 comparable countries in healthcare system performance. For the purposes of this discussion, it’s worth noting that the U.S. performs particularly poorly with respect to maternal mortality, and that it has the highest infant mortality rate among its peer countries.
In a country so rich in terms of both money and medical innovation, we can certainly do better. But how? Since this is a complex problem, I’m going to split this subject into two blog posts: one post about the problem of maternal mortality in the U.S., and a second about how a population health management (PHM) approach — plus improvements in federal legislation — might help turn the problem around.
Background
Opinions vary on what makes a good healthcare system, but one constant theme that emerges is the importance of patients establishing a relationship with their primary care physician. Although it’s important for a range of physician types to establish a rapport with their patients, our current system essentially places PCPs as gatekeepers of patient health. For that reason, the PCP-patient relationship is an important place to start.
As I discussed in a past blog post, the usual way PCPs conduct business in the States, i.e. acting as point people for assessing both mental and physical health, leaves a lot to be desired. In the current setup, people with some of the worst healthcare problems end up slipping through the cracks because PCPs aren’t highly trained at catching symptoms of poor mental health. Because of this, co-location of mental and physical care services is crucial. Sadly, this isn’t usually the case in the United States.
Although PCPs in this country are strapped for time and resources when it comes to treating physical ailments (let alone mental issues), at least there’s a chance they’ll catch a problem before it worsens. This is a key point, because research has found that establishing a relationship with a primary care provider can lead to positive health outcomes.
In keeping with these findings, a nationally representative survey study carried out in 2019 sought to find out if there was a connection between receipt of primary care and both high-value services and positive patient experience. The survey designers also analyzed temporal trends from 2002 to 2014. In the end, they discovered that “receipt of primary care was associated with significantly more high-value care, slightly more low-value care, and better health care experience.”
In an ideal world, everyone would establish an enduring relationship with a PCP based on deep trust, and they would seek primary care through their trusted doctor. This would be a particularly useful relationship in the case of women who plan to become pregnant, as their PCP could help point out potential causes of morbidity early on and help their patient avoid bad outcomes.
In the real world, however, these relationships don’t fulfill their potential. Case in point: instead of seeking medical care through primary care practitioners, on average some groups – either due to access to care issues, affordability, historical issues related to racism, or any number of other reasons – avoid forging a bond with a PCP.
One group in particular that suffers from this trend is African-Americans. In one study, African-Americans were found to be more likely than whites to use either the emergency department or hospital outpatient department as their “usual source of care.” A subset of this group, African-American women, are almost three times more likely to die from pregnancy-related complications than are white women. This mindset of avoiding institutional care for fear of experiencing poor outcomes (or because it’s flat-out inaccessible) seems to be one factor in America’s dismal performance when it comes to maternal mortality, particularly when it comes to African-American women.
But avoidance of primary care is just one factor among many. According to the Commonwealth Fund, here are three other significant causes:
- Obstetrician-gynecologists (ob-gyns) are overrepresented in the workforce compared to midwives. A recent study in the Lancet showed that increasing midwife-delivered interventions “could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2.2 million deaths averted per year by 2035.”
- There is a shortage of maternity care providers (both ob-gyns and midwives) relative to births. “In most other countries,” say the authors, “midwives outnumber ob-gyns by severalfold, and primary care plays a central role in the health system.” In the U.S., the supply of midwives is negatively affected by “state licensure laws, restrictive scope-of-practice laws, and rules requiring physician supervision of midwives.”
- The U.S. doesn’t guarantee access to provider home visits, nor does it guarantee postpartum paid parental leave. In making the argument that postpartum paid leave is necessary to allow mothers time to recover after childbirth, an opinion piece on the Bloomberg website noted that “40% percent of maternal deaths occur in the six weeks following labor. Almost 20% occur between six weeks postpartum and one year” and that “Just 8% of workers in the bottom wage quartile had access to paid family leave in 2020, with Black and Hispanic people being less likely to work in jobs with access to paid leave.”
Models of Success
At this point, it might help to examine what a high-functioning health system looks like with respect to maternal health. Although maternal health is only one criteria by which healthcare systems were judged in a 2021 Commonwealth Fund report, this study throws a spotlight on four central factors to keeping a country’s patients as healthy as possible:
- In high-performing countries, universal coverage is provided, and cost barriers are removed.
- Countries invest in primary care systems to ensure that high-value services are equitably available in all communities to all people.
- They reduce administrative burdens that divert time, efforts, and spending from health improvement efforts.
- They invest in social services, especially for children and working-age adults.
The study authors used indicators across five domains in their assessment: access to care, care process, administrative efficiency, equity, and healthcare outcomes. In terms of these metrics, two of the top-performing countries were Norway and the Netherlands. To illuminate what these countries do to stand out so much, let’s dive a little deeper into how they handle maternal health.
