By Rebecca B. Perkins, MD, MSc
Professor, Department of Obstetrics and Gynecology, Boston University School of Medicine/ Boston Medical Center, Boston
This article compares U.S. maternal mortality to other nations and explores reasons why mortality in the United States is four to 10 times higher than in peer countries.
Gunja MZ, Gumas ED, Masitha R, Zephyrin LC. Insights into the U.S. maternal mortality crisis: An international comparison. Published June 4, 2024. https://www.commonwealthfund.org/publications/issue-briefs/2024/jun/insights-us-maternal-mortality-crisis-international-comparison
This article by The Commonwealth Fund describes the state of maternal mortality in the United States compared to other high-income nations.1 The United States compares extremely poorly to its peers, with maternal mortality of 22.3 per 100,000 births compared to approximately 14 per 100,000 births in New Zealand and Chile (the countries with the next highest mortality), eight per 100,000 births in Canada, 5.5 per 100,000 births in the United Kingdom, and one per 100,000 births in Switzerland. Pronounced racial/ethnic disparities were noted: The rate of maternal mortality among Black women in the United States was 49.5 per 100,000 births, compared with 19 per 100,000 births for whites, 17 per 100,000 births for Hispanics, and 13 per 100,000 births for Asians.
Two-thirds of deaths occurred in the postpartum period: 12% within the first week, 23% between one and six weeks, and 30% between seven weeks and one year. When examining factors potentially related to excess mortality in the United States, the authors noted that the United States has relatively fewer midwives and OB/GYNs than most other high-income countries. Per 1,000 live births, the United States has only 16 providers (12 OB/GYNs and four midwives), compared to 55 in Switzerland (22 OB/GYNs and 33 midwives), 77 in Australia (eight OB/GYNs and 70 midwives), and 61 in the United Kingdom (13 OB/GYNs and 48 midwives). Only Canada had similarly fewer providers (14 total; nine OB/GYNs and five midwives).
The authors noted that, currently in the United States, more than 7 million women live in counties without obstetric care. This is expected to worsen in the future. Perhaps related to the shortage of obstetric care providers, the United States is the only country without national insurance coverage of any home postpartum visits. All other countries guarantee at least one home visit within the first week postpartum; most of these visits are performed by midwives.
The United States also is the only country without universal insurance coverage of maternity and postpartum care. The authors also compared maternal leave policies by country. Only the United States has no federally mandated maternal leave; all other countries have between 14 weeks (Switzerland) and 86 weeks (Norway).
COMMENTARY
Most cases of maternal death are preventable with high-quality prenatal, labor and delivery, and postpartum care. The maternal mortality rate in the United States is nearly twice as high as in the next peer country; approximately 20 times that of Norway, Switzerland, and Sweden; and nearly 10 times that of the Netherlands, Japan, Australia, and Germany. In addition, the maternal mortality rate for Black women in the United States is double the U.S. national average.
Several issues may contribute to maternal mortality rates, including lack of OB/GYNs and midwives and the absence of support for maternal leave and postpartum care. However, these metrics do not give a complete picture, since they vary widely between countries, including those with low maternal mortality. Maternal mortality is lowest (zero) in Norway, which has the longest federally mandated maternal leave policy (86 weeks), at least three weeks of postpartum visits, and 66 obstetric care providers per 1,000 births. However, Switzerland, with the second lowest mortality, has only 14 mandated weeks of leave, although it does have up to 16 home visits postpartum and 55 obstetric care providers per 1,000 births.
One could argue that the dearth of obstetric care providers plays a critical role; the United States has 16 per 1,000 births compared to more than 50 for most peer countries. However, Canada has fewer (13 per 1,000 births) but a nearly 40% lower maternal mortality rate.
Concerningly, maternal mortality in the United States has increased over the past two decades while mortality in peer countries has been declining. Key causes of maternal mortality include cardiovascular conditions, including cardiomyopathy, obstetric hemorrhage, and other medical conditions, as well as death from violence, overdose, and self-harm.2 The aging of the birthing population also contributes to increased mortality, as mothers aged 35 years or older have twice the mortality rate of those aged younger than 35 years.3 However, the trend of delaying childbirth is common to most high-income countries, therefore this cannot be considered an explanation of the U.S. mortality rate compared to its peers.
Since most deaths occur in the postpartum period and the United States is the only peer nation without standardized postpartum care, this seems a clear area in need of improvement. Postpartum care, particularly home visits, are attended in most countries by midwives. The United States has fewer midwives per live births than all but one peer country.
Increasing the number of trained midwives and normalizing postpartum home visits could be one concrete solution to begin addressing excess maternal mortality. However, because of the fractionated nature of the U.S. healthcare system, solutions to address excess maternal mortality may be more successful if data are incorporated at the state and county level, as well as by insurance status, to determine the effects of policy, healthcare access, and environmental factors such as violence and substance use.
REFERENCES
- Gunja MZ, Gumas ED, Masitha R, Zephyrin LC. Insights into the U.S. maternal mortality crisis: An international comparison. Published June 4, 2024. https://www.commonwealthfund.org/publications/issue-briefs/2024/jun/insights-us-maternal-mortality-crisis-international-comparison
- Collier ARY, Molina RL. Maternal mortality in the United States: Updates on trends, causes, and solutions. Neoreviews 2019;20:e561-e574.
- MacDorman MF, Thoma M, Declercq E, Howell EA. Causes contributing to the excess maternal mortality risk for women 35 and over, United States, 2016-2017. PLoS One 2021;16:e0253920.
