Health and Health Care for Women of Reproductive Age

Introduction

The maternal mortality crisis in the United States has been well documented: U.S. women have the highest rate of maternal deaths among high-income countries, while Black women are nearly three times more likely to die from pregnancy-related complications than white women are.¹ But maternal deaths and complications may be a bellwether for the U.S.’s wider failures with respect to women’s health and health care.

Using data from the Commonwealth Fund’s 2020 International Health Policy Survey and the Organisation for Economic Co-operation and Development (OECD), this brief compares selected measures of health care access and outcomes for women of reproductive age (18 to 49) in 11 high-income countries. After identifying gaps in U.S. health system performance for women in this age group, we explore some of the policies other nations have put in place to ensure more equitable access and better health outcomes. We also suggest policy options for the United States.

Findings

American women of reproductive age were significantly less likely to rate their country’s health care system as “very good” or “good” compared to women in the 10 other countries surveyed. A quarter of U.S. women rated the health system highly, in contrast to majorities of women in the other countries. The access and affordability problems highlighted in this brief may contribute to U.S. women’s overall lower assessment of the health care system.

Access and Affordability

Having a regular doctor or place of care, such as a primary care physician or a medical home, is important for ensuring good health outcomes, minimizing health disparities, and limiting health care costs.² Majorities of women of reproductive age in all 11 countries reported having a regular doctor or place to go for care. In Sweden, the U.S., Canada, and Australia, women were the least likely to report this, while nearly all women in the Netherlands and Norway said they have a regular doctor or place of care.

High health care costs are significant burdens for many U.S. households, even those covered by health insurance. Over one-quarter of women of reproductive age in the U.S. and Switzerland spend USD 2,000 or more in out-of-pocket medical costs, as compared with less than 5 percent of women in the U.K., France, and Netherlands. These high costs can discourage women from seeking needed medical care, as shown in the next chart.

The Commonwealth Fund survey asked women about times when cost prevented them from getting health care in the past year, including when they had a medical problem but did not visit a doctor; skipped a needed test, treatment, or follow-up visit; did not fill a prescription for medicine; or skipped medication doses. Half of women of reproductive age in the U.S. reported skipping or delaying needed care because of costs. U.S. survey respondents were significantly more likely to report skipping care than respondents in all other countries. In the Netherlands, only 12 percent of women said they had forgone care for cost reasons.

America’s outlier status on this measure likely stems from the large number of women who lack health insurance — 10 million — as well as the high copayments, coinsurance, and deductibles that many U.S. women enrolled in commercial health plans face when seeking care.³

The Commonwealth Fund survey asked women whether they’d had at least one medical bill problem in the past year, including: having serious difficulty paying for care they’d received or being unable to pay a medical bill; spending a lot of time on paperwork or disputes related to medical bills; or having their insurer deny payment or pay less than expected for a claim.

Compared to their counterparts in the other 10 countries, women of reproductive age in the U.S. were significantly more likely to report one or more of these medical bill problems, with over half saying they had experienced one or more. Only one in 10 women in the U.K., which provides free care to all residents through the country’s National Health Service, reported a medical bill problem.

Health Status and Outcomes

When looking at all women, we found that those in the U.S. have the highest rate of avoidable deaths: nearly 200 in 100,000 deaths could have been prevented or treated with the right care provided at the right time. Swiss women are the least likely to die from a preventable or treatable cause.

High rates of avoidable deaths often indicate shortcomings in public health and care delivery systems. Broad use of primary and preventive health care services, including cancer screenings and immunizations, can reduce the number of premature and unnecessary deaths.⁴

The U.S. has long had the highest rate of maternal mortality related to complications of pregnancy and childbirth. In 2020, there were 24 maternal deaths for every 100,000 live births in the U.S., more than three times the rate in the 10 other high-income countries studied.⁵ In Norway, no women died from maternal complications in 2019, the year with the latest available data.

A high rate of cesarean sections, inadequate prenatal care, and elevated rates of chronic illnesses like obesity, diabetes, and heart disease may be factors contributing to the high U.S. maternal mortality rate.⁶ Many maternal deaths result from missed or delayed opportunities for treatment.

The maternal health crisis is even more acute for Black women, who in the U.S. are nearly three times more likely than white women to die from maternal complications. Racial inequities are not unique to women in the U.S., however. In the U.K., for example, Black women are four times more likely than white women to die in pregnancy and childbirth.⁷

In the U.S., one in five women of reproductive age reported having two or more chronic conditions, in contrast with fewer than one in 10 women in Switzerland, Germany, Sweden, and France.⁸

Good management of chronic conditions is associated with good medical care, as well as with access to safe housing and nutritious food, adequate income, and education — social factors that are strongly linked to overall health.⁹ Despite the importance of robust primary health care and social services in helping people manage their chronic conditions, or avoid chronic illnesses in the first place, the U.S. invests less in these areas on a per person basis than other high-income countries.¹⁰

Women in each country answered a series of questions regarding their mental health at the start of the COVID-19 pandemic, when the survey was conducted. They were asked about being diagnosed with a mental health condition; experiencing stress, sadness, or anxiety that was difficult to cope with on their own; or wanting to talk to a mental health professional in the past year.

