1. 2020). Medicaid and CHIP Payment and Access Commission (MACPAC), Medicaid’s Role in Financing Maternity Care (MACPAC, Jan. 2020); and Sarah H. Gordon et al., “Effects of Medicaid Expansion on Postpartum Coverage and Outpatient Utilization,” Health Affairs 39, no. Women in the U.S. are the most likely to die from complications related to pregnancy or childbirth. The U.S. has the highest maternal mortality rate among developed countries, Many factors contribute to the high number of maternal deaths in the U.S., including too few maternity care providers, especially midwives, and lack of access to comprehensive postpartum supports. Other experts estimate that an even larger proportion of births, up to 90 percent, are considered uncomplicated. 33. WHO et al., Postnatal Care, 2015; and “ACOG Committee Opinion No. Hispanic women have the lowest rate (11.8).39 The pandemic has the potential to exacerbate existing U.S. racial disparities in maternal outcomes, as Black and Latino people have faced higher rates of economic hardship and mental health problems during the pandemic compared to their white counterparts.40. The data are estimated with a regression model using information on the proportion of maternal deaths among non-AIDS deaths in women ages 15-49, fertility, birth attendants, and GDP. Used by the World Health Organization (WHO) in international comparisons, this measure is reported as a ratio per 100,000 births. (eds. Under-5 mortality rate, , 2000. The United States has the highest maternal mortality rate of any developed country and the … Despite participation in the Millennium Development Goals (MDGs) and spending more than any other country on hospital-based maternity care, the maternal mortality ratio (MMR) in the U.S. remains at about 17 deaths per 100,000 live births. To better understand the high maternal death rate in the U.S., it is helpful to know when they happen. The maternal mortality ratio in developing countries in 2015 is 239 per 100 000 live births versus 12 per 100 … 7. 32. The American College of Nurse-Midwives estimates that approximately 60 percent of pregnancies are normal or low-risk. 6. 4. American College of Nurse-Midwives, Essential Facts About Midwives (ACNM, May 2019); World Health Organization, Nursing and Midwifery in the History of the World Health Organization 1948–2017 (WHO, 2017); Mary J. Renfrew et al., “Midwifery and Quality Care: Findings from a New Evidence-Informed Framework for Maternal and Newborn Care,” Lancet 384, no. 28. Renfrew et al., “Midwifery and Quality Care,” 2014. No other industrial nation has such a high rate of maternal mortality. 5 (May 2018): e140–e150. We used the latest data from the Centers for Disease Control and Prevention’s (CDC) Pregnancy Mortality Surveillance System on the timing of maternal deaths in the U.S. The high maternal mortality rate in the U.S. masks dramatic variation by race and ethnicity: the number of deaths per 100,000 births for black non-Hispanic women in 2018 (37.1) was more than two times higher than that for white mothers (14.7). 7. Sarah A. Donovan, Paid Family Leave in the United States, Report R44835 (Congressional Research Service, updated May 29, 2019). Because what we have today in the United States is the system that's perfectly designed to yield the results that we are seeing. Association of State and Territorial Health Officials, “COVID-19’s Impact on Pregnancy and Childbirth Policies,” ASTHO Experts Blog, Apr. World Health Organization et al., Postnatal Care for Mothers and Newborns: Highlights from the World Health Organization 2013 Guidelines (WHO et al., April 2015). Midwives in many countries are key care providers trained to provide a wide range of services. The American College of Nurse Midwives claims that the “U.S. Trade in Value Added (December 2018) Health Status. ), International Profiles of Health Care Systems 2020 (Commonwealth Fund, June 2020); and Stephen Morrissey et al., “International Health Care Systems,” New England Journal of Medicine 372, no. See UCSF Health, “High Risk Pregnancy,” n.d. 14. 26. ANCM, Ensuring Access, 2014; and Moore et al., Improving Maternal Health Access, 2020. However, maternal mortality in the United States has changed very little in the past 25 years (1, 3). 25. 22, 2020; and Taylor Platt, States Implement Strategies to Safeguard Pregnant Women during the COVID-19 Pandemic (National Academy for State Health Policy, Apr. They typically provide care in hospital-based settings. This podcast discusses conditions known to challenge maternal safety, the high incidence of preventable harm in this population, and care bundles as an improvement strategy. More than half of maternal deaths occur in fragile and humanitarian settings. But in the United States, there is rain on the parade. Data on paid maternity leave are from the OECD’s Family Database. (UNFPA, 2014). ), Building Primary Care in a Changing Europe (European Observatory on Health Systems and Policies, 2015). Martin Marshall, “A Precious Jewel — The Role of General Practice in the English NHS,” New England Journal of Medicine 372, no. Detailed Evaluation of Changes in Data Collection Methods, Centers for Disease Control and Prevention. Rates by age are: 40 and older – 81.9 ... Maternal and infant mortality Customise. For 2018, the maternal mortality rate is 17.4 per 100,000 live births in the United States. 