US has the highest rate of maternal deaths among high-income nations. Norway has zero

By Jacqueline Howard, CNN

(CNN) — The United States continues to have a higher rate of women dying in pregnancy, childbirth or postpartum compared with all other high-income nations, even despite recent declines in the US maternal death rate, a new report shows.

There were about 22 maternal deaths for every 100,000 live births in the United States in 2022, the most recent year for which data was available. That rate was more than double, sometimes triple, those seen in most other high-income countries that year, according to the report released Tuesday by the Commonwealth Fund, a private foundation focused on health care-related issues.

And the rate of maternal deaths among Black women in the United States remains even higher, at nearly 50 deaths per 100,000 live births, the new report shows.

Meanwhile, half of the high-income nations in the new report had fewer than 5 maternal deaths per 100,000 live births, and one country recorded zero maternal deaths: Norway.

Unlike Norway and some other peer nations, “the US has a maternal care workforce shortage problem, which is only supposed to get worse,” said Munira Gunja, lead author of the report and senior researcher at the International Program in Health Policy and Practice Innovations at the Commonwealth Fund.

In the United States, she noted, there is limited access to midwives, who provide support to a patient from the prenatal period through postpartum.

“We have an under-supply of midwives, and midwives are underutilized, whereas in most other countries, midwives greatly outnumber ob-gyns. They’re part of their health care systems. Midwifery care is not integrated enough into our system,” Gunja said.

In the United States, “there are several barriers to getting midwifery care, and other countries just don’t have that. They’re able to make sure that every woman has access to care, whether it be in some cases an ob-gyn and in most cases a midwife,” she said. “In the US, we’re the only country in this analysis without a universal health system. Nearly 8 million women of reproductive age are without health insurance.”

In Norway, which has universal health coverage, prenatal care is accessible free of charge, and high-risk pregnancies are effectively identified.

US ‘is still such an outlier’

Researchers at the Commonwealth Fund analyzed maternal mortality data from 14 high-income countries: Australia, Canada, Chile, France, Germany, Japan, Korea, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK and the US.

The data, which came from the US Centers for Disease Control and Prevention and the Organisation for Economic Co-operation and Development, showed that the top three nations with the highest maternal death rate were the United States, Chile and New Zealand. Chile and New Zealand each recorded about 14 deaths per 100,000 live births.

The three nations with the lowest maternal death rate were Norway with zero, Switzerland with a rate of 1 death per 100,000 live births and Sweden with about 3 deaths per 100,000 live births.

During the Covid-19 pandemic, maternal death rates increased in Australia, Japan, the Netherlands and the US, according to the report, which notes that the increase may have been due to a rise in Covid-related infections, complications worsened by the virus or delays or decreased access to care at the time. More recently, maternal death rates have started to decline in Chile, Norway and the US.

The US maternal mortality rate fell from 32.9 maternal deaths per 100,000 live births in 2021 to 22.3 per 100,000 in 2022, according to data from the CDC.

“It is encouraging to see fewer maternal deaths in the U.S. in 2022, however the U.S. is still such an outlier, and the racial disparities are profoundly disturbing,” Dr. Laurie Zephyrin, senior vice president for advancing health equity at the Commonwealth Fund, said in a news release.

“It is time to center equity by diversifying the workforce and addressing head on the racial inequities in health care quality and access,” she said. “Now is the time to prioritize what we know is already working well in other countries: expanded health insurance coverage, stronger workforce and support systems, and paid maternity leave.”

The new report points to the US health care system, policy differences and maternity care deserts – where residents have limited or no access to maternity health care – as among the factors driving the high US maternal mortality rate.

The US and Canada have the lowest overall supply of midwives and ob-gyns to care for pregnant and postpartum mothers, with only 16 and 13 providers per 1,000 live births respectively, according to the new report. In Canada, the maternal death rate is estimated to be about 8 deaths per 100,000 live births.

More than 2.2 million US women of childbearing age – 15 to 44 – live in maternity care deserts, a report by the nonprofit March of Dimes found in 2022. And last year, a separate analysis found that hospitals in a 10th of US counties have lost their childbirth units in the past five years.

Midwives “could help address maternity workforce shortages in the U.S., where nearly half of counties lack a single ob-gyn. An estimated 8,000 more ob-gyns are needed to meet demand — a number that may rise to 22,000 by 2050,” according to the new report.

Additionally, nearly two-thirds of maternal deaths occur in the postpartum period, up to 42 days after giving birth, and US women are least likely to have postpartum home visits, according to the new report. All the countries in the report, apart from the US, guarantee at least one home visit within a week postpartum. On the state level, only some Medicaid programs in the US cover these visits.

