The United States spends more on healthcare than any other high-income nation. Yet an American woman is roughly three times more likely to die from pregnancy-related causes than a woman in most of Western Europe. That gap isn't explained by biology or bad luck. It's a policy gap.

When we talk about maternal mortality, the conversation often drifts toward clinical failures—a missed diagnosis, a delayed intervention. Those matter. But they sit atop a scaffolding of policy choices that determine who gets care, where they get it, and for how long after delivery.

Three policy dimensions stand out when you compare the U.S. to peer nations: how insurance coverage works during and after pregnancy, how the delivery system is organized and resourced, and what happens in the critical postpartum window. Each one reveals a structural vulnerability that clinical excellence alone cannot fix.

In most high-income countries, pregnancy triggers automatic, continuous coverage from conception through at least a year postpartum. In the United States, coverage depends on a patchwork of employer insurance, marketplace plans, and Medicaid—each with different eligibility rules, enrollment timelines, and benefit structures. The result is what health economists call insurance churn: women cycling in and out of coverage at precisely the moments they need stability.

Medicaid covers roughly 42 percent of all births in the U.S. But eligibility is tied to income thresholds that vary dramatically by state. A woman might qualify during pregnancy, lose coverage 60 days after delivery, and spend months uninsured before her next enrollment window opens. During those gaps, chronic conditions go unmanaged. Warning signs go unchecked. Preventable complications become emergencies.

The coverage problem also shapes when women enter prenatal care. Enrollment delays—waiting for eligibility determinations, navigating paperwork, switching providers when coverage changes—push first prenatal visits later into pregnancy. Late entry to care is consistently associated with worse outcomes, particularly for women with hypertensive disorders, gestational diabetes, or mental health conditions that benefit from early monitoring.

What makes this a policy problem rather than a clinical one is that the churn is designed into the system. Eligibility redeterminations, enrollment periods, and coverage cliffs exist because of deliberate policy architecture. Nations with lower maternal mortality didn't eliminate medical risk—they eliminated administrative barriers to continuous care.

Takeaway

Coverage gaps aren't just inconveniences—they are structural interruptions in care that convert manageable conditions into fatal ones. Continuity of coverage is itself a form of clinical intervention.

Since 2004, more than 200 rural hospitals in the United States have closed their obstetric units. The trend is accelerating. For communities that lose their local labor and delivery ward, the nearest hospital may be 50, 70, or over 100 miles away. Drive times of that length don't just create inconvenience—they create measurable risk. Research consistently shows that longer distances to obstetric care correlate with higher rates of out-of-hospital births, preterm deliveries, and maternal complications.

The closures follow an economic logic. Obstetric units are expensive to maintain. They require 24/7 anesthesia coverage, neonatal capacity, surgical readiness, and specialized nursing staff—all for a volume of births that may not cover costs in a low-population area. Hospitals operating on thin margins make rational financial decisions. But those decisions have population-level consequences that no single hospital is accountable for.

Staffing compounds the capacity problem. The U.S. faces a growing shortage of obstetricians, particularly in underserved areas. Certified nurse-midwives and other advanced practice providers could fill part of that gap, but scope-of-practice laws vary widely by state. Some states allow midwives to practice independently; others require physician supervision arrangements that are difficult to establish in areas where physicians are already scarce.

Peer nations approach this differently. The United Kingdom, the Netherlands, and Scandinavian countries use midwifery-led models as the default for low-risk pregnancies, reserving obstetrician involvement for complications. This isn't just a workforce strategy—it's a system design choice that distributes capacity more efficiently. The U.S. delivery system, by contrast, concentrates expertise in urban centers and leaves growing swaths of the country without adequate coverage.

Takeaway

Hospital closures and staffing shortages aren't random misfortunes—they're the predictable results of a delivery system organized around financial sustainability rather than geographic equity. Where you live shouldn't determine whether skilled hands are available when complications arise.

Here's a fact that reframes the entire maternal mortality conversation: more than half of pregnancy-related deaths occur after delivery, many of them between one week and one year postpartum. Cardiovascular conditions, infections, mental health crises, and substance use disorders claim lives well beyond the delivery room. Yet historically, the U.S. policy framework treated the postpartum period as an afterthought—a single six-week checkup, then silence.

The American Rescue Plan Act of 2021 gave states the option to extend Medicaid postpartum coverage from 60 days to 12 months. As of early 2024, the vast majority of states have adopted this extension. It's a meaningful shift. But extension of eligibility doesn't automatically translate into utilization. Women still need to know coverage exists, maintain enrollment, find providers accepting Medicaid, and navigate systems during one of the most physically and emotionally demanding periods of their lives.

International comparisons are instructive. In France, postpartum home visits by midwives or nurses are standard. In the Netherlands, kraamzorg—professional maternity home care—is a universal entitlement for the first week after birth. These aren't luxury add-ons. They're structured touchpoints that catch hemorrhage warning signs, screen for postpartum depression, monitor blood pressure, and connect new mothers to ongoing care before small problems become catastrophic ones.

The policy lesson is that coverage duration matters, but care architecture matters more. Extending Medicaid to 12 months postpartum is necessary. It is not sufficient. Without proactive outreach, home-based care models, and integration of mental health and substance use services into postpartum care, the extension risks becoming coverage on paper without care in practice.

Takeaway

Extending coverage is a policy input. Preventing deaths is a health outcome. The gap between the two is filled by care design—structured, proactive contact that meets women where they are, not where the system expects them to show up.

The United States doesn't have a single maternal mortality problem. It has three interlocking policy failures: fragmented coverage that interrupts care, a delivery system that concentrates resources away from those who need them most, and a postpartum framework only now beginning to match the medical reality of when deaths actually occur.

No one of these can be fixed in isolation. Extending Medicaid coverage matters less if there's no hospital within driving distance. Building obstetric capacity matters less if women lose insurance before complications surface. The solutions are systemic because the failures are systemic.

Other nations haven't solved maternal health through superior medicine. They've solved it through superior policy architecture—continuous coverage, distributed capacity, and proactive postpartum care. The clinical knowledge exists. The policy will to apply it is the variable.