12. Annual rate of reduction (%) Under-5 mortality rate, 1990-2000. And several countries provide more than a year of maternity leave (Exhibit 5). The U.S. is the only high-income country that does not guarantee all mothers paid maternity leave,36 although a few states have recently introduced some paid leave.37 Women receiving paid leave use fewer health care services compared to women with only unpaid leave.38, Racial disparities. 11. The maternal mortality rate is two times lower in Canada than the United States, according to a global survey conducted by the United Nations and the World Bank. All Rights Reserved. The authors wish to thank Dr. Jodie D. Katon, Dr. Eugene Declercq, and Reggie Williams II for their helpful review comments; and Jesse Baumgartner and Gabriella N. Aboulafia for their careful data review. This analysis used data from the 2020 release of health statistics compiled by the Organisation for Economic Co-operation and Development (OECD), which tracks and reports on a wide range of health system measures across 37 high-income countries. Maternal mortality: Death while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. 1). Maternal mortality in the United States is gaining increased attention as a patient safety concern. 29. Eugene Declercq and Laurie Zephyrin, Maternal Mortality in the United States: A Primer (Commonwealth Fund, forthcoming). For 2018, the maternal mortality rate is 17.4 per 100,000 live births in the United States. For everyone. All other countries have a supply that is between two and six times greater. In the U.S., where maternal health outcomes are poor relative to many other parts of the world, policymakers and delivery system leaders can examine international models of maternity care to inform strategies for improvement. 736: Optimizing Postpartum Care,” Obstetrics and Gynecology 131, no. In most countries, maternity care is well integrated with other primary care, and midwives play an important role. Some U.S. states have strengthened access to midwives and achieved positive outcomes.25 During the COVID-19 pandemic, as demand for midwifery care has grown in the U.S. (as it has around the world), several states issued emergency orders expanding midwifery services to pregnant women, including Maine, New Jersey, and New York.26, While the ACA requires Medicaid to pay for midwifery care provided in freestanding birth centers, more needs to be done to expand access to services and make them more affordable. 10 (Mar. Roosa Tikkanen et al. Annual rate of reduction (%) Under-5 mortality rate, 2000-2012. The well-being of mothers and babies should be a top policy priority in all countries. In 2018, there were 17 maternal deaths for every 100,000 live births in the U.S. — a ratio more than double that of most other high-income countries (Exhibit 1). Saraswathi Vedam et al., “Mapping Integration of Midwives Across the United States: Impact on Access, Equity, and Outcomes,” PLoS One 13, no. 2 Increased rate of maternal mortality The maternal mortality rate in the United States has rapidly risen, and healthcare issues are hugely fundamental at the political level. In most other countries, however, midwives greatly outnumber ob-gyns. 3. 38. Under-5 mortality rate, , 2012. 16. 44 (National Center for Health Statistics, Jan. 2020); Marian F. MacDorman et al., “Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends from Measurement Issues,” Obstetrics and Gynecology 128, no. For example, many types of non-ACA-compliant plans, such as short-term plans or association health plans as well as some student health plans, don’t cover maternity benefits. Some states are expanding coverage up to one year, in line with recommendations by maternal mortality review committees and others.35, Paid leave. U.S. Has The Worst Rate of Maternal Deaths In The Developed World More American women are dying of pregnancy-related complications and that rate is rising. 2. OECD Family Database, “Parental Leave Systems,” Aug. 2019. Global Burden of Disease 2015 Maternal Mortality Collaborators, “Global, Regional, and National Levels of Maternal Mortality, 1990–2015: A Systematic Analysis for the Global Burden of Disease Study 2015,” Lancet 388, no. 5. 1.4. Emily Eckert, “It’s Past Time to Provide Continuous Medicaid Coverage for One Year Postpartum,” Health Affairs Blog, Feb. 6, 2020; Laurie Zephyrin et al., “Increasing Postpartum Medicaid Coverage Could Reduce Maternal Deaths and Improve Outcomes,” To the Point (blog), Commonwealth Fund, Nov. 21, 2019; Review to Action and MMRIA, Report from Nine Maternal Mortality Review Committees (Review to Action, 2018); and Petersen et al., “Vital Signs,” 2019. 