“The World Health Organization recommends at least four health contacts in the first six weeks following birth, yet two of five U.S. women — more often than not younger, low-income, and uninsured — skip their one postpartum check-up,” according to the new report.

In the first week postpartum, the most common contributors to maternal deaths were severe bleeding, high blood pressure and infection, while cardiomyopathy – a heart muscle disease – was the leading cause of deaths later in the postpartum period, according to the new report.

The US also stands alone as the only high-income country where there is no federally mandated paid leave policy for postpartum mothers, according to the new report. US women are less likely to have guaranteed paid leave compared with women in other high-income nations, where at least 14 weeks of paid leave from work is mandated.

“Maternal deaths are a preventable problem, and this problem can be solved. A lot of countries have been able to figure out ways to make it so that all women are in safe hands when it comes to having a baby and after giving birth. We need to extend that to women in the US as well,” Gunja said. “We know most deaths are during the postpartum period – so making sure we have federally mandated paid leave, making sure we make it easy for women to get postpartum care, which means having home visits and not making women go to the doctor.”

A need for maternal health equity

Racial disparities in maternal death rates persist not only in the United States but in other parts of the world where some women have less access to postpartum support, according to the new report.

“In the United Kingdom, for example, Black women are four times more likely to die than white women are. In Australia, Aboriginal women are about twice as likely as non-Aboriginal women to die from maternal complications,” the researchers wrote.

“Our findings suggest that an undersupply of maternity providers, especially midwives, and lack of access to comprehensive postpartum support, including maternity care coverage and mandated paid maternity leave, are contributing factors,” they wrote. “Because both these factors disproportionately affect women of color, centering equity in any future policy changes will be a key to addressing the crisis.”

The Commonwealth Fund’s report “highlights the need to have enhanced maternal health care and maternal health equity in the US,” said Dr. Tochi Iroku-Malize, a family physician in Long Island, New York, and board chair of the American Academy of Family Physicians, who was not involved in the new report.

“For us in family medicine, we know that we do play a crucial role in providing the obstetric care throughout pregnancy and the postpartum period, which is needed, and maternal health care cannot stop after a patient gives birth,” she said, calling on her US colleagues to watch out for maternal health complications – such as inflammation of the heart muscle or mental health conditions – in their postpartum patients, as the majority of maternal deaths occur during that time.

“A postpartum patient’s body is still going through immense physical, hormonal and emotional changes that you really cannot overlook,” she said. “And our training as family physicians, it helps us to screen and address the full spectrum of physical, emotional and social needs during pregnancy and the postpartum period.”

Adding more birth workers to the maternal health care workforce remains an important component and major need, said Dr. Michelle Owens, an obstetrician-gynecologist in Jackson, Mississippi, who was not involved in the new report.

“But we also need to ensure we have systems in place to facilitate escalation of care when needed so that each birthing person has access to the appropriate care in a timely manner. Timely diagnosis and treatment of complications are essential to ensuring the overall health and safety of our mothers and their children,” Owens, a member of the American College of Obstetricians and Gynecologists, wrote in an email.

“ACOG recommends that expectant mothers engage as active partners in their care, attend their scheduled appointments during and after pregnancy, and consider pregnancy planning in order to optimize pregnancy outcomes,” she added. “Finally, patients need to feel empowered to voice their concerns to their healthcare providers, and for their providers to listen to their concerns and work collaboratively with patients for resolution of their concerns.”

The report joins several other studies that have highlighted the United States’ high maternal mortality rate, said Dr. Christopher Zahn, interim CEO and chief of clinical practice and health equity and quality for ACOG.

“Despite capturing different time periods and using different methodologies, what we can confidently take away from these reports is that the number of maternal deaths in this country is still unacceptably high,” Zahn, who was not involved in the Commonwealth Fund’s latest report, wrote in an email.

“In 2016, the public was surprised to learn from a widely publicized study in The Lancet that the United States had the highest rate of maternal mortality compared to other developed countries. The Commonwealth Fund report shows that nearly a decade later this is still the case. This is obviously disheartening news, but we also must acknowledge that, despite the collective effort put toward improving maternal health outcomes, we have faced tremendous setbacks,” Zahn said, referring to disruptions in access to care due to the Covid-19 pandemic, the overturning of Roe v. Wade and ongoing health inequities resulting in racial and ethnic disparities.

“The areas of weakness in our policies and systems have been longstanding pain points and are clearly all contributors to the poor maternal health outcomes we are experiencing today,” he added. “ACOG will continue its work in improving quality and safety in maternal health care, educating its members on the necessity of eliminating racism and bias in medicine and advocating for policies that are supportive of both clinicians and patients in an effort to improve outcomes.”

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