Sam Podnar

29 February 2024

Why is the U.S. a stark outlier in maternal mortality rates among developed countries? Despite spending the most per capita on health care among wealthy nations, the U.S. has the worst maternal health outcomes among them, and while global maternal mortality has decreased worldwide since the turn of the 21st century, it has more than doubled in the U.S. in the same time period (1). Countrywide numbers conceal even greater disparities, with the maternal mortality rate for Black women nearly three times that of white women and the rate for American Indian and Alaska Native populations also elevated (2). It is tempting to think of maternal mortality as a problem that inevitably fades into the background as countries industrialize, as medicine advances and health outcomes improve across the board. But it is greatly affected by the health care infrastructure around it and the material conditions of mothers, children, and families. That the U.S. is an outlier among wealthy countries should make us look into what it is uniquely doing wrong as a starting point for fixing this preventable problem.

A pregnancy-related death occurs any time during pregnancy and up to 42 days after birth or termination, for any cause related to the pregnancy or its management (3). Several causes could be contributing to the rise in maternal mortality in the U.S., including a rise in chronic conditions, women having children at older ages, and an increased frequency of C-sections, all of which raise the risk of complications during and after pregnancy (4). Deaths also spiked during the COVID pandemic, when the disease made pregnant women more vulnerable and access to care was more limited (5). 

Most of the leading underlying causes of pregnancy-related deaths have to do with the stress put on the body while carrying a child: hemorrhage, cardiac conditions, infection, blood clots, and high blood pressure. But the foremost cause is actually mental health conditions, including suicide and drug overdoses, which encompass nearly a quarter of maternal deaths (6). That this is the leading cause should be the first signal that there is a major chance for intervention in all cases of maternal mortality. A second signal is that maternal mortality during labor and delivery has actually decreased in U.S. hospitals across the board, suggesting that a rise in postpartum complications is driving the overall increase (7). 

Complications do not inevitably lead to death—an overwhelming 84 percent of pregnancy-related deaths are preventable (8). While the U.S. has dragged its feet, other countries, specifically in western Europe and Scandinavia, have health care systems that prevent these deaths. In 2020, the maternal mortality rate in the U.S., for example, was four times that of Sweden (9).

Paid parental leave is one component of a generous social safety net that could greatly improve maternal health. One recent study found that paid maternity leave was associated with a 51 percent decrease in the odds of pregnant women being re-hospitalized (compared to women taking unpaid or no leave), and another linked an increase in leave from 6 or fewer to 12 weeks with a 15 percent decline in postpartum depressive symptoms (10). 

But the U.S. federal government mandates no paid maternity leave and only 12 weeks of unpaid leave; it is one of the only industrialized nations that still provides no paid leave, though there is variation among the states (17). 22 states have some variation of a paid leave system either implemented or ready to go into effect; New Yorkers get 12 weeks of paid leave, for instance, Californians and New Jerseyans six weeks (18). These policies are by no means limited to blue states. However, solidly Democratic states tend to favor mandatory leave largely funded through pooled payroll taxes, while many Republican-controlled states, such as Texas, Arkansas, and Tennessee, have voluntary systems that permit the sale of paid family leave insurance (19). 

Still, just 14 percent of private sector workers in the U.S. have access to paid leave through their employers. The Federal Maternity Leave Act (FMLA) established the federal standard of 12 weeks of leave, including job protection, in 1993, and it only applies to companies with 50 or more workers. Only two-thirds of the American workforce is eligible for leave under FMLA, and low-wage workers are less likely to be covered (20).

In contrast, subsidizing mothers so that they can better attend to their own health and the health of their children after giving birth is the norm in the Nordic countries, where parental leave benefits are extremely generous. In Sweden, parents share 480 total days of paid leave per child and are able to transfer the days between them, while 90 days are set aside for each that cannot be transferred (11). In Denmark, parents get 52 weeks (12). In Norway, they receive a total of 36 months, between a shareable 12 months after the birth and one year for each parent immediately after; the benefits even extend to adoptive and foster parents (13). Other European countries offer subsidies in a different form, including a cash payment of €274 per week for 26 weeks in Ireland (14).