2012): 263–70; and Kenneth A. Pregnancy-related death: Death during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. Countries also have rapidly reorganized their maternity care delivery systems during COVID-19 to expand use of telemedicine and the capacity to provide home births.28 To strengthen maternity care during the pandemic, the U.S. could look to countries with long-standing experience in home births and midwifery-led care. Affordable, quality health care. Kathy Gifford et al., Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a State Survey (Henry J. Kaiser Family Foundation, Apr. CONCLUSIONS: Maternal mortality continues to be an issue in developed countries, such as the United States and Canada. Universal, comprehensive maternity care coverage, along with exemptions from cost-sharing, also are the norm in other high-income countries.29 While the ACA strengthened maternity care coverage, access to benefits often depends on type of insurance and geographic location, and out-of-pocket costs vary significantly as well.30, Postpartum care. What has happened in the United States has been an increase in maternal mortality since 2003, actually going against the Healthy People 2020 goal of decreasing maternal mortality to 11.4 deaths per 100,000. Data on postpartum home visits were compiled from a variety of country-specific sources, as specified in the notes to Exhibit 4, including a series of patient vignettes of a healthy 23-year-old woman who is pregnant for the first time, funded by the Commonwealth Fund and published in the New England Journal of Medicine in 2015.42. 24. International Labor Organization, “Maternity Leave and Related Types of Leave,” in Maternity Protection Resource Package: From Aspiration to Reality for All (ILO, 2012). Dionne S. Kringos et al. 37. maternity workforce is upside down relative to patient needs,”12 noting that the majority of births are low-risk and could be managed by midwives, family practitioners, or general practitioners.13 In several countries, including Canada, France, and New Zealand, primary care physicians also play a large role (although comparative international data are lacking). In addition, the ACA’s 10 essential health benefits that insurers must cover, which include maternity care, apply only to individual marketplace insurance plans and small-group plans — but not employers with more than 50 workers. 2 (Feb. 21, 2018): e0192523. 10. Some young adults staying on a parent’s health plan have not had their maternity care costs covered, because the ACA only mandates maternity care coverage for primary beneficiaries, not for their children. 36. Used in the U.S. only, this CDC measure is typically reported as a ratio per 100,000 births. Almost all maternal deaths (99%) occur in developing countries. Annual rate of reduction (%) Under-5 mortality rate, 1970-1990. While the reasons behind the high U.S. maternal mortality rate are multifaceted, our findings suggest that an undersupply of maternity providers, especially midwives, and lack of access to comprehensive postpartum supports are contributing factors. The 10 comparator countries included in this brief represent those high-income countries that take part in the Commonwealth Fund’s annual International Health Policy Survey: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. Roosa Tikkanen et al., Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries (Commonwealth Fund, Nov. 2020). 21. More efficient use of health system resources, including lower use of unnecessary and potentially harmful interventions like C-sections for low-risk deliveries, epidurals, and instrument-assisted births. 21 percent of all maternal deaths are between one and six weeks postpartum. 10053 (Oct. 8, 2016): 1775–812. 4 (July–Aug. Morrissey et al., “International Health Care Systems,” 2015. Rates also increased with age. The U.S. and Canada have the lowest overall supply of midwives and ob-gyns — 12 and 15 providers per 1,000 live births, respectively (Exhibit 3). 5, 2015): 893–97; and Ewout van Ginneken, “Perennial Health Care Reform — The Long Dutch Quest for Cost Control and Quality Improvement,” New England Journal of Medicine 373, no. Placing a priority on natural reproduction processes and relationship-building, midwives also can help address the social and personal needs of mother, baby, and family.8 Ob-gyns, meanwhile, are physicians trained to identify and intervene in abnormal conditions that come up before, during, and after pregnancy. Because of potential data comparability concerns, we omitted these findings from our formal analysis. The maternal mortality ratio, on the other hand, is the number of maternal deaths per 100,000 live births. There are three commonly used measures of maternal deaths in the United States. The correction factor f… Full details on how indicators were defined, as well as country-level differences in definitions, are available from the OECD. You will be subject to the destination website's privacy policy when you follow the link. Although considered mainly as problems of the developing world, maternal mortality and morbidity remain a challenge in the United States of America (USA). While international data are available regarding timing of maternal and pregnancy-related deaths, findings for the U.S. did not correspond with the latest data from the CDC. The United States (U.S.) fares worse in preventing pregnancy-related deaths than most other developed nations. Maternal mortality rates have been stable recently, despite evidence that many maternal deaths continue to be preventable. Pregnancy-associated death: Death while pregnant or within one year of the end of the pregnancy, irrespective of cause. 