By Laurie Zephyrin, So O’Neil and Kara Zivin
In conversations about the woeful state of maternal care in the United States — pregnancy-related death is three times more likely here than it is in 10 similar countries — pregnancy-related complications often take a back seat. They shouldn’t.
Pregnancy and childbirth are generally safe, wonderful, and even transformative experiences. But they can turn dangerous, especially for people of color.
Each year in the U.S., at least 60,000 mothers experience complications from pregnancy and delivery — also known as severe maternal morbidity — that can seriously affect their health. These include diabetes, high blood pressure, difficult-to-control bleeding, heart and blood vessel problems, and severe depression. Many who experience maternal morbidity never fully recover and live the rest of their lives with pain, reduced ability, trauma, and fear. Maternal morbidity also can have lasting effects on infants and children — a multigenerational burden.
Racial and ethnic health disparities are pervasive in America’s health care system; maternal morbidity is no exception. Rates of severe maternal morbidity are 3.2 times higher among Black mothers than white mothers, and 2.3 higher among American Indian and Alaska Native mothers. In fact, a Black mother with commercial health insurance is nearly three times more likely to experience severe maternal morbidity than a white mother with Medicaid coverage.
In addition to the human costs, there are serious financial costs to pregnancy-related complications. With several colleagues, we estimated their monetary costs to be at least $32.3 billion for all children born in 2019 through their fifth birthdays to account for the medical and nonmedical impacts on both mother and child. More than two-thirds of these costs affect children’s health and development.
The most expensive maternal outcome was lost productivity ($6.6 billion), which affects the U.S. workforce and economy. For children, the costliest outcomes were preterm birth ($13.7 billion), developmental disabilities ($6.5 billion), and respiratory distress syndrome ($2.2 billion), a breathing disorder that affects newborns.
As astonishing as our estimate may seem, it likely falls far short of the actual cost because of the paucity of comprehensive, relevant data collected on maternal morbidity. We could very well be talking about hundreds of billions of dollars, rivalling the cost to society of chronic diseases like diabetes or cardiovascular disease.
Timely, comprehensive care before and after pregnancy can prevent most pregnancy-related deaths and complications. But many people, especially people of color and those with public insurance, cannot readily afford or access such care.
For every maternal death in the U.S., at least 70 to 80 cases of severe maternal illness occur. Yet little has been done about it to date, because it is so poorly measured and because it is part of the legacy of racism and sexism in U.S. health care.
Unveiling the short-term and long-term personal and societal impacts of poor and inequitable maternal health care is one step toward changing them. Making a substantial change will require intentional investments that include not only expanding access to health care and improving maternal care but also addressing racism and other factors that influence health. We see three paths forward:
First, it’s important to recognize that maternal health does not begin with pregnancy and end two months after delivery, as Medicaid pregnancy-related coverage does in many states. Every person needs access to health care, not only before pregnancy but soon after it as well as in the years after delivery, when complications like postpartum depression and chronic disability can still arise. Better — and more affordable — access to health care could decrease the likelihood of developing the conditions that lead to severe maternal morbidity.
The Build Back Better Act would expand and extend Medicaid coverage for one year after giving birth, and would cover mental illness, a major contributor to maternal morbidity. And the Black Maternal Health Momnibus Act of 2021 would invest in and expand the maternal health care system and address social factors that affect maternal health, like housing, nutrition, and transportation.
Second, a more diverse maternal health workforce — both in the types of providers and in the representation of people served — is needed to increase access to comprehensive, culturally safe maternal care. The U.S. has a relatively low number of maternity care providers per capita, with obstetricians and gynecologists making up roughly two-thirds of the workforce, even though midwives and family practitioners can safely and effectively manage most low-risk pregnancies. Increasing the availability of midwifery care would expand access to maternal care and free up OB-GYNs to focus on the most complicated cases.
Third, data collection on maternal morbidity needs a drastic overhaul, starting with a comprehensive definition of what it is and determining how it should be tracked. We cannot improve what we do not measure.
Although most childbearing people have safe and healthy births, maternal morbidity continues to be all too common in the U.S., especially among historically marginalized people. These near misses must be taken seriously because they can have lifetime effects.
As a society, we must make pregnancy and childbirth in the U.S. safer for mothers and their babies.
Laurie Zephyrin is an obstetrician-gynecologist and vice president of health system equity at The Commonwealth Fund. So O’Neil is a senior researcher and director of the health philanthropy portfolio at Mathematica. Kara Zivin is a professor of psychiatry and of obstetrics and gynecology at the University of Michigan, a research career scientist at the Ann Arbor VA Center for Clinical Management Research, and a senior health researcher at Mathematica.