For my cousin in Dallas, pregnancy and childbirth was a journey of choice. With the benefit of private insurance, she had the freedom to shop for the perfect maternity ward, enticed by the promise of five-star dinners, post-labor photography, and assorted amenities. Hospitals vied for her business, eager to secure the generous reimbursements that come with privately insured pregnancies.

In stark contrast, a colleague’s niece from South Dallas who had no prenatal care delivered at the local safety-net facility, Parkland Hospital. Her pregnancy culminated in a crash cesarean section, a frantic race against time to save both mother and child. Her labor was complicated by a blood clot in her lung, and a lengthy stay in the neonatal intensive care unit (NICU) after the C-section. There were no gourmet meals or plush robes, only the stark reality of delivering at a hospital stretched thin.

These disparate experiences are emblematic of the underlying disparities that fuel maternal mortality in the United States. Women in the U.S. are more likely to die from pregnancy-related complications than those in any other developed country, and the problem is only getting worse.

Between 2000 and 2017, while other countries saw their maternal mortality rates decline, the U.S. experienced a staggering 16.7% increase to 19.7 deaths per 100,000 live births.

The burden is not evenly distributed. Black women, in particular, are three to four times more likely to die from pregnancy-related complications than their white counterparts. In some states, the disparity is even more pronounced, with Black women facing a maternal mortality rate six times higher than white women.

The cause is not simply the lack of money or education that prevents access to good prenatal care. Rather, the pregnancy-related mortality rate for Black women who completed college education or higher is 5.2 times higher than the rate for white women with the same educational attainment and 1.6 times higher than the rate for white women with less than a high school diploma.

The disparities persist even when accounting for factors like income and education, pointing to a deeper, more insidious problem: systemic racism and implicit bias in healthcare. The legacy of discrimination and unequal treatment has created a system where Black women often receive lower quality care, their concerns dismissed or minimized by medical professionals.

The roots of this inequity run deep, intertwined with the historical legacies of institutionalized racism and bias in medicine. For centuries, Black bodies have been subjected to unethical experimentation, neglect, and abuse at the hands of the medical establishment. From the infamous Tuskegee syphilis study (in which Black men were denied treatment for syphilis to study its natural disease course) to the forced sterilization of Black women, the scars of this our history continue to shape the experiences of Black mothers today.

Structural racism acts as an upstream driver of maternal mortality, creating a cascade of disadvantages that place Black women at higher risk. The insidious nature of implicit bias cannot be overstated. Even well-intentioned healthcare providers can harbor unconscious prejudices that color their perceptions and decisions. For Black women, this can mean having their symptoms dismissed, their concerns minimized, and their pain under treated. They are, as a result, more likely to experience severe maternal morbidity, and to face life-threatening complications like infections. And they are more likely to have their voices silenced, their agency denied, in a healthcare system that too often fails to listen to their needs and experiences.

The allostatic load, a concept that describes the cumulative physiological toll of chronic stress on the body, plays an additional role in maternal mortality. Allostatic load is the wear and tear on the body’s systems caused by repeated exposure to stressors, such as discrimination, poverty, and adverse living conditions. Over time, this chronic stress can lead to dysregulation of the body’s stress response systems, increasing the risk of various health problems, including pregnancy complications.

For Black women, the allostatic load is often compounded by the intersecting burdens of racism, sexism, and socioeconomic disadvantage. The daily experiences of discrimination, both interpersonal and institutional, contribute to a state of constant vigilance and stress that takes a toll on both physical and mental health. This chronic stress can lead to a heightened inflammatory response, which has been linked to adverse pregnancy outcomes such as preterm birth, low birth weight, and maternal illness.

Chronic health conditions and comorbidities also play a significant role in maternal health outcomes. Women with obesity, hypertension, diabetes, heart disease, or fibroids are at higher risk for pregnancy complications. Advanced maternal age, while not an inherent risk factor, can also increase the likelihood of certain complications, underscoring the need for individualized, risk-appropriate care.

Allostatic load can interact with other risk factors, such as inadequate prenatal care, to further exacerbate the risk of maternal mortality. Women who experience chronic stress may be less likely to seek or receive regular prenatal care, either due to financial barriers, lack of trust in the healthcare system, or competing life demands.

The lack of social support during and after pregnancy can have a profound impact on maternal health and well-being. Many women, particularly those from disadvantaged backgrounds, lack access to affordable childcare, paid parental leave, or supportive family and community networks. This isolation and stress can contribute to perinatal depression and other mental health challenges, which affect one in seven women during and after pregnancy.

