In their brief report, researchers assessed maternal mortality, composition of the maternal care workforce, and access to postnatal care in 10 high-income countries and compared the findings with the United States. Data from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the UK were obtained from the 2020 health statistics compiled by the Organization for Economic Cooperation and Development. US data are drawn from the CDC Pregnancy Mortality Monitoring System.

According to the World Health Organization (WHO), maternal death is defined as “the death of a woman while pregnant or within 42 days after termination of pregnancy, regardless of the duration and place of pregnancy, from any cause related to or exacerbated by pregnancy or its management but not from any cause. accidental or incidental. “

Overall pregnancy-related mortality in the United States occurs at an average rate of 17.2 deaths per 100,000 live births. The main causes of death included cardiovascular conditions, bleeding, and infections. However, in the Netherlands, Norway and New Zealand, that figure has fallen to 3 women or less per 100,000.

More than 50% of pregnancy-related deaths in the United States occur after child birth, or postpartum. Any death within the last 1 year of pregnancy due to pregnancy complications or death during pregnancy is classified as pregnancy-related death. Deaths occurring within 1 week postpartum (19% of all maternal deaths) were largely due to heavy bleeding, high blood pressure, and infection.

In terms of service providers, the United States and Canada “have the lowest supply of midwives and obstetricians-gynecologists (OB-GYN) overall – 12 and 15 providers per 1000 live births, respectively,” while all other countries have supplies that are between 2 and 2 6 times bigger.

Midwives differ from OB-GYN in that they help manage normal pregnancies, assist with childbirth, and provide care during the postpartum period. In contrast, the OB-GYN is a doctor trained to identify problems and intervene if abnormal conditions arise. The OB-GYN usually only provides care in a hospital-based setting.

The role of the midwife has been found to be comparable or preferable to doctor-led care in terms of maternal and infant outcomes and more efficient use of health care resources. WHO recommends midwives as an evidence-based approach to reducing maternal mortality.

According to the American College of Nurse Midwives, “The US maternity workforce is inverted relative to patient needs.” Although OB-GYN outnumbered midwives in the United States and Canada, in most other countries the converse is true.

“Midwives provide the majority of prenatal care and childbirth in the UK and the Netherlands – countries that are considered to have the strongest primary care systems in Europe. Dutch midwives also give birth at home, which represents 13% of all births, the highest rate among developed countries, ”the report states.

Midwifery services are not uniformly covered in private insurance programs in the United States, whereas midwifery and midwifery services are covered by universal health insurance in several other countries.

Under the Affordable Care Act (HERE), The Medicaid program is required to cover midwifery care, but “the supply of providers is often so low that beneficiaries are often unable to access these services.” State licensing laws, restrictive scope of practice laws, and regulations requiring physician supervision of midwives can all contribute to the low supply of midwives in the United States. Medicaid is also currently covering 43% of all deliveries in the United States but only extends coverage to a maximum of 60 days postpartum.

Additionally, in some states, appellate courts have ruled ending Medicaid funding to the Planned Parenthood clinic, which provides a number of health services for low-income women, incl pregnancy services like postnatal care.

Postnatal care, including home visits by midwives, also improved mental health and breastfeeding outcomes among new mothers and was associated with reduced health care costs. Some Medicaid recipients can receive this service in the United States, but all other countries included in the report warrant at least 1 visit in 1 week after birth.

Recent cross section analysis of nearly 600,000 commercially insured individuals found that the prevalence of suicidal ideation and self-harm (suicide) occurring in the year before or after birth increased substantially from 2006 to 2017.¹

In 2006, the prevalence of suicide was estimated at 0.2% per 100 individuals and increased to 0.6% per 100 individuals in 2017, while the diagnosis of suicide with comorbid depression or anxiety increased from 1.2% in 2006 to 2. 6% in 2017 (per 100 individuals for both.). During the study period, younger, non-Hispanic blacks and lower-income individuals experienced a greater increase in suicide.

“Policymakers, health planners and physicians must ensure access to universal suicide screening and appropriate treatment for pregnant and postpartum individuals and seek health systems and policy avenues to mitigate this growing public health crisis, especially for high-risk groups,” the analysis writer wrote.

In the United States, non-Hispanic black women are more than 3 times more likely to experience maternal death than white women. Non-Hispanic black women were also significantly more likely to experience severe incidence of maternal morbidity at the time of delivery.

Importantly, these figures reflect the official United States accounting for maternal morbidity and are not taken into account undocumented pregnant women, many of whom delayed prenatal care and home delivery in response to recent immigration enforcement policies.

In terms of paid maternity leave, a Commonwealth Fund report finds that the United States is the only high-income country that does not guarantee paid leave to mothers after childbirth. All 10 other states guarantee at least 14 weeks of paid leave from work while some provide more than one year of maternity leave.

Despite these bleak trends, some progress has been made to increase maternal morbidity and mortality in the United States. ACA attestation helps women gain access to maternity care that requires coverage for free preventive services, broadens Medicaid eligibility, offers premium subsidies for low-income women, and provides protection for young women.

But the authors note that more changes need to be put in place to reverse this disproportionate impact trend woman of color. Solutions include strengthening postpartum care, ensuring paid maternity leave, and working to close the racial disparity gap in this population.

“Addressing systemic racism so that Blacks and Indigenous people are not at risk while they are pregnant is critical to reducing maternal mortality in the US, while offering paid maternity leave to all those who give birth will contribute to their health and the health of their babies, and strengthen the financial security of families. , ”Wrote Laurie Zephyrin, MD, and Roosa Tikkanen of The Commonwealth Fund at STAT News.

“The US clearly wants to invest in health care, but is not investing enough in the people who give birth… When it comes to maternal health care, it’s time we started investing wisely in ensuring that no one dies a preventable death while carrying life to the world. “

Reference

1. LK Advice, Dalton VK, Kolenic GE, et al. Trend of suicide 1 year before and after birth among individuals with commercial insurance in the United States, 2006-2017. JAMA Psychiatry. Published online 18 November 2020.doi: 10.1001 / jamapsychiatry.2020.3550