Authors: Rose L. Molina, M.D., M.P.H. et al
N Engl J Med 2017; 377:1705-1707
Recently, the media have devoted increasing attention to maternal mortality in the United States, as in a ProPublica and National Public Radio article describing the devastating death of a nurse shortly after her first child was born. These reports have heightened public awareness of grim realities that have been on obstetricians’ minds for years: that the rate of maternal death in the United States is higher than rates in most other high-income countries; that this rate has been rising over the past two decades; and that there are profound racial, ethnic, and socioeconomic inequities in women’s risk of dying during or soon after pregnancy. Despite this increased awareness, issues surrounding maternal mortality have been notably absent from most health care policy debates. Although congressional Republicans have narrowly failed to repeal the Affordable Care Act (ACA) so far, efforts to weaken the law’s provisions continue and could have important implications for maternal health.
Maternal mortality is usually defined as the death of a woman during pregnancy or within 42 days after delivery when the cause is directly or indirectly related to pregnancy. The maternal mortality ratio in the United States (28 deaths per 100,000 live births in 2013) is low compared with the average ratio in low-income regions (230 deaths per 100,000 live births). However, it has more than doubled since 1990 and is higher than the maternal mortality ratio in most high-income countries; Canada, for example, had 11 maternal deaths per 100,000 live births in 2013. Furthermore, most high-income countries have seen maternal mortality decrease in recent years. High maternal mortality in the United States as compared with other high-income countries and the continuing upward trend highlight gaps in our care for reproductive-age women that are particularly worrisome in light of some lawmakers’ recent efforts to reduce access to health insurance and reproductive health care.
To understand how current and future health care legislation may affect maternal outcomes, it is critical to examine what we know — and don’t know — about factors contributing to maternal mortality in the United States. It is important to note that the magnitude of the increase in maternal mortality is controversial. Improvements in data collection (for example, the addition of a pregnancy question and checkbox on death certificates and updated International Classification of Diseases diagnostic codes) have increased detection of maternal deaths and may have led to overreporting in some cases. However, although measurement changes probably explain some of the reported increase, we believe there is still cause for concern, for several reasons. First, even when only the deaths that are least likely to be subject to overreporting are considered, maternal mortality in the United States remains higher than that in other high-income countries. Second, even after new reporting methods were adopted, maternal mortality has continued to rise in some states, particularly among women over 40 years of age. Finally, severe pregnancy-related morbidity has also markedly increased.
The most important cause of these findings may be the changing demographic and clinical characteristics of women who become pregnant, specifically rising maternal age at first birth and the increasing prevalence of obesity, hypertension, and diabetes in young women. As a result of these changes, the contribution of chronic medical conditions to maternal morbidity and mortality has increased, and cardiovascular disease is now a leading cause of maternal death. Exacerbating these factors are the increase in the rate of cesarean delivery over the past two decades and variation in the quality of hospital-based intrapartum care.
As deeply troubling as the overall rise in maternal mortality are the inequities in maternal outcomes in the United States. Low-income women and women from rural areas are more likely to die during pregnancy, and a non-Hispanic black woman is almost three times as likely to die during or shortly after childbirth as a white woman (56.3 versus 20.3 deaths per 100,000 live births in one analysis of 27 states and Washington, D.C.). The reasons for these disparities are poorly understood and undoubtedly complex; they include social determinants of health and biases in care delivery. But such inequities signal that we can do far better for the most disadvantaged women.
The effect of insurance status before, during, and after pregnancy on maternal outcomes is remarkably understudied. Early prenatal care, however, can play an important role in the detection and surveillance of pregnancy complications and chronic disease. The ACA improved access to maternity care for many women by expanding opportunities to obtain health insurance and mandating coverage of essential health benefits. Much of this progress would have been undone by Republican proposals that would have reduced insurance coverage and allowed states to waive maternity coverage requirements. Although these proposals failed, the ACA faces ongoing challenges, including efforts by the Trump administration to eliminate subsidies to insurance companies that help reduce cost sharing for low-income people.
Proposals to reduce Medicaid coverage would particularly affect pregnant women — especially those who are at highest risk for adverse outcomes. Medicaid covers prenatal care, care during childbirth, and postpartum care for nearly half the women who give birth in the United States. Many uninsured women become eligible for Medicaid during pregnancy, since current federal regulations require Medicaid to cover pregnant women with incomes up to 133% of the federal poverty level. Republican proposals to cut federal Medicaid spending by 35% by 2030 could certainly have jeopardized eligibility for many pregnant women.
In addition, restricting Medicaid eligibility for nonpregnant women would worsen pregnancy-related churning (disruptions in health insurance coverage), since many new mothers who were eligible for Medicaid only because they were pregnant would lose coverage 60 days after delivery. The growing burden of chronic diseases and their sequelae in pregnancy highlight the link between prepregnancy health and pregnancy outcomes and underscore the need for coordinated primary, obstetrical, and specialty care. Increasing insurance transitions could be harmful for women with chronic diseases and those with pregnancy complications, many of which have implications for subsequent pregnancies and long-term health. The ACA expanded privately insured women’s access to primary and preventive health services, including chronic disease screening and management. Although we don’t yet know how increased access to these services has affected maternal health, undermining primary care for reproductive-age women could be particularly problematic given their growing burden of chronic disease and its implications for pregnancy.
The ACA also required most insurance plans to cover contraception without cost sharing. Access to effective contraception reduces the risk of unintended pregnancy (which is associated with adverse outcomes) and improves women’s ability to manage conditions such as diabetes before conception. The Republican proposals would have cut funding to Planned Parenthood and allowed states to reduce contraceptive coverage. The current administration is now weakening the ACA’s contraceptive coverage requirements by allowing more employers to claim exemptions on religious or moral grounds. In addition, the Department of Health and Human Services has reduced funding for adolescent pregnancy prevention programs, an ominous sign of the deprioritization of evidence-based reproductive health policy.
More research is needed to explore the reasons for the United States’ suboptimal and inequitable maternal outcomes and to clarify the effect of insurance coverage before, during, and after pregnancy. The ACA is not perfect: there are still gaps in insurance coverage and care for pregnant and postpartum women, including for undocumented immigrant women and women who become eligible for Medicaid only because of pregnancy. Furthermore, expanding insurance coverage won’t eliminate all inequities in maternal outcomes; comprehensive approaches to poverty and discrimination will also be required. Recent Republican proposals would indisputably have been a step backward. However, other efforts to erode access to primary and reproductive health care are ongoing and will worsen inequities in maternal health. Health in pregnancy affects the long-term well-being of women and their families, and maternal outcomes are a key indicator of a health care system’s effectiveness. Improving maternal outcomes in the United States will require increased study and investment and renewed focus in health care policies.
From the Division of Global and Community Health, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center (R.L.M.), and the Women’s Health Policy and Advocacy Program, Connors Center for Women’s Health and Gender Biology and the Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital (L.E.P.) — both in Boston.