31. 42. 11. Lianne Zondag, Franka Cadee, and Myrte de Geus, Midwifery in the Netherlands, 2017 (Royal Dutch Organization of Midwives, Jan. 2017); and Dorothy Shaw et al., “Drivers of Maternity Care in High-Income Countries: Can Health Systems Support Woman-Centred Care?,” Lancet 388, no.10057 (Nov. 5, 2016): 2282–95. The United States has the highest maternal and infant mortality rates among developed nations. Among the key issues to address are state variations in scope-of-practice rules for health care practitioners, low reimbursement rates for midwives, and payment parity.27. There is no one explanation as to why the United States is seeing such high maternal mortality rates. 3 (Mar. Judy Jou et al., “Paid Maternity Leave in the United States: Associations with Maternal and Infant Health,” Maternal and Child Health Journal 22, no. S1 (Feb. 2014): S136–S143. Since more than half of maternal deaths occur after birth, strengthening postpartum care should be a priority. Dodge et al., “Implementation and Randomized Controlled Trial Evaluation of Universal Postnatal Nurse Home Visiting,” American Journal of Public Health 104, no. Maternal mortality rates calculated without using information obtained from the checkbox are also presented for 2002, 2015, 2016, 2017, and 2018 to provide comparisons over time using a comparable coding approach across all states. Insurance coverage. There has been renewed interest recently in investigating the United States’ rising maternal mortality rate, as studies show that the U.S. is the only developed country to see the maternal mortality rate increase as countries such as France, Spain, Germany, Canada and Portugal witness a steady decrease.. 15. 20, 2020). https://doi.org/10.26099/411v-9255, © 2021 The Commonwealth Fund. Additionally, the maternal mortality rate in the United States has risen 113% since 1990. The overall maternal mortality rate was 17.4 deaths per 100,000 live births. Around one-third of U.S. pregnancy-related deaths, counted up to one year postbirth, occur during pregnancy (Exhibit 2). Lauren M. Rossen et al., “The Impact of the Pregnancy Checkbox and Misclassification on Maternal Mortality Trends in the United States, 1999–2017,” Vital and Health Statistics, series 3, no. The most recent U.S. maternal mortality ratio, or rate, of 17.4 per 100,000 pregnancies represented approximately 660 maternal deaths in 2018. (eds. 34. Economic Outlook. 28, 2016): CD004667. 8. The World Health Organization recommends at least four health contacts in the first six weeks, yet U.S. women typically have a single office-based physician visit within this period, and some don’t have one at all.33, Expanding eligibility for Medicaid, which pays for 43 percent of U.S. deliveries, can lead to more stable postpartum coverage.34 Currently, however, the program’s coverage extends to only six weeks postpartum. Midwifery-led care models have been shown to provide care that is comparable to, or sometimes even better than, that provided by obstetrician-gynecologists, or ob-gyns (see box).9. For example, midwives provide most prenatal care and deliveries in the U.K. and the Netherlands14 — countries considered to have among the strongest primary care systems in Europe.15 Dutch midwives also deliver home births, which represent 13 percent of all births, the highest rate of any developed countries.16, In some countries, women can choose their maternity care provider, as both midwife and obstetrician care services are covered by universal health insurance. 2.9. Its maternal-mortality rate has been steadily rising — the only developed country whose is. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Simply totaling the raw, unadjusted data from all states regardless of whether they revised their death certificates results in a reported U.S. maternal mortality rate that more than doubled from 9.8 maternal deaths per 100,000 live births in 2000 to 21.5 in 2014.17 However, the adjusted maternal mortality rate increased more slowly for a group of 24 states and Washington, DC (analysis group 1, Table 1) that only included a pregnancy question after they revised their death certificates (Fig. Maternal mortality ratio (national estimate, per 100,000 live births) Mortality rate attributed to household and ambient air pollution, age-standardized, male (per 100,000 male population) Prevalence of stunting, height for age, male (% of children under 5) 9. 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