The United States spends more per capita on healthcare than any other country in the world. It has some of the most sophisticated medical technology, some of the most rigorous clinical research, and some of the most highly trained physicians available anywhere on the planet. It also has a maternal mortality rate that is three to four times higher than Canada, the United Kingdom, France, Germany, and most of Western Europe.
This contradiction is not a paradox. It is a predictable consequence of specific policy choices: the absence of universal prenatal care coverage, the absence of federal paid parental leave, the absence of affordable childcare, and the particular inadequacies of a healthcare system that is excellent at high-technology acute care and consistently inadequate at the population-level preventive care and social support that determines whether women survive the experience of having children.
The countries where maternal mortality rates are lower, where the financial experience of new parenthood is less devastating, and where mothers return to work at higher rates with better economic outcomes are not countries that discovered something secret about how to improve maternal health. They made different policy choices. They decided that the health and economic security of mothers is a public responsibility rather than a private one, and they built the systems that reflect that decision.
The solutions are known. The evidence is overwhelming. The question is whether the United States, in the current policy environment, will choose to act on what is already understood.
The scale of the crisis
The US maternal mortality rate relative to Canada, the United Kingdom, and most of Western Europe. The gap has not closed over the past two decades. In some dimensions it has widened. This is not a medical mystery. It is a policy outcome.
The US maternal mortality crisis in context
The KFF International Comparison of Health Systems puts the picture in stark relief. In 2023, the US maternal mortality rate was 18.6 deaths per 100,000 live births — more than three times the comparable rate among peer nations of 5.1 per 100,000. The United States, the wealthiest country in the world by total GDP, allows mothers to die at rates that comparable nations have decisively outperformed.
The racial dimensions of the crisis amplify the injustice further. The CDC's data on maternal mortality shows that Black women die from pregnancy-related causes at rates approximately three times higher than white women — 50.3 deaths per 100,000 live births in 2023 compared to 14.5 for white women — a disparity that persists across income and education levels and that reflects the compounding effects of structural racism in healthcare access, quality, and treatment. Native American and Alaska Native women face similarly elevated rates. The maternal mortality crisis in the United States is not merely a crisis of aggregate outcomes. It is a crisis of systematic inequity in which the most marginalised populations bear the greatest burden of a preventable catastrophe. (It is the same crisis the federal government recently made harder to even measure, when it quietly stopped tracking maternal deaths the way it once did.)
The Commonwealth Fund's Mirror, Mirror 2024 report consistently ranks the United States last among comparable high-income nations on measures of healthcare access, equity, administrative efficiency, and health outcomes. The ranking is not coincidental. It is the predictable consequence of a health system structured around market principles in a domain where market principles consistently produce inadequate results for the populations with the greatest need.
What the countries getting it right have in common
The countries where maternal health outcomes are substantially better than in the United States are not uniformly identical in their policy approaches. They have different healthcare systems, different labour markets, different cultural contexts, and different political traditions. What they share is a set of specific policy features that the research consistently identifies as the primary drivers of better maternal health outcomes.
Universal prenatal care
In Canada, the United Kingdom, Scandinavia, Germany, France, and most of Western Europe, prenatal care is a public service available to every pregnant person regardless of income, employment status, or insurance coverage. The quality and availability of prenatal care does not vary with the patient's ability to pay.
The consequences for outcomes are well-documented. Prenatal care identifies and manages the conditions that become catastrophic when they are caught late: gestational hypertension, preeclampsia, gestational diabetes, anaemia, and the range of pregnancy complications that, when identified and treated appropriately, rarely produce maternal death — and when missed or undertreated, frequently do. The United States covers prenatal care through a patchwork of private insurance and Medicaid that leaves significant gaps, particularly for the women who fall between coverage categories or who live in states with restrictive or shrinking Medicaid eligibility.
