Why US mothers are more likely to die in childbirth

The United States remains one of the most dangerous wealthy nations for a woman to give birth.

Maternal mortality rose by 40% at the height of the pandemic, according to new data released by the US Centers for Disease Control and Prevention.

In 2021, 33 women died out of every 100,000 live births in the US, up from 23.8 in 2020.

That rate was more than double for black women, who were nearly three times more likely to die than white women, according to the CDC.

Compared to other countries, the maternal mortality rate was twice as high in the US than in the UK, Germany and France; and three times higher than in Spain, Italy, Japan and several other countries, according to the most recent global comparison data kept by the World Bank.

And, it has consistently increased in the US since at least 2000. Yet the average maternal mortality rate among the 37 other countries accounted for in the data has declined over the same time period.

"Clearly the US is an outlier," said Joan Costa-i-Font, a professor of health economics at the London School of Economics. "Covid has made [maternal mortality] worse, but it was already a major issue in the US."

Mr Costa-i-Font said the maternal mortality rate spike in the US in 2021 was the result of a "perfect storm" of events between a deadly pandemic, racial inequality, comparatively low health insurance coverage, and high health insurance costs.

"The insurance design is to be blamed for the excessive barriers that women [in the US] face when pregnant", he said. "It's basically a system that is not giving care to the ones most at need. It provides great care to the wealthy but low income care is below standards."

However, in other countries in the UK and Europe, the cost of delivering a baby is free, compared to thousands of dollars in the US - even among the insured - and co-payments for things like pregnancy screenings and post-natal care are minimal.

"Covid has only made it worse, but [maternal mortality] is a structural problem here in the United States," Mr Joan Costa-i-Font said.

The high cost of healthcare, coupled with glaring disparities across racial and socio-economic backgrounds, have kept the mortality rate in the US stubbornly high for years, he said.

Also, pregnant women are at a higher risk of experiencing severe illness if infected with Covid-19. That risk was compounded for pregnant women living with comorbidities like obesity and diabetes, who were more likely to experience pregnancy complications, including death.

"Lower income people in the US find themselves with higher needs, more disease, and less coverage," Mr Costa-i-Font said.

Black Americans are disproportionately at the axis of all three points raised by Mr Costa-i-Font - they have the highest rates of obesity or being overweight in the US, and have a 20% higher chance of having hypertension. Yet the rate of uninsured black Americans remains two-thirds higher than white Americans.

The CDC defines maternal mortality as a death that occurs while pregnant or within 42 days of the end of a pregnancy.

Experts say the vast majority of the maternal deaths happen shortly after giving birth, when many women are forced to return to work and are unable to continue with post-partum care.

Black Americans in particular are often employed in low-income jobs that offer little-to-no health insurance coverage and minimal time off for maternity leave.

Many of those same jobs, like food service, were deemed essential during the pandemic and workers were unable to work from home. This increased black women's chances of exposure to Covid-19 and, without adequate access to healthcare, contributed to higher rates of death.

"Women are saying, I can't come in for this bleeding, for this headache, because I don't have the support afterward," said Dr Rochanda Mitchell, a Howard University physician who specialises in maternal-foetal medicine and high-risk pregnancies.

"During the pregnancy everybody is there, celebrating the pregnancy," she added. "But if most of our mothers are dying after delivery - then we need help after delivery."

But without the systems in place to support employees of low-income jobs, many mothers are forced to ignore early signs of health concerns.

Some mothers, even those with health insurance, can be discouraged from seeing a doctor post-partum because of the potentially high cost and may wait until the most dire circumstances, she said, which in many cases can be too late.

Dr Mitchell explained that until there is a vast overhaul of how the health care system in the US functions, the situation is unlikely to improve.

"It's really difficult to narrow it down to one thing," she said. "I think some of the poor outcomes and disparities that we see are all part of the bigger picture of health disparities."