How fragmented U.S. health care endangers expectant moms

As I noted previously, the steady rise in the percentage of babies delivered via Cesarean section (currently just under 1 in 3 deliveries in the U.S.) is due in large part to "too much care" - a high-technology mindset that permeates training programs in obstetrics and gynecology, combined with a low tolerance for uncertainty driven by concerns about malpractice lawsuits. While surgical deliveries are sometimes unavoidable, it's clear that less interventional maternity care providers such as midwives and family physicians can spare many more women from having C-sections, with comparable maternal and infant health outcomes.

However, for many expectant mothers, the problem is too little care - poor access to prenatal care to poverty, a lack of health insurance, non-citizen status, or other barriers. "Deadly Delivery," a report released earlier this month by Amnesty International, chronicles the failure of the high spending U.S. health system to provide adequate prenatal care for 1 in 4 women, leading to a maternal mortality rate that ranks 41st in the world and has more than doubled over the past two decades. The report observes that 13 million women between the ages of 15 and 44 are uninsured, and many who become pregnant have trouble obtaining Medicaid coverage due to bureaucratic obstacles. Even women who obtain coverage have a hard time accessing care due to a shortage of maternity providers in rural and urban areas.

Living and working in the Washington, DC area since 2004, I've seen firsthand how difficult it is for uninsured women to get good prenatal care, despite a physician to population ratio that is one of the highest in the nation. It isn't surprising, then, that pregnant women in the District of Columbia have a risk of death that is nearly 3 times the national average, and more than 7 times the Healthy People 2010 goal of 4.3 deaths per 100,000 live births. The only five states that have achieved that goal are Massachusetts, Vermont, Minnesota, Maine, and Indiana. Interestingly enough, Massachusetts, Vermont, and Minnesota are #1, 2, and 3 in state rankings of the lowest percentage of the population without insurance. Coincidence? I think not.