Paid parental leave that is actually used
The countries with the best maternal health outcomes are also the countries with the most generous paid parental leave policies. In Sweden, parents share 480 days of paid leave, with 390 of those days paid at approximately 80% of wages, as documented by Sweden's Social Insurance Agency, Försäkringskassan. In Germany, parents receive up to 14 months of Elterngeld (parental allowance) at 65–67% of pre-birth net income, per the German Federal Family Portal. In Canada, parents can take up to 18 months of leave with Employment Insurance parental benefits.
The research on paid parental leave and maternal health outcomes is consistent: paid leave is associated with reduced rates of maternal depression, higher rates of breastfeeding initiation and duration, improved maternal physical health outcomes in the postpartum period, and better long-term economic outcomes for mothers who can take leave without losing their jobs or their income. The United States provides none of these benefits at the federal level. The absence is not an oversight. It is a policy choice that produces predictable outcomes.
Subsidised or universal childcare
The countries where maternal workforce participation is highest and where the gender wage gap is smallest are, almost without exception, the countries where childcare is publicly subsidised to the point where it is accessible to families across the income spectrum. France's crèche system subsidises centre-based care from birth to age three with fees calculated on a sliding scale. Sweden's förskola provides publicly funded care for all children aged one to five. Denmark caps family fees at 25% of the actual cost of care, with the remaining 75% funded publicly. The economic returns are documented and significant: higher maternal employment, lower gender wage gaps, better child developmental outcomes, and reduced long-term expenditure on remedial education and social services.
The AEI's childcare regulation and affordability report documents that in the United States, infant care costs in high-cost states approach or exceed the in-state tuition cost of a four-year public university. This is not a feature of childcare markets in the countries that have solved this problem. It is a feature of a childcare market that has been left to operate as a private market good in a domain where private market dynamics consistently produce inadequate results for the families with the greatest need.
Comprehensive postpartum care
The countries with the best maternal health outcomes invest significantly in the postpartum period, recognising that a substantial proportion of maternal deaths and morbidity occur not during delivery but in the weeks and months that follow. Home visiting programmes, universal postpartum screening for mental health conditions, guaranteed primary care follow-up, and extended postpartum coverage through public health systems are standard features of the maternal health infrastructure in countries with substantially lower maternal mortality rates than the United States.
The National Partnership for Women and Families has documented the evidence base for postpartum care investments extensively, finding that targeted postpartum interventions — particularly the screening and treatment of postpartum mental health conditions — can significantly reduce the maternal morbidity and mortality that occur in the weeks and months after delivery. The US healthcare system has historically provided very limited postpartum coverage, with most insurance plans providing a single postpartum visit at six weeks — a standard that ACOG's postpartum care guidance identified as inadequate and recommended changing in 2018.
The economic case for the policy changes
The argument that paid parental leave, universal prenatal care, subsidised childcare, and comprehensive postpartum care are not affordable in the United States is not supported by the economic evidence. The argument is made on the basis of the direct costs of the programmes themselves, which are real and significant. It does not account for the substantial costs of not having them, which are also real and significant — and which are currently being borne by families, by the healthcare system, and by the economy.
The MMHLA's data on the cost of untreated perinatal mood and anxiety disorders — drawing on Mathematica's peer-reviewed modelling — estimates that untreated perinatal mood and anxiety disorders cost the United States approximately $14.2 billion per year in direct healthcare costs, indirect costs from lost productivity, and downstream costs from child developmental impacts. This is the cost of not treating a condition that is highly treatable when identified and addressed. The cost of adequate treatment is a fraction of this figure.
The NBER lifecycle benefits study of early childhood programmes — Heckman, García et al. — consistently finds returns of 13.7% per annum and a benefit-to-cost ratio of 7.3, measured in improved educational outcomes, higher adult earnings, reduced crime, and lower expenditure on remedial services. These returns are not speculative. They are documented in longitudinal studies of specific early childhood programmes followed for decades.