In this context, one-third of U.S. counties are considered “maternity care deserts” that lack hospitals or birth centers providing obstetric services. This problem disproportionately affects rural areas and communities of color, where hospital closures and limited Medicaid payment rates make it financially challenging for facilities to maintain obstetric units. The issue of access and quality of care becomes even more pressing when we consider that Medicaid covers 42% of births in the United States.

While popular media and movies often depict maternal mortality asa dramatic event, with scenes of hemorrhage during childbirth taking center stage, the reality of pregnancy-related deaths in the United States today tells a different story. Thankfully, due to advances in obstetric care and emergency management, hemorrhage now accounts for less than 1 in 7 maternal deaths. However, this progress does not mean that the crisis of maternal mortality has been solved. Instead, it has shifted, with the major causes of pregnancy-related deaths now occurring in the postpartum period, up to a year after childbirth.

This shift in the timing and nature of maternal mortality is deeply connected to the issues we have explored in previous chapters: the critical importance of primary care and behavioral healthcare in addressing the complex, intersecting needs of mothers. The leading cause of pregnancy-related death today is not a sudden, catastrophic event, but rather the culmination of unmet physical and mental health needs over time.

Mental health conditions, including deaths by suicide and overdose related to substance use disorders, now account for nearly a quarter of all pregnancy-related deaths, including including deaths by suicide and overdose related to substance use. This staggering statistic underscores the vital role of behavioral healthcare in supporting mothers during the transformative and often challenging postpartum period. It highlights the need for a maternal healthcare system that integrates robust mental health screening, treatment, and support as a core component of postpartum care, rather than an afterthought or a luxury.

Chronic conditions, such as heart disease, hypertension, and diabetes, also play a significant role in maternal mortality, particularly in the postpartum period. Cardiac and coronary conditions account for 13% of pregnancy-related deaths. Infection is another significant contributor, accounting for 9% of pregnancy-related deaths. These infections can range from common urinary tract infections to more severe conditions like sepsis. Postpartum infections, such as endometritis (infection of the uterine lining), are a particular concern, as they can quickly escalate if not promptly identified and treated. Thrombotic embolism, a blood clot, also accounts for 9% of pregnancy-related deaths. Pregnancy is a hypercoagulable state, meaning that the blood has an increased tendency to clot. This adaptation is thought to be a protective mechanism against hemorrhage during childbirth, but it also increases the risk of dangerous blood clots, particularly in the postpartum period when women are often less mobile. Cardiomyopathy, a disease of the heart muscle, is responsible for another 9% of pregnancy-related deaths. And hypertensive disorders of pregnancy, relating to high blood pressure, contribute to 7% of pregnancy-related deaths.

In the context of the rising chronic and behavioral health causes of maternal mortality, several positive initiatives have emerged in the Medicaid space. Amongst the more well-established is the Centering Pregnancy (Centering) model, which is a group prenatal care approach that brings pregnant women together for enhanced support and education.

In the Centering model, a cohort of eight to ten women with similar gestational ages participate in ten 90- to 120-minute interactive group visits. These sessions, led by trained facilitators, cover a comprehensive curriculum including medical and non-medical aspects of pregnancy, such as nutrition, stress management, labor and delivery, breastfeeding, and infant care.

During each session, participants have short individual health assessments with the provider facilitator to discuss personal questions or issues. They also actively engage in their own care by taking their own vital signs and belly measurements, which they record in a notebook to track their progress. The group setting allows women to share experiences, learn from each other, and develop supportive relationships with their peers and the facilitators.

While the Centering model has shown promise in improving birth outcomes, reducing disparities, and increasing patient satisfaction, its implementation can be challenging. Many of the Medicaid recipients receiving prenatal care obtain their care through Federally Qualified Health Centers (FQHCs) that offer services specifically to low-income populations. FQHCs are paid a per-visit rate under the Prospective Payment System (PPS), which does not automatically accommodate the longer, more resource-intensive group visits or the additional services provided in Centering.