Norway: As noted in an article in the Infant Mental Health Journal, citizens of Norway have universal access to healthcare. This universal care is financed by a mix of taxation, income‐related employee and employer contributions, and out‐of‐pocket copayments. The authors highlight the fact that “All residents, including migrants, labor immigrants from EEA, legal immigrants, refugees, or asylum seekers under assessment, are covered by the National Insurance Scheme (Folketrygden, NIS), managed by the Norwegian Health Economics Administration (Helseøkonomiforvaltningen).”
Importantly, all pregnant women in Norway, regardless of legal status, have access to “free abortion, prenatal care, and care related to delivery, and the immediate follow up at the Maternal and Child Health Care Service (MCHS).” Newborns in Norway receive one home visit by a public health nurse, along with one home visit by a midwife. Further, each infant receives “monthly clinic‐based checkups of growth and development during the first year of life.” And this medical monitoring continues at regular intervals where children receive development assessments, clinical examinations, and vaccines.
Emblematic of the country’s approach to nurturing the health of mothers and their children, and to address rapidly-changing demographics, Norway recently launched an initiative that supports immigrant mothers and children called the New Families Program. This program supports first‐time mothers and their infants in one Oslo district that’s composed of 53% minorities from 142 countries. “Anchored in salutogenic theory,” write the authors, “the program aims to support the parent–child relationship, children’s development and social adaptation, and to prevent stress‐related outcomes.”
The Netherlands: Over the past few decades, cultural norms in the Netherlands have shifted toward placing a higher premium on maternal health. As a 2021 JAMA article points out, in the Netherlands, “access to health care is universal and free of charge and access to perinatal care is fully covered by basic mandatory health insurance.” When a Dutch woman begins her course of treatment, an approach called “risk selection” is used to place them into one of two tracks: one for low-risk pregnancies, or one designed for high-risk pregnancies. Care is then calibrated to the appropriate risk level. These tracks are further subdivided into three possible paths which allow for greater flexibility.
Midwives, who – as is the case in Norway – play an important role in the country’s healthcare system, are allowed to specialize, forming two groups: community midwives and clinical midwives. Similar to “birthing centres” throughout the world, as defined in one study, Dutch birthing centres “are midwifery-managed locations that offer care to low risk women during labour and birth. They have a homelike environment and provide facilities to support physiological birth. Community midwives take primary professional responsibility for care. In case of referral the obstetric caregiver takes over the professional responsibility of care.”
In the community setting, midwives are assisted by maternity care assistants. Birth centres in which community midwives work are family-oriented and encourage client participation in the decision-making process when it comes to their own care.
Clinical midwives, on the other hand, work exclusively in hospital settings. If risk factors emerge during pregnancy, a woman is referred to secondary care and put under the responsibility of an obstetrician. In this scenario, clinical midwives can also be involved. Evidently, clinical midwives and obstetricians agree that continuity of intrapartum care (i.e. the period from the commencement of labor through the first, second, third, and fourth stages of labor) could be improved by extending the role of primary care midwives, but they disagree on how to redistribute responsibilities. Still, the fact that midwives are even in this conversation speaks volumes about the value the Dutch system puts on the field.
And the results from embedding midwives in the pregnancy and birthing process are stunning. Although women with a non-western ethnic background had an increased maternal mortality ratio (MMR) when compared to Dutch women, overall maternal mortality was halved between 2006-2018 when compared with the years 1993–2005. This should be taken in its proper context, however: one study noted that people living in neighborhoods with a low socioeconomic status (SES) were associated with “higher odds of adverse birth outcomes.”
Potential Solutions
As frustrating and tragic as these outcomes are in the United States, there is some reason for optimism that things can improve. This is particularly true when it comes to government-sponsored health coverage.
More to the point, the Centers for Medicare and Medicaid Services (CMS), has proven to be a significant source of coverage for low-income women, covering about four in ten births nationwide. Up until recently, postpartum care only extended a couple of months, but this changed with the passage of the American Rescue Plan Act, or ARPA, in 2021 (a piece of legislation I discussed previously in this blog post). Now, most states have exercised an option (or plan to exercise the option) to extend Medicaid postpartum coverage to a full year.
In another promising development, during the COVID-19 pandemic, states including Maine, New Jersey, and New York issued emergency orders that expanded midwifery services. In addition, the Affordable Care Act (ACA) requires Medicaid to cover midwifery care that’s provided in freestanding birth centers.
While these are steps in the right direction that will hopefully remain after the public health emergency ends, there’s still a lot of work to do when it comes to stemming the tide of maternal mortality in the U.S. The current landscape is at best a patchwork of solutions that cause stress in those affected. As other nations have shown us, this approach can and must change. In my second blog post on this topic, I’ll explore how population health management, in tandem with effective federal legislation, can help the U.S. begin to make maternal health a higher priority.