How the Maldives Reduced Maternal Mortality by More Than 90 Percent — While the U.S. Rate Has Since Tripled
In 1990, a staggering 677 women in the Maldives died of pregnancy-related complications for every 100,000 live births. By 2017, the government had brought this down to 46 deaths per 100,000 — the world’s largest drop in maternal mortality in the past three decades.
Maternal mortality rates are broadly comparable in the United States, but the disparities within the U.S. are revealing. While approximately 23 women died for every 100,000 live births in 2020, the rate was nearly two-and-a-half times higher for Black women — about 55 deaths per 100,000 live births. And while the Maldives was able to reduce maternal mortality by more than 90 percent between 1990 and 2017, the United States saw an increase of more than 100 percent during this same period, and by 2020, nearly 200 percent.
The Maldives has made incredible progress despite major challenges: the country comprises 187 islands and has a health care system that has historically been considered underdeveloped. This has meant trying to guarantee adequate access to obstetric care for women spread across dozens of islands with few hospitals and little capacity to provide such services.
The Maldivian government began with an extensive review of maternal death causes in the country. Officials then implemented approaches that nations with the some of the lowest rates of maternal deaths, such as the Netherlands and Australia, have adopted. These strategies included:
Today, nearly all Maldivian women give birth with the support of skilled medical staff in a health care facility. The country now has double the number of midwives and nurses per 1,000 people than the U.S., and every hospital has an emergency obstetric care facility.
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A U.S. Crisis That Should Never Have Come to Pass
The progress made in the Maldives tells us that the concurrent rise in maternal deaths in the U.S. was avoidable. It’s a product of the U.S. failing to ensure equitable access to care delivered through a well-staffed maternal health system, critical factors in the rapid drop in maternal mortality achieved by the Maldives and many high-income countries.
Access to care. Too many American women lack reliable, consistent access to health care services during pregnancy. Some of the most marginalized women of reproductive age don’t have any affordable insurance coverage options — a big reason why some 10 million U.S. women are uninsured, disproportionately Black and low-income. One study found that nearly 2 million women of reproductive age living in states that haven’t expanded Medicaid don’t meet eligibility requirements to obtain even basic primary care.
While home visits proved essential in the Maldives for providing direct, regular access to reproductive care throughout pregnancy, women in the U.S. are among the least likely to be seen by a doctor at home. They are also among the least likely to have a regular doctor.
The situation is similar when it comes to contraceptive care, which can prevent high-risk births and lower the number of maternal deaths. Although the Affordable Care Act guarantees the right to free contraception for all women, more than 19 million women live in areas without any health centers that offer a full range of contraceptive methods.
The maternal health workforce. Among high-income countries, the U.S. continues to have one of the lowest numbers of maternal health workers, especially midwives. The American College of Nurse Midwives called the U.S. maternity workforce “upside down relative to patient needs,” meaning most low-risk births could, and should, be managed by midwives, yet nearly all births are delivered by an ob/gyn. While demand for midwifery services has increased in recent years, and the ACA requires Medicaid to pay for midwifery care in birthing centers, many clinics struggle to serve Medicaid patients. Low reimbursement rates, administrative hurdles, and billing problems are often to blame. Expanding access to midwifery care alone could substantially reduce maternal deaths.
It was important for the Biden administration to acknowledge that the U.S. is failing women. But we are far from solving the nation’s maternal health crisis, which has been exacerbated by the COVID-19 pandemic. Without guaranteeing that everyone — regardless of income, location, race, or ethnicity — has access to comprehensive reproductive care, Americans will continue to die at unacceptable rates.
Dr Faisal Saeed MBBS, LLM (Health Law), FISQua
1 年We've achieved quite a lot in the public health space given the spread out geography of the islands, and need to spread the learnings from what we have done well (reduction in infant and maternal mortality, elimination of a number of communicable diseases) to other areas of health. In particular improving the safety and quality of care and uptake of new technologies to bridge the gap to access care.
Licensed Physician | Epidemiologist | Evaluator | Researcher
1 年Seems like the Maldives put a value on a stronger multi-layered maternal health workforce.
Senior Consultant | Physician, ABOS, MBA
1 年why don't Anerican women feel obligated to get prenatal care? I
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