To address the problem, FQHCs have begun to focus on various alternative payment models (APMs) to support the sustainability of Centering programs. These involve negotiating with health plans to pay more for improved metrics of quality and improved outcomes in pregnancy, postpartum, or infant-related metrics, and reductions in avoidable healthcare utilization such as emergency room visits and hospitalizations. The participating providers have argued successfully that Centering can be paid for by reducing complications, C-section rates, NICU stays, and unplanned repeat pregnancies. Numerous studies have found positive impacts on preterm birth rates, low birthweight rates, breastfeeding rates, and perinatal care costs. Notably, research suggests that Centering may be particularly beneficial for reducing preterm birth risk among Black women. A study in South Carolina also demonstrated Medicaid cost savings associated with improved outcomes.

As states seek to improve maternal and child health, particularly within Medicaid populations, supporting the expansion of Centering has extended to another even more time-tested model: the Nurse-Family Partnership (NFP). The NFP is a community health program that has been supporting first-time, low-income mothers and their children for over four decades. The program’s core strategy involves providing comprehensive, ongoing support to vulnerable families during the critical early years, aiming to improve maternal and child health, economic self-sufficiency, and social well-being. NFP’s model centers around a series of regular home visits conducted by trained registered nurses, beginning early in pregnancy and continuing through the child’s second birthday. The program follows a well-defined schedule of 64 planned visits, with the frequency of visits varying based on the stage of pregnancy and the child’s age.

During these visits, nurses provide a range of education and support tailored to each mother and family’s needs. They offer guidance on prenatal care, child development, and parenting skills, while also helping mothers navigate social and community services and providing emotional support. The effectiveness of this comprehensive, sustained support has been extensively studied through three randomized controlled trials (RCTs) and numerous follow-up studies conducted over the past four decades. These long-term studies have demonstrated that families who participate in NFP experience a wide range of positive outcomes that persist well beyond the program’s conclusion.

Mothers in the program have been shown to have a 32% reduction in subsequent pregnancies, a 56% reduction in emergency room visits for accidents and poisonings, an 82% increase in months employed, and a 20% reduction in months on welfare. Additionally, the program was associated with 61% fewer arrests of the mother, 60% fewer convictions of the mother, and a 46% increase in father presence and stability as the nurse-family partnerships developed support for employment, childcare, and family stability to offset the social pressures to resort to illegal activities or for couples to split up under stress associated with raising children in poverty.

These benefits have been shown to yield significant economic returns with a benefit-cost ratio of up to 5.7 to 1, indicating that every dollar invested in NFP can generate over five dollars in savings and benefits to society through reduced healthcare costs, increased tax revenues, and reduced spending on social services and incarceration.

Nurses with maternal health expertise are not available in all regions of the US, and in this context several states have also supported coverage for doulas under Medicaid. Doulas are community health workers who provide social support, education, accompaniment, and navigation for mothers (not to be confused with midwives, who deliver babies). Doulas and CHWs have both been studied in experiments such as the SafeStart program, which paired women with such services through a high-volume inner-city prenatal clinic, and observed higher rates of adequate prenatal care initiation, lower rates of hospitalization and lower durations of neonatal intensive care than a control group.

Among the most important lessons from NFP and similar initiatives are the long-term effects on children from prenatal and early childhood support. Children in the NFP program have experienced a 48% reduction in child abuse and neglect, which was then associated with a 67% reduction in behavioral and intellectual problems by age 6, and then a 59% reduction in child arrests by age 15. The intergenerational nature of poverty and poor health, and their mutual interrelationships, became clear in the long-term follow-up in the NFP studies, and because the interventions were rigorously studied through randomized controlled trials (RCTs), we know that the results were not due to those people who were already better off being more likely to enter the program (rather, the ‘confounders’ that could lead to better outcomes were evenly distributed among the intervention and control group through the randomization process, which is the reason for randomization itself in the experiment).

While the RCTs provide robust evidence of NFP’s effectiveness, it is important to note that the program’s widespread adoption has been a gradual process. Despite the strong evidence base, it has taken time for the program to gain traction and secure sustainable funding across diverse communities. To support the program’s implementation and maintain quality, NFP provides comprehensive training, technical assistance, and data reporting tools to local implementing agencies through its National Service Office. Funding for NFP comes from various sources, including government grants, Medicaid, and private foundations, with some states integrating the program into their Medicaid managed care contracts or other payment models.

How can the Medicaid program better support programs like NFP? In addition to APMs to support providers delivering such services, Medicaid also has to grapple with administrative barriers to receiving sufficiently long postpartum coverage for mothers after birth.