These policies reflect a culture of supporting families that yields benefits, whether through the immediate impacts on maternal health and poverty reduction or the later returns in educational outcomes and productivity. Sweden’s family allowance specifically redistributes money from families without children to families with children, setting aside 120 euros per month per child up to 16 years old (15). This culture is the norm worldwide, with more than 120 countries providing paid maternity leave and health benefits to parents (16).

There are concerns that paid leave could have a negative impact on employment and incentivize discriminatory hiring practices against new mothers or young women. But leave up to one year has been found to increase employment shortly after childbirth and have a neutral to positive effect on wages (21). A study of California’s paid leave program found that it was associated with higher work and employment probabilities for mothers nine to 12 months after birth (22). The broader point is that other countries have been able to provide much more generous benefits than in the U.S., evidently without disaster to employers or women’s employment outcomes—a sign that solving the maternal mortality crisis is a matter not of economic or institutional constraints but, rather, of misplaced priorities. 

The improvements to child and maternal health can go far beyond just paid leave, as demonstrated by innovations in European countries. France offers cash payments to incentivize women to attend prenatal appointments, which have been shown to improve birth outcomes by giving doctors the chance to identify and address pre-existing conditions early, screen for mental health and domestic violence, and establish a trusting patient-provider relationship (23). Schemes for financing maternity care in Europe generally limit the financial burden on patients, but many women in the U.S. have to provide an up-front payment before receiving care and shell out thousands for months of services (24). This could explain why western Europe sees very high rates of compliance with recommended schedules of prenatal visitation (though the recommended number of visits varies by country, and is in some cases lower than in the U.S.), while American women, particularly women of color, receive sufficient prenatal care at much lower rates (25).

Home health visitations, where a public health nurse checks in on a home following the birth of a child, are common in northern and western European countries as part of national universal health care systems. These programs connect parents with other social services and identify childhood abuse and neglect, developmental lags, and postpartum depression in new mothers. Home visits are voluntary, free, and not income-tested (26). But only some U.S. states provide these for Medicaid beneficiaries (27). 

The disparities in maternal health outcomes in the U.S. and western Europe also trace back to factors that emerge before birth. U.S. women typically use contraceptives less and face higher unplanned pregnancy rates, and unwanted childbearing is associated with higher rates of smoking during pregnancy, less prenatal visitation, and a greater prevalence of low birth weights (28). Women in the U.S. have fewer incentives to seek early medical confirmation of pregnancy compared to western Europe, where there are plenty of social benefits attached to pregnancy that can only be attained by notifying employers, government agencies, and child care and housing authorities. Early confirmation of pregnancy accelerates access to prenatal care and lifestyle changes that improve the health of the pregnancy (29). 

But even more fundamentally, western European countries typically tackle impoverished conditions that negatively affect mothers and children more head-on than in the U.S., where social safety net programs are often means-tested, not universal. One article suggests that persistent barriers to accessing basic goods and services might be diminishing more targeted reforms eliminating obstacles to maternity care, so poor U.S. maternal health outcomes may only truly improve by addressing systemic factors that keep generations entrenched in poverty and by building a more ambitious, comprehensive social safety net (30).

In the U.S., the Affordable Care Act, enacted in 2010, made several substantial changes to health care coverage that specifically impacted pregnant individuals. The ACA barred insurers from denying coverage to individuals with pre-existing conditions, which encompasses pregnancy, and from charging women higher health care premiums than men, which was a common practice justified by the higher anticipated costs surrounding childbearing. The legislation also mandated that insurers provide free preventive services, such as certain types of cancer screening and contraceptives, and included the use of nurse midwives as a covered benefit under Medicaid. And the added eligibility of young people to stay on a parent’s plan until age 26 increased insurance coverage among young women (31). 

