Giving Birth in America: Arkansas

Nearly 99 million people live in areas with shortages of primary health care providers, mostly in rural or under-resourced urban communities. Shortages of obstetricians, midwives, hospitals, and birth centers mean that some people, especially in rural areas, have to travel an hour or more to get basic prenatal and delivery care. For women with complications who need to see a specialist, the trip can be prohibitive, leading some women to go without the level of care they need for the best chance at a healthy birth.

The countries with the best maternal health outcomes also have universal health coverage. America’s health care system is the most expensive in the world, yet many people go without the care they need. People of color are more likely to remain without coverage; Hispanic and Black women have significantly higher uninsured rates (22% and 12%, respectively), compared with white women (7%). Women with consistent access to health care throughout the perinatal period are more likely to access preventative care and be able to manage or address risks or complications early to maximize the chances of a healthy pregnancy and birth.

Following the Affordable Care Act, 13 states, mostly concentrated in the South, decided not to expand Medicaid. As a result, approximately 4 million poor, uninsured adults fall into a “coverage gap”; i.e., they earn too much to qualify for Medicaid but not enough to purchase insurance on the Marketplace.When women are unable to access affordable health care throughout their lifetimes, they are more likely to enter into pregnancy with unmanaged chronic conditions that can lead to poor maternal health outcomes.

The United States’ national cesarean section rate is nearly one third (32.1%). While c-sections can be lifesaving, the WHO has found that cesarean section rates higher than 10% do not offer benefits to mothers or babies. In addition to c-sections, overused procedures include: inducing labor early, requiring women to stay in bed, and restricting food and drink. Because all medical procedures come with risks as well as benefits, procedures should not be used for the convenience of maternity care providers or facilities and should always be performed with the mother’s consent.

Many hospitals and provider practices are committing to improving maternal health care by revising practice guidelines to prevent unnecessary procedures and support women in laboring longer. Additionally, low-risk, evidence-based approaches such as the midwifery model and doula support result in lower rates of interventions, such as induction of labor and epidural use, and lead to higher rates of vaginal delivery.

Racial disparities in maternal mortality in the U.S. have been documented for over 100 years—as long as maternal mortality data has been available. Today, significant racial disparities persist: Black and Indigenous women are 2 to 3 times more likely to die from a complication of pregnancy or childbirth than white women. Maternal mortality rates are twice as high for women living in counties with high poverty rates, compared with women living in counties with low rates of poverty.

Many pregnant people, especially those enrolled in Medicaid, see different care providers at each prenatal visit and meet the physician or midwife attending their birth for the first time when they arrive at the hospital in labor. Information often falls through the cracks when a person is not able to build a trusting relationship with their care provider. In addition, many women don’t know about available perinatal support services or have difficulty navigating a complex health system. A comprehensive and integrated team-based approach to care can have a powerful beneficial impact, especially for those at the greatest risk of poor health outcomes, and make a difference in achieving a safe and healthy birth.

In the U.S., women have reported a range of disrespectful, coercive, and abusive behaviors in care related to pregnancy and childbirth. Women report that they have been ignored, shouted at, or threatened (including with coerced or withheld treatment or with calling child protective services), had their physical privacy violated, and more rarely, experienced physical abuse. A disturbing number of cases have been documented where women with a life-threatening complication knew something was wrong, but their requests for help went unheeded.

The midwifery model, doula support, and other patient-centered models of care emphasize the value of respectful, equitable treatment, and engage birthing people as active participants in their care.

Yet this stage of pregnancy is often neglected in maternal health policy, leaving many moms and new parents without the support they need and deserve. Policies like guaranteed paid maternity leave, Medicaid coverage through at least the full year following childbirth, and Medicaid coverage for postpartum doula support are immediately needed to support U.S. families during this critical period.

Despite this, many families experience significant barriers to accessing needed support, including stigma, distance to care, cost, inadequate insurance coverage, and lack of integration of mental health screening into routine maternity care visits.