After the ACA Medicaid expansion extended coverage to millions of low-income adults, studies showed (at best) mixed results regarding its impact on maternal health outcomes. While some studies reported a reduction in maternal mortality rates in expansion states compared to non-expansion states, particularly among minority groups, others found no significant changes. Similarly, the impact of Medicaid expansion on prenatal birth outcomes, such as low birth weight and preterm births, has been inconsistent. Some studies found improvements, while others reported minimal or no significant changes. A study found that Medicaid expansion was associated with a 1.4 percentage point increase in Medicaid-covered deliveries but no significant changes in the rate of women initiating prenatal care in the first trimester.

In contrast, the extension of postpartum Medicaid coverage from 60 days to 12 months after birth has shown more consistent positive results. Several states extended the duration of coverage during and after the COVID-19 pandemic lock-down period. Several studies found that extending postpartum coverage led to improved health outcomes for both mothers and babies. One study reported that states with extended postpartum coverage had a 1.6 percentage point reduction in maternal mortality rates. Another found that extending coverage was associated with a 5.1 percentage point increase in the probability of receiving post-partum care.

But the responsibility for improving maternal mortality and associated household- or family-level and child outcomes does not squarely fall on Medicaid. The United States has long struggled with maternal mortality rates and early childhood outcomes that lag behind many other developed nations. By looking to the social policies and interventions implemented in other countries, the U.S. can find valuable lessons and strategies for improving the health and well-being of mothers and children.

One key area where the U.S. falls short is in its support for new parents. While many other developed countries offer generous paid parental leave policies, the U.S. remains the only high-income country without a national paid leave program. This lack of support can have serious consequences for the health of both mothers and babies. Studies have shown that paid parental leave is associated with lower rates of infant mortality, low birth weight, and maternal depression. In California, for example, each additional week of paid leave was associated with a 3.6% decrease in the share of underweight births and a 7.3% decrease in late prenatal care utilization. Across OECD countries, an additional month of paid maternity leave was linked to a 13% lower infant mortality rate.

The benefits of paid parental leave extend beyond just health outcomes. Research has found that these policies can yield substantial returns on investment, with estimated cost-benefit ratios ranging from $1.50 to $2.80 per $1 spent. By allowing parents to take time off work to care for their newborns without sacrificing their economic security, paid leave policies can promote family stability, child development, and long-term productivity.

Another area where the U.S. can learn from other countries is in its investment in early childhood education. High-quality preschool and childcare programs have been shown to have a profound impact on children’s cognitive and social-emotional development, as well as their long-term educational and economic outcomes. The Perry Preschool Program, a landmark study of a high-quality preschool program for low-income children, found a return on investment of $7.16 for every dollar spent due to increased earnings, reduced crime, and improved health outcomes later in life. Similarly, the Abecedarian Project, an intensive early childhood education program, demonstrated significant improvements in educational attainment, employment, and reduced likelihood of criminal behavior, with a cost-benefit ratio of $2.50 to $4.10.

While the U.S. has made some progress in expanding access to early childhood education through programs like Head Start, it still lags behind many other developed countries in terms of the quality and availability of these programs. By investing in high-quality, universally accessible early childhood education, the U.S. could not only improve outcomes for individual children and families, but also realize significant long-term benefits for society as a whole.

Another social policy that has shown promise in improving birth outcomes is increasing the minimum wage. Studies have found that higher minimum wages are linked to lower rates of low birth weight and preterm birth, likely due to the increased economic stability and reduced stress experienced by low-income families. One study estimated that a $1 increase in the minimum wage could lead to a 1.6% decrease in low birth weight and a 0.5% decrease in preterm births, resulting in substantial cost savings for healthcare and long-term economic benefits.

While the specific policies and interventions may vary across countries, the underlying principles are clear: investing in the health, education, and economic security of families, particularly those who are most vulnerable, can yield significant returns in terms of improved maternal and child outcomes, reduced healthcare costs, and increased productivity and social well-being.

For the U.S. to make meaningful progress in addressing its maternal and child health challenges, it will require an approach that draws on the best available evidence and the experiences of other countries. This will likely involve a combination of expanded access to health-care, including through Medicaid; increased support for new parents through paid leave policies and other family-friendly benefits; greater investment in high-quality early childhood education; and policies that promote economic stability and opportunity for low-income families.

Implementing these changes will not be easy, and will require significant political will and resources. The potential benefits are enormous, not just for individual mothers and children, but for the health and prosperity of the nation as a whole. By learning from the successes of other countries and adapting them to the unique context of the U.S., we can create a future where every child has the opportunity to thrive, and where no mother has to face the tragedy of preventable death or disability.