Medicaid is the single largest payer of maternity care in the U.S. (32). Medicaid coverage extends 60 days postpartum (33). The ACA expanded Medicaid eligibility to individuals earning up to 138 percent of the federal poverty level, though the adoption of the expansion was ultimately left up to each state, with 41 to date choosing to expand (34). Researchers, comparing states that expanded Medicaid with those that did not between 2006 and 2017, have explicitly linked the expansion to lower maternal mortality rates (35). With 65 percent of Black women relying on Medicaid, compared to 42 percent of mothers overall, bolstering this program could prove key to shrinking racial disparities in maternal health outcomes (36). 

The ACA Medicaid expansion was not a panacea. Insurance transitions before and after childbirth continue to harm the continuity of care women receive; one study found that over half of women with Medicaid or Children’s Health Insurance Program (CHIP) coverage at the time of delivery lost coverage in the next six months (37). In 2022, 10 percent of 19- to 64-year-old women in the U.S. were uninsured, with rates twice as high among American Indian/Alaska Native and Hispanic women (38). In states that have elected to forego the Medicaid expansion, largely concentrated in the South, hundreds of thousands of women fall into the “coverage gap,” with incomes just above the Medicaid cutoff (39). The 2021 American Rescue Plan implemented further financial incentives for these holdout states and created a new option to provide insurance coverage 12 months postpartum, which most states have adopted (40).

Other, more precise policy interventions are available to tackle maternal mortality. Telehealth could expand access to prenatal care, and better surveillance and data reporting would give a better understanding of the vastness of the crisis. (It wasn’t until 2003 that a checkbox for “pregnancy” was added to the standard death certificate in the U.S. (41).) The Data Mapping to Save Moms’ Lives Act, signed into law in 2023, combined both of these approaches, calling for the FCC and CDC to include maternal health data in their Mapping Broadband Health in America platform to identify where higher rates of maternal mortality coincide with a lack of broadband services—places where access to telehealth is most crucial (42). More diffuse solutions could come in the form of preventive care that tackles the chronic conditions associated with a greater risk of complications before and after pregnancy, such as hypertension, diabetes, and obesity, and consistent care across hospitals, which necessarily involves tackling the biases Black women face from doctors that dismiss their pain and concerns, sometimes to a point of fatality (43). 

Screening during the prenatal period is essential in tackling the leading underlying cause of maternal deaths: mental health challenges. Over the past decade, nearly nine percent of females of childbearing age who died by suicide were pregnant or recently postpartum, a shocking statistic that could be directly addressed by screening (44). Among populations of low-income, largely single women, the prevalence of domestic violence can be as high as 50 percent, and pregnant and postpartum women are at a 35 percent higher risk of homicide than their counterparts, a number multiplied seven times for Black women compared to white women (45). Because pregnancy and the first year postpartum are a time when many women are coming into increased contact with the health care system, this period is a good opportunity to screen for suicide risk, depression, and substance use disorder, as well as domestic violence. And suicide and homicide are major enough concerns as underlying causes of maternal mortality that addressing gun violence is another prong to the solution of this crisis.

The maternal mortality crisis is best understood as it affects Black women, a group whose abhorrent maternal health outcomes were attributed to systemic racism and sexism in medical systems in a recent United Nations analysis (46). Not only are Black women more likely to face denial of services and abuse in health care settings, but their biological age can be up to 10 years older than that of their white counterparts because of the chronic stressors of racism and socioeconomic hardship, which increases risk of maternal death (47). And this extends to western or northern Europe, whose countries should be viewed as a model, but not a perfect one; in the U.K., which has universal health care and up to 50 weeks of shared parental leave for new parents, maternal deaths were still five times more common among Black women than white women before the pandemic (48).

It is important to note that maternal mortality rates in wealthy industrialized nations are still markedly better than those in the developing world. While the U.S. experienced 21 maternal deaths per 100,000 live births in 2020, rates in some sub-Saharan African countries reached beyond 1,000 deaths per 100,000 live births (49). However, this does not mean that the U.S.’s maternal health crisis is trivial, especially considering that deaths are just one maternal health metric and the U.S. maintains a poor performance compared to other high-income countries. 

