One of the greatest achievements of modern medicine has been reducing the risk of death due to childbirth. The introduction of antibiotics, safe use of cesarean section, and greater focus on prenatal care have caused maternal mortality rates to decline by 99% since the year 1900. However, recent decades have shown a slight backtracking of this progress and room for improvement compared to other countries.
According to the CDC, the U.S. maternal mortality rate has increased from 7.2 to 18.7 per 100,000 births between 1987 and 2023. This is still remarkably low, but the increase is a cause for concern and we are higher than most other developed nations. In 2022, the maternal mortality rate spiked during the pandemic and was 22.3 per 100,000 births. The next highest country was Chile with 14.3, which is almost halved. Canada and the UK had 8.8 and 5.4 deaths, respectively.
While death during labor has actually decreased, it is death during the postpartum period that has increased. Data from 2022 found that 65% of maternal deaths happen postpartum, almost half of which occur between 42 and 365 days after birth. Complications such as heavy bleeding, high blood pressure, infection, and weakened heart muscles (cardiomyopathy) are some of the main causes of postpartum death, 80% of which are considered preventable.
There are many contributing factors to the situation we face in the United States, but some of it can be attributed to a declining supply of care. There was a net loss of 399 obstetric wards around the country between 2010 and 2022, and the Department of Health and Human Services projects a shortage of over 5,000 OB/GYNs by 2030. This can mean women have to travel long distances for prenatal appointments or giving birth far from home, especially if they live in rural areas.
Less supply puts greater pressure on the remaining wards and providers, which may lead to women feeling less supported or comfortable during their pregnancy and postpartum. In a 2023 CDC survey, 45% of mothers reported holding back their questions because they were told what they were feeling was normal, were embarrassed or unsure of their experiences, felt their doctor was rushed, or didn’t want to be seen as difficult.
It’s clear that we need to expand pathways for maternal care providers to meet the needs and preferences of their patients, giving mothers more options for their maternal care experience.
One way to do this is by removing barriers to opening birthing centers which have many benefits for women. Participating in birth center care results in better outcomes such as lower rates of preterm births and higher rates of breastfeeding. They are also much more affordable, averaging around $8,000 compared to almost $19,000 for a hospital birth. Birthing centers are not the right fit for every woman or pregnancy, but they are a safe and cost-effective option for many, such as those with low-risk pregnancies living in areas without nearby hospitals.
Unfortunately, there are laws and regulations that prevent birthing centers from opening, such as Certificate of Need (CON) laws that require approval for health facilities to open or expand. CON laws are a major obstacle to open birth centers especially because existing hospital systems, which may see them as competition, can oppose the application. There are 35 states and the District of Columbia with CON laws that either directly require approval for birthing centers, or for specific actions which may be applicable to birthing centers.
Part of the great success of birthing centers is their greater utilization of certified nurse midwives (CNMs) which are helpful in every setting. Maternal care providers such as CNMs offer more personalized care and education before, during and after childbirth leading to improved outcomes for the mother and baby. The United States is actually an outlier compared to most other countries where midwives are the primary provider of maternal care rather than an OB/GYN.
Providing full practice authority for CNMs, meaning they can practice without physician oversight, would be a meaningful step toward expanding access to their care. Some 26 states require physician relationships to some extent, which can severely restrict their ability to care for mothers. In Nebraska, for example, CNMs are banned from attending home births, even though lay midwives with less training do not have that restriction. Pushing for full practice authority would go a long way in making CNMs more accessible and better integrated in our maternal care system.
We should be incredibly grateful for modern medicine making childbirth a much safer event for both mothers and babies, but there is still room to improve on this progress. We can empower maternal care providers to offer their services to the best of their ability, and parents by expanding their choices for safe maternal care.