The KPMG Great Exit report documents the labour market cost of inadequate childcare and parental leave in the most direct terms available: mothers are leaving the workforce at record rates because the systems that were supposed to support their participation have failed them. The productivity loss from those departures, combined with the recruitment and replacement costs absorbed by their employers, represents a substantial and ongoing economic cost — one the economy bears without ever accounting for it as a consequence of inadequate policy.
The racial equity dimension
Any serious engagement with US maternal health policy must address the racial equity dimension explicitly, because the maternal mortality crisis in the United States is not experienced equally — and the policy changes that would address it most effectively are the same changes that would reduce the specific and severe disparities that Black, Native American, and Alaska Native mothers face.
Universal prenatal care coverage eliminates the coverage gaps that fall disproportionately on women of colour, who are more likely to be uninsured or enrolled in Medicaid programmes with restricted provider networks. Paid parental leave is more likely to be available to higher-income workers in employer-sponsored plans, and less likely to be available to the lower-wage service and care workers who are disproportionately women of colour. Subsidised childcare reduces the financial burden that falls most heavily on single-parent households, which are disproportionately headed by women of colour.
The Black Mamas Matter Alliance has produced some of the most rigorous and specific research on the policy interventions most likely to reduce the maternal mortality disparity for Black women. Its research consistently identifies expanding Medicaid coverage, increasing investment in community birth workers, addressing implicit bias in clinical settings, and improving the social determinants of health — particularly housing and economic security — as the interventions with the strongest evidence base for reducing racial disparities in maternal health.
The solutions to the general maternal health crisis and the solutions to the racial equity crisis in maternal health are not separate lists. They overlap substantially. Universal policies that ensure every mother has access to quality prenatal care, paid leave, affordable childcare, and comprehensive postpartum support reduce disparities precisely because the women who have been most denied those things are the women who stand to gain the most from their provision.
What change would actually require
The barriers to implementing the policy changes that the evidence supports are not technical. The technical questions have largely been answered: what policies work, at what cost, with what returns, and how they can be implemented within the existing federal and state government structure. The barriers are political.
They are political in the specific sense that the policy changes required to bring US maternal health outcomes in line with comparable nations represent a significant reorientation of who bears the cost of having children in this country. Currently, that cost is borne overwhelmingly by individual families, and within families, overwhelmingly by mothers. The policy changes that would improve maternal health outcomes transfer a meaningful portion of that cost to the broader society, through taxation and through the public programmes that taxation funds.
This reorientation requires a political decision that the health and economic security of mothers is a shared social responsibility, not a private one. It is the same decision that Canada made, that Germany made, that Sweden and France and the United Kingdom made — in different political contexts and over different time periods, but with the same underlying logic: that a society that says it values children and families should be willing to fund the systems that make it possible to have them without sacrificing your health, your career, your financial security, or your life.
What you can do
Vote with this in mind
Maternal health policy, paid parental leave, childcare funding, and Medicaid coverage for pregnant women are determined by the people elected to federal and state office. The National Women's Law Center and the Maternal Mental Health Leadership Alliance's advocacy resources provide guidance on the specific policy positions most relevant to maternal health. Research candidates' positions on these issues before elections.
Advocate explicitly
The organisations most effectively advancing maternal health policy at the federal level include the Black Mamas Matter Alliance, the Maternal Mental Health Leadership Alliance, the National Partnership for Women and Families, and MomsRising. Each provides specific advocacy resources and guidance on how to engage with elected officials on maternal health policy.
Tell your story
Personal narratives about the experience of becoming a mother in America — the cost of childcare, the experience of taking unpaid leave, the gaps in healthcare coverage, and the specific moments when the system failed to support you — carry weight in policy conversations in ways that data alone does not. Contact your elected representatives using the Congressional member finder, write to your local newspaper, share your story with the organisations doing this work. The cumulative voice of mothers telling the truth about their experience is one of the most powerful forces available in the policy conversation.