The wide swath of interventions available to tackle America’s maternal mortality crisis reveals that the grim statistics are not a matter of marginal detail in American policy-making but a symptom of a weak social safety net and an inherently unequal society stratified along lines of class, gender, and race. The obstacle to implementing policy solutions is not some insurmountable institutional barrier, nor an absence of inspiration, nor a lack of resources. Broadly, it is a matter of priorities and a choice to disregard the needs of mothers, children, and families. Our maternal mortality crisis is solvable with concrete, identifiable, already-implemented-elsewhere policy solutions. But to find the will to enact them, we must reexamine our priorities and our vision for who this country should value. 

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Photo by Vyacheslav Argenberg via Wikimedia Commons under Attribution 4.0 International license, https://commons.wikimedia.org/wiki/File:Mother_and_newborn_baby,_Moscow,_Russia.jpg

Works Cited

(1) McGough, Matthew, Imani Telesford, Shameek Rakshit, Emma Wager, Krutika Amin, and Cynthia Cox. 2023. “How Does Health Spending in the U.S. Compare to Other Countries?” Peterson-KFF Health System Tracker. February 9, 2023. https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#GDP%20per%20capita%20and%20health%20consumption%20spending%20per%20capita.; “What Explains the United States’ Dismal Maternal Mortality Rates? | Wilson Center.” n.d. http://Www.wilsoncenter.org. https://www.wilsoncenter.org/event/what-explains-the-united-states-dismal-maternal-mortality-rates#:~:text=More%20women%20are%20having%20children.

(2) Fleszar, Laura G., Allison S. Bryant, Catherine O. Johnson, Brigette F. Blacker, Aleksandr Aravkin, Mathew Baumann, Laura Dwyer-Lindgren, et al. 2023. “Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States.” JAMA 330 (1): 52–61. https://doi.org/10.1001/jama.2023.9043.

(3) Hoyert, Donna. 2023. “Maternal Mortality Rates in the United States, 2021.” http://www.cdc.gov. Centers for Disease Control and Prevention. March 16, 2023. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm#:~:text=In%202021%2C%20the%20maternal%20mortality.

(4) ‌‌Katella, Kathy. 2023. “Maternal Mortality Is on the Rise: 8 Things to Know.” Yale Medicine. May 22, 2023. https://www.yalemedicine.org/news/maternal-mortality-on-the-rise.

‌Tu, Lucy. 2023. “Why Maternal Mortality Rates Are Getting Worse across the U.S.” Scientific American. July 25, 2023. https://www.scientificamerican.com/article/why-maternal-mortality-rates-are-getting-worse-across-the-u-s/.

(5) Ibid.

(6) “Four in 5 Pregnancy-Related Deaths in the U.S. Are Preventable.” Centers for Disease Control and Prevention. September 19, 2022. https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html.

(7) Katella, “Maternal Mortality Is on the Rise: 8 Things to Know.” 

(8) Katella, “Maternal Mortality Is on the Rise: 8 Things to Know.”

(9) “Maternal Mortality Rates and Statistics.” n.d. UNICEF DATA. https://data.unicef.org/topic/maternal-health/maternal-mortality/#data.

(10) ‌Staehelin, Katharina, Paola Coda Bertea, and Elisabeth Zemp Stutz. 2007. “Length of Maternity Leave and Health of Mother and Child – a Review.” International Journal of Public Health 52 (4): 202–9. https://doi.org/10.1007/s00038-007-5122-1.; McGovern. 2017. “Paid Maternity Leave in the United States: Associations with Maternal and Infant Health.” Maternal and Child Health Journal 22 (2): 216–25. https://doi.org/10.1007/s10995-017-2393-x.; Jou, Judy, Katy B. Kozhimannil, Jean M. Abraham, Lynn A. Blewett, and Patricia M. 

