The US maternal mortality rate is higher than that of any other high-income country in the world, and it is nearly three times greater for Black and Indigenous women than for white women. Despite these alarming statistics, policies to address the maternal health crisis continue to fall short as the US maternal mortality rate continues to rise.
Although policymakers and advocates have ramped up efforts to address the maternal health crisis in recent years, the experiences and preferences of people who become pregnant and give birth have not always been reflected. Without their perspectives, policies are disconnected from patients’ preferences and risk being ineffective or causing more harm.
“It’s essential to have the voices of those individuals who would be most affected by maternity care policies reflected in the discussion,” said Sarah Benatar, a principal research associate in the Urban Institute’s Health Policy Center. By listening to the people most affected by maternal health care policies, policymakers can better understand their experiences and craft policies that meet their needs.
Urban researchers conducted interviews and small-group discussions with more than 30 women who had given birth in the last five years to better understand how their maternity care preferences align with proposed maternity care solutions. (To reflect how the interviewees identify, we use the terms “women” and “mothers” throughout this piece. However, we recognize that not all people who become pregnant and give birth identify as women.) They also spoke with maternal health stakeholders, including providers and advocates.
To gather evidence for policies that truly reflect women’s needs and desires, the researchers prioritized asking women about the type of care they want and the barriers they face when trying to access it. “The goal is to be able to describe the nuances of people's experiences that quantitative work may not be able to capture. There is big power in hearing people's stories and experiences,” said Jackie Liu, a research assistant at Urban who worked on the project.
Above all else, the interviewees said they want to feel prioritized, be informed and heard, and have a sense of autonomy and choice throughout their pregnancy journeys. Two key areas of opportunity for better centering those needs emerged: patient-provider relationships and the postpartum period.
Women want providers who are empathetic, respectful, and informative
In the interviews, women highly prioritized wanting to trust and feel comfortable with their providers throughout their pregnancy journeys.
Recent studies have examined the effects of having a provider of the same racial or ethnic background on patients’ health and other outcomes. And though patients of color often find additional comfort with providers who look like them and may have had similar life experiences, the research team found that above all else, women wanted providers who listen, are compassionate and empathetic, respect them, answer their questions, and help them make informed decisions.
[I want a provider] who is really knowledgeable and takes the time to explain different options, when there are options, and the risks. Someone who provides you information to be able to make informed decisions about your care, and not just someone who just presents one option and that’s what you have to go with.
But numerous barriers complicate women’s abilities to build trusting relationships with their providers, including subtle and overt discrimination that is rooted in racism.
In addition, for many, where they live and what health insurance they have limit their options for providers. In 2022, more than 2.2 million women of childbearing age in the United States lived in maternity care deserts, or counties lacking a hospital, birth center, or practicing obstetrician. Even in areas with greater provider choice, health insurance can still limit those options. And many women simply do not know the breadth of their provider and care options, including midwives, doulas, and family physicians.
I don’t know what a doula is….But I’ve heard about the midwife, and I was looking into the possibility of [getting] a midwife with my last pregnancy. But I think the insurance has to be able to cover it…and I don’t think I saw it in my insurance, so I don’t think that was an option. And the nearest place that had a midwife was…quite far.
Distrust in the medical system can also prevent women from forming relationships with their maternity care providers. This is especially true for Black and Indigenous women, who have faced systemic racism in the health system for centuries and have the poorest maternal health outcomes
One woman, who did not trust her doctor and conducted her own research before giving birth to understand her options, described one such interaction: “They say you need an IV. No, I don’t. I don’t want Pitocin….[The doctor] asked me how I know all that. I said, ‘Do you think I’m stupid?’”
The numerous barriers women face when trying to access care and build trust with providers underscore the importance of centering women’s experiences and needs in strategies to improve the maternal health care they receive.
Women want comprehensive postpartum coverage and more thoughtful care
Though women expressed a desire for thoughtful, compassionate care throughout their pregnancies, they often shared that their postpartum visits felt especially rushed. The postpartum period is a crucial time for maternal and child health, and more than half of maternal deaths occur after birth. Despite the importance of receiving care during this fragile period, postpartum insurance coverage and the care women receive are rarely enough to support the health and well-being of new mothers and their babies.
Some women the researchers spoke with who had pregnancy-related Medicaid coverage struggled to maintain coverage after their babies were born. Under federal law, Medicaid, which covers more than 40 percent of births nationwide, has to provide pregnancy-related coverage until 60 days postpartum. As a result, many women risk becoming uninsured and missing critical care after just two months. States’ new option under the American Rescue Plan to extend postpartum Medicaid coverage to 12 months could help new mothers maintain coverage for up to a year, but so far, only 30 states and DC have implemented the expansion.
When I was pregnant, they gave me Medicaid. I definitely took advantage of it, but once I had him, that ended. I didn’t know what to do when I needed that help. I didn’t have anybody really to go to because I didn’t have health insurance.
Adequately supporting women postpartum is not only about insurance coverage but also the quality of care they receive. In general, women described their care during the postpartum period as perfunctory, inconvenient, and even forgettable, and they described their providers as rushed or uncaring. One participant recalled that her postpartum appointments were “very much like an assembly line, not individualized at all—very much just moving through everyone.”
