What's the state of women's health, care access in the U.S.?

Health outcomes

The Commonwealth Fund used numerous metrics to measure health outcomes, which include the following:

• All-cause mortality, maternal and infant mortality.
• Preterm birth rates.
• Syphilis rates among women of reproductive age.
• Infants born with congenital syphilis.
• Self-reported health status.
• Postpartum depression.
• Breast and cervical cancer deaths.
• Poor mental health.
• Intimate partner violence.

The highest-ranking states for health outcomes included Massachusetts, New Jersey and Connecticut.

All-cause mortality for women of reproductive age (ages 15 to 44) is highest in southeastern states, ranging from around 142 to 204 deaths per 100,000 women. This is likely due to poor access to healthcare before, during and after pregnancy, plus socioeconomic status and social determinants of health.

According to the researchers, all-cause mortality is driven in large part by preventable deaths, like maternal mortality.

Maternal mortality rate nearly doubled between 2018 and 2022, a figure mostly driven by increases in Black and American Indian/Alaska Native (AI/AN) women. Maternal mortality rates are highest in Arkansas, Louisiana, Mississippi and Tennessee. Notably, these places are ripe with maternity care deserts.

The Commonwealth Fund also pointed out the top performers for maternal mortality, which are Vermont, California and Connecticut. These states might have better outcomes because they have more maternity care providers, fewer women going without prenatal care, fewer women going without postpartum checkups and fewer uninsured women ages 19 to 64.

In addition to highlighting maternal mortality rates, the report zeroed in on syphilis infections, which are increasing nationwide. Specifically, syphilis infection rates are highest in South Dakota, New Mexico, Mississippi, Arkansas and Oklahoma.

Rising rates are likely driven by increases in substance use; limited access to care and health services for screening, diagnosis and treatment; limited screening during pregnancy; and isolated social networks, the researchers posited.

Healthcare quality and prevention

The Commonwealth Fund assessed healthcare quality and prevention by looking a births by Cesarean section (C-section) for low-risk pregnancies, preventive care utilization, prenatal and postpartum care and mental health screening.

Massachusetts, Rhode Island and Connecticut were among the highest-ranking states, while Nevada, Mississippi and Texas were the lowest.

Overall, the U.S. is underperforming in terms of C-sections in low-risk pregnancies. Although C-sections can be life-saving in certain circumstances, the Commonwealth Fund said they can be a proxy for low-quality care because of their increased risk for maternal morbidity and mortality, longer recovery, adverse outcomes in subsequent births and negative impacts on infant health.

Right now, HHS has set a goal of 23.6% of low-risk births to be done by C-section by 2030; in 2022, it was 26.3%.

But rates of C-sections in low-risk births vary by region. States in the Deep South and some parts of the Northeast have high C-section rates in low-risk births. Meanwhile, C-section rates are lower in states with strong midwifery care models, like in Alaska. They are higher in states with higher Medicaid spending and overall higher healthcare utilization, the researchers added.

In terms of preventive care delivery, there is also state-by-state variance. For example, states screen for postpartum depression at different rates. This comes as mental health concerns serve as the leading cause of pregnancy-related deaths during or after a pregnancy.

However, the data shows that post-partum depression is less common in states with more screening protocols.

Preventive screening practice also varies even when it does not concern maternal healthcare. For example, states in the South have the highest rates of breast and cervical cancer deaths, which are considered preventable and treatable with timely access to screening, diagnosis and treatment.

In the Northeast, breast and cervical cancer screening rates are high, and mortality rates for those cancers are low. Conversely, screening rates in the South tend to be low, while mortality and racial health disparities for these two cancers are steep.

There are many reasons someone might not get screened, the researchers commented. While initial cancer screenings are free under the ACA, follow-up tests are not, so cost might serve as a deterrent.

In terms of breast and cervical cancer mortality disparities, quality of care could be at play. The researchers said Black women are more likely to be up to date on their screenings than white women, but they see poorer outcomes and are more likely to die from the cancers. This could be due to poorer access to follow-up testing, poorer quality of care and a longer lag in abnormal mammograms to diagnostic follow-up.

Coverage, access and affordability

Finally, the report examined women's health in terms of health insurance coverage and how it affects healthcare affordability and access. Specifically, the Commonwealth Fund looked at insurance coverage, usual source of care, cost-related problems accessing healthcare and workforce capacity for reproductive healthcare delivery.

Vermont, the District of Columbia and Maine were the top-ranked states in this area, while Texas, Georgia and Nevada rounded out the bottom performers.

Nationally, the uninsured rate among women of reproductive age is high. Although aided by the Affordable Care Act (ACA), uninsured rates for women of reproductive age are still higher than for women ages 45 to 64, oscillating from 2.6% in Massachusetts to 22% in Texas.

Meanwhile, challenges associated with accessing Medicaid coverage continue. Ten states have not expanded Medicaid, which is now allowable under the ACA. Additionally, issues for immigrants, limited awareness and Medicaid disenrollments get in the way.

Gaps in insurance coverage are reflected in limited access to certain types of healthcare. For example, in states that have not expanded Medicaid, women of reproductive age are more likely to skip necessary healthcare due to cost. This practice was most common in Texas, Nevada, Georgia, Oklahoma, Alabama, Wyoming, Florida, Mississippi, and South Carolina (all but Nevada and Oklahoma have declined Medicaid expansion).

Medicaid plays a big role in access to maternity care. All state Medicaid programs are required to provide pregnancy-related coverage up to 138% of the federal poverty level, but most states set the threshold at 200%. States must also provide 60 days of postpartum coverage, although 47 states have extended this to 12 months.

All said, Medicaid covers 42% of births in the U.S. and two-thirds of births for Black and AI/AN people.

However, the Commonwealth Fund indicated that this creates a gap in insurance access when a woman is and is not pregnant. Uninsured rates for pregnant women are markedly lower than they are for women before they become pregnant. This trend is pronounced in states that haven't expanded Medicaid, such as Alabama, Georgia, Mississippi and Tennessee.

The Commonwealth Fund also addressed workforce capacity in this report section, zeroing in on trends in maternity care providers. Previous reports have shown that maternity care deserts have become more common, in part due to the closure of birthing wards.

This report also found that abortion restrictions are linked to workforce issues. In particular, states with abortion restrictions have the fewest number of maternity care providers, potentially due to the risk providers face practicing reproductive healthcare in such states.

Of the 24 states with abortion restrictions, gestational limits or pending legislation, 21 are in the bottom fifth of states with the fewest number of maternity care providers relative to the number of people who might need them.

"In 2023 and 2024, fewer medical school graduates applied to residency programs in states that banned abortion, both in obstetrics and gynecology and across all specialties, compared to states without bans," the report authors added. "This is an ominous development for these states, where providers are already scarce."

The report authors stressed that there is more on the line in terms of women's health moving forward. Pending healthcare policy could affect access to in vitro fertilization, other types of reproductive healthcare and Medicaid access.

"The current and future policy environment could make those divides deeper still and weaken performance in even more states," the researchers concluded. "Our findings suggest that urgent action by Congress and state policymakers is necessary to ensure women have timely access to complete health and reproductive care, regardless of who they are, what they earn, or where they live."

Sara Heath has covered news related to patient engagement and health equity since 2015.