‌Chatterji, Pinka, and Sara Markowitz. 2005. “Does the Length of Maternity Leave Affect Maternal Health?” Southern Economic Journal 72 (1): 16–41. https://doi.org/10.1002/j.2325-8012.2005.tb00686.x.

(11) “Learnings from Scandinavia on How Shared Parental Leave Can Encourage Gender Equality.” Reba.global. September 1, 2020. https://reba.global/resource/learnings-from-scandinavia-on-how-shared-parental-leave-can-encourage-gender-equality.html.

(12) Ibid.

(13) ‌“An In-Depth Look at Norway’s Progressive Parental Leave Policies – Global People Strategist.” 2023. Globalpeoplestrategist.com. July 25, 2023. https://globalpeoplestrategist.com/parental-leave-in-norway/.

(14) ‌“Maternity Benefit.” 2018. http://www.gov.ie. May 25, 2018. https://www.gov.ie/en/service/apply-for-maternity-benefit/#:~:text=If%20you%20are%20eligible%20for.

(15) Tools, Baseline. n.d. “Expanding Choices Gender-Responsive Family Policies for the Private Sector in Western Balkans and Moldova Public Policies Best Practices: Examples from Sweden, Estonia, and Slovenia.” https://eeca.unfpa.org/sites/default/files/pub-pdf/public_policies_best_practices_-_sweden_estonia_and_slovenia_.pdf.

(16) “More than 120 Nations Provide Paid Maternity Leave.” International Labour Organization. February 16, 1998. https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_008009/lang–en/index.htm.

(17) “More than 120 Nations Provide Paid Maternity Leave.”

(18) ‌“State Paid Family Leave Laws across the U.S. | Bipartisan Policy Center.” 2022. Bipartisanpolicy.org. January 13, 2022. https://bipartisanpolicy.org/explainer/state-paid-family-leave-laws-across-the-u-s/.

(19) Ibid.

(20) Rosin-Slater, Maya. “Easing the Burden: Why Paid Family Leave Policies Are Gaining Steam.” Stanford Institute for Economic Policy Research (SIEPR). February 2018. https://siepr.stanford.edu/publications/policy-brief/easing-burden-why-paid-family-leave-policies-are-gaining-steam.

(21) Rosin-Slater. “Easing the Burden.”

(22) Ibid.

(23) ‌Miller, C. Arden. 1993. “Maternal and Infant Care: Comparisons between Western Europe and the United States.” International Journal of Health Services 23 (4): 655–64. https://doi.org/10.2190/rr4g-ntb1-l229-fvhg.

(24) Miller. “Maternal and Infant Care.”

(25) Ibid.

(26) Kamerman, Sheila B, and Alfred J Kahn. 1993. “Home Health Visiting in Europe.” The Future of Children 3 (3): 39–52. https://doi.org/10.2307/1602542.

(27) Tikkanen, Roosa, Munira Gunja, Molly Fitzgerald, and Laurie Zephyrin. 2020. “Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries.” The Commonwealth Fund. The Commonwealth Fund. November 18, 2020. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries.

(28) Miller. “Maternal and Infant Care.”

(29) Ibid. 

(30) Miller. “Maternal and Infant Care.”

(31) Tikkanen. “Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries.”

(32) “States Act on Postpartum Medicaid Coverage.” n.d. National Conference of State Legislatures. Accessed February 14, 2024. https://www.ncsl.org/state-legislatures-news/details/states-act-on-postpartum-medicaid-coverage.

(33) Ibid.

(34) ‌“Status of State Medicaid Expansion Decisions: Interactive Map.” The Henry J. Kaiser Family Foundation. December 1, 2023. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.

(35) Eliason, Erica L. 2020. “Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality.” Women’s Health Issues 30 (3). https://doi.org/10.1016/j.whi.2020.01.005.

