The U.S. has the highest maternal death rate among high-income countries — almost three times that of the next country on the list.

The concerning trend disproportionately affects Black women, and it’s growing. Yet childbearing services are withering away nationwide.

What can states do about it?

Between 2006 and 2020, more the 400 childbearing services closed, and upwards of 11 health systems between March and June 2022 announced plans to end their obstetric services.

As birthing specialists relocate, maternity care deserts expand, especially in rural counties, nearly half of which lack any such services. Rural areas also rely more on Medicaid, which pays less than private insurance for child birthing.  

The authors of a paper in JAMA Forum argue for expanding community-based approaches and addressing workforce shortfalls by widening the use of doulas, midwives and child birthing centers (CBCs) for low-risk births.

Freestanding CBCs can offer perinatal care, including labor and delivery, but transfer patients to hospital partners should complications arise.

Broadly speaking, studies link the more continuous support offered by CBCs and midwives to a reduced need for birth interventions.

Depending on the approaches used, research also finds associations with shorter labor, fewer cesarean deliveries, newborns with higher Apgar scores, higher patient satisfaction and lower rates of postpartum depression and anxiety.

Apgar refers to a brief health evaluation performed on infants one and five minutes following birth. It is named for Dr. Virginia Apgar, the Columbia University anesthesiologist who developed it in 1952.

Arizona grants wide authority to certified nurse midwives (CNMs), and the state Medicaid agency reimburses them at 90% of the physician rate. Twenty-three states do not currently grant full practice authority to CNMs.

The state does not reimburse non-nurse midwives.