[The postpartum visit] was very quick. It’s all like, ‘Do you have any pain? Are you bleeding still? Are you feeling okay? Everything is good? Okay, well call us if you need us or anything.’ It’s very much like that. I don’t know quite what you get out of it when they kick you out right away.
The postpartum experiences interviewees described contrast starkly with the nuanced, respectful, and thoughtful care they wanted. Women expressed a desire for more in-depth conversations on postpartum depression and mental health, contraception, and parenting, and they wanted a kind provider who would listen to them and answer their questions.
Maternal health policies should reflect women’s experiences and preferences
These research findings show that women want to feel cared for, informed, and respected throughout their pregnancy journeys. Several policies and strategies could help achieve this goal:
- Extending postpartum Medicaid coverage. Extending pregnancy-related Medicaid coverage to 12 months postpartum in the 20 states that have not done so could ensure women have access to ongoing health care and, in turn, improve both maternal and child health outcomes. Combining extended postpartum coverage in Medicaid with expanded benefits like postpartum doula coverage, which some states have implemented, could be especially meaningful.
- Ensuring guidelines about postpartum care are reflected in practice. In 2018, the American College of Obstetricians and Gynecologists recommended that postpartum care include at least two visits at 3 weeks and 12 weeks postpartum, as opposed to the one visit recommended in previous guidance. Despite this standard, interviewees’ experiences suggest it is not consistently reflected in practice. Standardizing what type of care women receive during check-ins, designing check-ins to meet postpartum women’s needs, and making these visits easier for women to attend could better support new mothers and babies and lead to better physical and mental health outcomes in the months and years after delivery.
- Equipping patients and providers with information about the breadth of care options. Women emphasized wanting to be informed about their maternity care choices. Midwifery care, for example, is one option that has been shown to lead to improved maternal health outcomes. But health plans do not always cover midwifery, and patients’ and providers’ awareness of and comfort with it vary widely. These factors can limit people’s understanding of midwifery as well as the availability of these services. Better educating patients and providers about women’s care options, especially those that diverge from traditional maternity care models, could help women make more informed decisions about their care and reap the benefits of nontraditional maternity care.
- Diversifying the maternal health care workforce. Research shows that a diverse and representative health care workforce (PDF) can improve patients’ access to care, perceptions of the care they receive, and health outcomes, especially for patients of color. Both the demographic makeup of the maternal health workforce and the types of providers in the workforce need diversification. Investing in the training of more physicians, midwives, doulas, and community health workers from marginalized backgrounds could help women feel more comfortable with and trusting of their providers.
- Training providers to treat patients with compassion and respect. Interviewees highly valued providers who were caring and empathetic, but many described negative interactions with their providers. Training programs that help providers develop their communication and interpersonal skills and encourage empathy and kindness could ensure more women receive compassionate care.
- Shifting the maternity care model. The current approach to maternity care is predominantly clinical, but a more holistic approach would better align with the types of care women want. This could take the form of providers screening for social determinants of health and making referrals to resources, multidisciplinary teams with midwives offering women more robust care during their pregnancy journeys, or reforms allowing for greater insurance coverage and reimbursement for doula services.
To truly integrate women’s maternity care preferences and experiences in the policies that affect them, researchers, policymakers, and advocates need to regularly ask for women’s input. “Increasing maternal mortality trends in the US require a close examination of how the policies being implemented are aligned with the realities of how care is delivered to birthing people—particularly birthing people of color,” said Laurie Zephyrin, a doctor, public health expert, and senior vice president for Advancing Health Equity at the Commonwealth Fund.
Benatar explained that a consistent, frequent, and nationally representative survey of women could help achieve this goal. “We need to have an ongoing resource for understanding maternity care issues that can both identify where the issues are and then track how policy changes are affecting perceptions and experiences,” she said.
Zara Porter, a research analyst at Urban who worked on the project, added that while exploring disparities in health care is important, merely acknowledging these gaps is not enough to achieve true equity. “It's also about looking at the bigger picture of the social determinants of health—the food insecurity, the education, the housing—and how all these systems come together and lead to people not being able to access equitable health care,” she said.
By placing women’s voices at the center of conversations and policies meant to serve them, these strategies can help women access care during their pregnancy journeys that reflects what they want: to be listened to, cared for, and understood.
The research team conducted individual interviews and small-group discussions in the summer and fall of 2022 with women who reported on the June 2022 round of the Health Reform Monitoring Survey that they had given birth in the last five years. The 35 people who participated in the interviews and group discussions identified as women and were of Black, Latinx, multiracial, and white descent. The researchers also spoke with maternal health stakeholders, including birthing advocates and providers with community-based experience.
This story was funded by the Commonwealth Fund. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of our experts.
We thank Laurie Zephyrin, Morenike Ayo-Vaughan, and Noël Manu of the Commonwealth Fund for their support on this project.
DESIGN Rhiannon Newman
EDITING Irene Koo
ILLUSTRATION Scott Siskind (scottsiskind.com)
WRITING Rachel Kenney