(36) Winny, Annalies. 2023. “Solving the Black Maternal Health Crisis | Johns Hopkins | Bloomberg School of Public Health.” Publichealth.jhu.edu. May 12, 2023. https://publichealth.jhu.edu/2023/solving-the-black-maternal-health-crisis.

(3‌7) Daw, Jamie R., Laura A. Hatfield, Katherine Swartz, and Benjamin D. Sommers. 2017. “Women in the United States Experience High Rates of Coverage ‘Churn’ in Months before and after Childbirth.” Health Affairs 36 (4): 598–606. https://doi.org/10.1377/hlthaff.2016.1241.

Kaiser Family Foundation. 2021. 

(38) “Women’s Health Insurance Coverage.” KFF. January 12, 2021. https://www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage/.

‌(39) Solomon, Judith. 2021. “Closing the Coverage Gap Would Improve Black Maternal Health.” Center on Budget and Policy Priorities. July 26, 2021. https://www.cbpp.org/research/health/closing-the-coverage-gap-would-improve-black-maternal-health.

(40) Hasan, Anoosha. 2022. “State Efforts to Extend Medicaid Postpartum Coverage.” NASHP. July 8, 2022. https://nashp.org/state-tracker/view-each-states-efforts-to-extend-medicaid-postpartum-coverage/#:~:text=The%20American%20Rescue%20Plan%20Act.

Katch, Hanna, Anna Bailey, and Judith Solomon. 2021. “American Rescue Plan Act Strengthens Medicaid, Better Equips States to Combat the Pandemic.” Center on Budget and Policy Priorities. March 22, 2021. https://www.cbpp.org/research/health/american-rescue-plan-act-strengthens-medicaid-better-equips-states-to-combat-the.

(41) McGough, Matthew. “How Does Health Spending in the U.S. Compare to Other Countries?”

(42) ‌“New Law Provides Data-Mapping Tool to Lower Maternal Mortality.” n.d. American Medical Association. https://www.ama-assn.org/delivering-care/population-care/new-law-provides-data-mapping-tool-lower-maternal-mortality.

(43) Katella, “Maternal Mortality Is on the Rise: 8 Things to Know.” 

(44) Akkas, Farzana. “Suicides during and Shortly after Pregnancy Are an Urgent Concern.” n.d. pew.org. https://www.pewtrusts.org/en/research-and-analysis/articles/2022/10/06/suicides-during-and-shortly-after-pregnancy-are-an-urgent-concern.

(45) ‌Alhusen, Jeanne L., Ellen Ray, Phyllis Sharps, and Linda Bullock. 2015. “Intimate Partner Violence during Pregnancy: Maternal and Neonatal Outcomes.” Journal of Women’s Health 24 (1): 100–106. https://doi.org/10.1089/jwh.2014.4872.; Wallace, Maeve E. 2022. “Trends in Pregnancy-Associated Homicide, United States, 2020.” American Journal of Public Health 112 (9): 1333–36. https://doi.org/10.2105/ajph.2022.306937.; Campbell, Jacquelyn, Sabrina Matoff-Stepp, Martha L. Velez, Helen Hunter Cox, and Kathryn Laughon. 2021. “Pregnancy-Associated Deaths from Homicide, Suicide, and Drug Overdose: Review of Research and the Intersection with Intimate Partner Violence.” Journal of Women’s Health 30 (2): 236–44. https://doi.org/10.1089/jwh.2020.8875.

(46) ‌Baumgaertner, Emily, and Farnaz Fassihi. 2023. “Racism and Sexism Underlie Higher Maternal Death Rates for Black Women, U.N. Says.” The New York Times, July 12, 2023, sec. Health. https://www.nytimes.com/2023/07/12/health/maternal-deaths-americas-un.html.

(47) Katella, “Maternal Mortality Is on the Rise: 8 Things to Know.”

(48) “Learnings from Scandinavia on How Shared Parental Leave Can Encourage Gender Equality.”; Tikkanen. “Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries.”

(49) “Maternal Mortality Rates and Statistics.”