The choice that remains
The maternal health crisis in the United States is not a mystery. It is the predictable, documented, extensively researched consequence of specific policy choices that have been made and can be unmade. The countries that do not have this crisis made different choices. Their systems are not perfect. Their policy debates are real. But their mothers survive the experience of giving birth at rates that the United States cannot currently claim, and their families navigate the early years of parenthood with financial and social support that American mothers can currently only read about.
The United States is not incapable of making better policy choices. It has made them before, on other health crises, when the political will was sufficient to the scale of the evidence. The question is whether it will choose to make them here, for mothers, in the current moment.
The maternal mortality rate that is three to four times higher than comparable nations is not inevitable. The childcare crisis that is pushing mothers out of the workforce is not inevitable. The financial devastation of new parenthood in the absence of paid leave is not inevitable. The racial disparities in maternal health outcomes that persist across income and education levels are not inevitable. They are all policy outcomes. They are all the consequence of choices made and choices not made. And they are all available to be changed, if the country decides they should be.
The women giving birth in America right now cannot wait for the policy conversation to resolve at the pace it has been resolving. This article — and the others in this series — have tried to give them the most accurate possible picture of what that system contains, what it costs, and what it would look like if the country chose differently.
Motherhood never made anyone less. The policy that surrounds it should reflect that. The countries that have decided it does reflect it in the outcomes their mothers experience. The United States can get there. The question is not how. The question is when. And the answer to that question is made, one policy decision at a time, by the people the country elects and the pressure those people face from the mothers who have decided that this matters enough to fight for.
Frequently asked questions
Why is the US maternal mortality rate so much higher than other wealthy countries?
It's a policy outcome, not a medical mystery. In 2023 the US rate was 18.6 deaths per 100,000 live births versus 5.1 among peer nations — more than three times higher. The drivers are structural: no universal prenatal care coverage, no federal paid parental leave, unaffordable childcare, and a health system excellent at high-tech acute care but weak on the population-level preventive care and social support that determines whether women survive childbirth. The countries with better outcomes didn't find a medical secret; they made different policy choices.
What policies do countries with better maternal outcomes have in common?
Four features recur: universal prenatal care available regardless of income or insurance; generous paid parental leave that is actually used (Sweden's 480 shared days, Germany's up to 14 months of Elterngeld, Canada's up to 18 months); subsidised or universal childcare (France's crèche, Sweden's förskola, Denmark's 25% fee cap); and comprehensive postpartum care including home visits and universal mental-health screening. The US provides none of these at the federal level.
How much worse is the crisis for Black mothers?
Black women die from pregnancy-related causes at roughly three times the rate of white women — 50.3 deaths per 100,000 live births in 2023 versus 14.5 — a gap that persists across income and education levels and reflects structural racism in healthcare access, quality, and treatment. Native American and Alaska Native women face similarly elevated rates. Crucially, the universal policies that would improve outcomes overall reduce these disparities most, because the women most denied prenatal care, paid leave, and affordable childcare have the most to gain from their provision.
Isn't this kind of policy change too expensive for the US?
The economic evidence says the opposite. Untreated perinatal mood and anxiety disorders alone cost an estimated $14.2 billion a year (MMHLA, drawing on Mathematica modelling) — and treatment costs a fraction of that. NBER's lifecycle research on early childhood programmes (Heckman, García et al.) finds a 13.7% annual return and a 7.3 benefit-to-cost ratio. And KPMG documents the productivity and replacement costs of mothers leaving the workforce. The cost of inaction is already being paid — by families, the health system, and the economy.
What can I actually do about it?
Three things. Vote with maternal health policy in mind — paid leave, childcare funding, and Medicaid for pregnant women are decided by elected officials; the National Women's Law Center and MMHLA publish guidance on candidates' positions. Advocate explicitly through organisations like the Black Mamas Matter Alliance, MMHLA, the National Partnership for Women and Families, and MomsRising. And tell your story to your representatives (via the Congressional member finder) and your local paper — personal narratives move policy in ways data alone cannot.
