Every mom deserves a safe pregnancy and healthy birth experience, but in the United States, every year at least 700 to 900 women die and at least 50,000 women experience life-threatening complications from pregnancy, according to the Centers for Disease Control and Prevention (CDC). The reasons why are complicated, and include a combination of barriers to quality care, our fractured health care system and systemic racism.
Conditions for pregnant women and new moms vary widely state by state. “There are big differences based on where you are and that’s not right,” says Neel Shah, M.D., an assistant professor at Harvard Medical School, an OB-GYN at Beth Israel Deaconess Medical Center.
Here are some of the qualities that the worst states for maternal health have in common and qualities that the better states share.
The worst states for maternal health
Alabama, Arkansas, Georgia, Kentucky, Louisiana, Mississippi, Oklahoma, Tennessee, Texas
What the worst states have in common
They limit access to healthcare. The Affordable Care Act required that all 50 states make more people eligible for Medicaid. However, a 2012 Supreme Court ruling held that states couldn’t be forced to do this, and to date, 13 states still haven’t expanded the program, many of them in the South. The Kaiser Family Foundation estimates that 2.3 million more Americans would have insurance if their states expanded Medicaid, including more than 750,000 people in Texas alone.
Any woman can enroll in Medicaid when she gets pregnant, but being able to afford care before she’s expecting is important to ensuring a safe pregnancy. If a woman learns at her first prenatal appointment that she has diabetes, for example, her blood sugar levels have been affecting fetal development for weeks, says Joia Crear-Perry, M.D., an OB/GYN and founder and president of the National Birth Equity Collaborative. “Waiting to give someone insurance after they can prove they are pregnant defeats the purpose of trying to have healthy births in the United States,” she says.
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They have more restrictions on abortion. Many of the states that haven’t expanded Medicaid are also states that the Guttmacher Institute considers to be hostile to abortion. Many Southern states also forbid Medicaid or Affordable Care Act insurance from covering abortion, further putting the procedure out of reach. From a numbers perspective, more people who give birth means more people who have a potential risk for a poor outcome, explains Rachel Hardeman, Ph.D., M.P.H., an associate professor at the University of Minnesota School of Public Health. And because of structural racism, Black women already come into pregnancy less healthy. Barriers to abortion could also lead to pregnancies not adequately spaced, plus mental health issues and economic strain and stress, all of which affect health, says Ana Delgado, C.N.M., clinical professor at University of California San Francisco and Director of Inpatient Midwifery Services at Zuckerberg San Francisco General.
They have fewer places and options for getting care. Almost 40 percent of U.S. counties had neither an OB/GYN nor a certified nurse midwife, according to a 2018 March of Dimes report. People in rural areas routinely have to drive long distances to reach providers and hospitals and rural hospitals and rural maternity units have been closing for years, says Dr. Shah. The further the trip, the more it costs, which is an additional barrier for low-income people. Access is also an issue for indigenous or Native American communities whose hospitals are underfunded. Some states like Georgia only allow certified nurse midwives to practice, meaning non-nurse midwives cannot legally deliver babies.
They have more racial segregation and income inequality. Racism isn’t only an issue in the South. Black and other minority communities across the country are more likely to face greater exposure to pollution, more likely to have fewer sources of healthy, affordable food, and, as Hardeman notes, in highly segregated areas of the country Black people have less intergenerational wealth and lower rates of homeownership due to historical practices like redlining. While New Jersey has had paid family leave since 2009 and it expanded Medicaid, it has fairly large cities like Newark and Camden that are racially segregated and people there have worse health outcomes, Dr. Shah says. Nationally, if local medical practices don’t accept Medicaid, those people have to go to clinics where they will likely see a different provider each time, which makes it difficult to track concerning symptoms like swelling and pain, Dr. Crear-Perry says.
The best states for maternal health
California, Massachusetts, Minnesota, New Hampshire, Oregon, Vermont, Washington state
What the best states have in common
They’ve expanded access to health insurance. States that rank well for maternal health provide more access to healthcare, and they do so beyond when women are pregnant. People in Massachusetts had more ways to get health insurance even before the Affordable Care Act was passed, thanks to so-called Romneycare (named for then-Governor Mitt Romney). Many people enter pregnancy healthier because they’ve always had access to care, Dr. Crear-Perry says. In California, undocumented immigrants can get coverage from MediCal, the state’s Medicaid program.
And since MediCal offers enhanced prenatal services like nutrition and health education, plans sold via the Affordable Care Act in California have to cover those too, Delgado says.
The U.S. House recently passed the Patient Protection and Affordable Care Enhancement Act, a bill that would encourage more states to expand Medicaid to low-income people, allow DACA recipients to buy health plans through the Affordable Care Act marketplaces and expand postpartum Medicaid coverage from 60 days to one year nationwide.
They have more options for full-spectrum birthing care. Midwife-assisted births are associated with fewer interventions and better maternal and child outcomes. Oregon and Washington are among the states that have strong midwifery inclusion in their health systems. The Kaiser Permanente system in California also very liberally employs midwives, Delgado says, which could mean fewer interventions and complications. Additionally, Oregon and Minnesota are the only two states that allow Medicaid to cover doulas as advocates for pregnant patients.
They have paid family leave—and paid sick days. Only five U.S. states plus Washington D.C. offer state-mandated paid family leave. Paid family leave is associated with better maternal health, possibly because it allows time to recover with limited financial impact. Paid time off is equally important for getting care during pregnancy, especially for moms-to-be who work hourly jobs, as people sometimes have to make decisions between feeding their family and getting prenatal care, Dr. Crear-Perry says. Women who don’t have paid leave may not be able to make their 6-week postpartum visit either.
Nationwide challenges
Even though dozens of states have expanded Medicaid, there were still 28 million people without health insurance as of 2018, per the Kaiser Family Foundation. That could mean millions of moms starting pregnancies with undiagnosed conditions or chronic health issues that aren’t under control.
And even in states that seem to be doing well, disparities still exist. “What the average doesn’t show is the gap between people who are the least well off and the people who are the best,” Dr. Shah says. For example, in Boston where Dr. Shah practices, he notes that there are five big academic medical centers, but there are still parts of the greater Boston area where people have less money and face more housing insecurity and their health suffers as a result.
How data is collected can also elude researchers studying maternal health. In Minnesota, for instance, there’s a somewhat large population of African immigrants who have better health outcomes than Black people born in the U.S. who are descendants of slaves, Hardeman says. But both groups are classified as “Black” in federal maternal health data so the differences are lost.
Overall, to improve outcomes for moms and their babies, health care needs to improve across the board. “Maternal outcomes don't just happen,” says Alina Salganicoff, vice president and director of women's health policy at the Kaiser Family Foundation. “They're not just shaped by when women get pregnant. A lot of that is shaped by their health before they get pregnant and being able to choose whether or not they want to be pregnant.”
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