Since the pandemic began, rates of mental health conditions have risen globally.¹¹ Our survey found that women of reproductive age in Canada, Australia, and the U.S. were the most likely to report having a mental health care need. Women in Germany were the least likely.

Discussion

Research shows that investing in women’s health results in a healthier overall population, healthier future generations, and greater social and economic benefits.¹² Yet the U.S. remains the only wealthy country without universal health care, leaving about 10 million women without insurance.¹³

Other countries have made substantial efforts to ensure women are able to get needed primary care as well as maternal and mental health care. There are a number of steps U.S. policymakers can take to substantially improve health and wellness for women of reproductive age.

Ensure all women have access to affordable health care.

Primary care. Although the Affordable Care Act (ACA) did away with cost sharing for preventive services like wellness visits, immunizations, and screenings, U.S. women still can face high out-of-pocket costs for other care. In other countries, women do not face these high out-of-pocket costs. For example, Canada, Germany, the Netherlands, and the U.K. impose no cost sharing for primary care visits.¹⁴ U.S. policymakers could extend affordable and comprehensive primary care to all women by expanding on the ACA’s reforms, such as enhancing marketplace plan subsidies and providing coverage for those who fall in the “Medicaid coverage gap.”¹⁵

Maternal care. In the U.S., many women have high out-of-pocket payments for maternity care, even if they are insured, in the form of copays and deductibles. The types of maternity services that insurers cover are limited, too. For example, pregnancy-related Medicaid coverage lasts only 60 days postpartum. Maternal care, including postpartum care, is free in most of the countries we studied and includes home visits by a nurse.¹⁶ U.S. policymakers have an opportunity to encourage all states to extend Medicaid coverage to a minimum of 12 months postpartum, as well as to expand implementation of federal guidelines for coverage of women’s preventive services without cost-sharing to encompass all women, including those enrolled in traditional Medicaid.

Mental health care. Despite having the highest rate of mental health care needs, women in the U.S. are more likely to report skipping needed care, including mental health care, for cost reasons than women in the other 10 countries. Other nations have made mental health care more affordable in recent years. France waives all copays for care related to long-term chronic mental illnesses.¹⁷ In response to COVID-19, Australia is covering additional subsidized therapy sessions provided by psychologists, psychiatrists, general practitioners, and other clinicians.¹⁸ At a minimum, U.S. policymakers could extend the ACA’s requirement to cover essential health benefits, including mental health care, to the large-group employer plans that cover most Americans.¹⁹

Grow and diversify the health care workforce.

Primary care. The U.S. health care system has one of the lowest supplies of primary care clinicians — most people’s first point of contact with the health care system — of the 11 OECD countries in our survey. With a growing and aging population, the demand for physicians is likely to continue to outpace the supply.²⁰

The U.S. also has the largest wage gap between primary care physicians and specialists and the highest tuition fees for medical students. Other countries invest more in primary care and have greater parity between wages for primary care physicians and specialists.²¹ The U.S. could increase the supply of primary care physicians in several ways, including subsidizing medical education to incentivize medical students to opt for primary care practice, and introducing legislation to increase the number of federally supported Medicare residency positions.²²

Maternal health. In the U.S., which on a per capita basis has among the fewest maternal health providers overall and among the fewest midwives, most women see an obstetrician in a hospital.²³ Top-performing health systems like those of Norway, the Netherlands, and Australia are better at preventing maternal deaths for several reasons, including the wide use of alternate models of care.²⁴ In the U.S., expanding the maternal care workforce to include more nurses, midwives, and doulas could improve perinatal and postpartum outcomes, particularly for people experiencing significant inequities in birth outcomes.²⁵

Greater investment in the U.S. primary health care workforce and an expansion of the medical home model to include women-centered primary health care could also have a significant impact on maternal health.²⁶ One bill introduced in Congress, the Midwives for MOMS Act, aims to provide targeted grant funding for accredited midwifery education programs.²⁷ Additional efforts to incentivize medical residents to work in rural or other underserved areas could increase the overall supply of maternal health providers.²⁸

Mental health care. The short supply of mental health workers in the U.S. — 105 professionals per 100,000 people — can make it challenging for some Americans to get the help they need.²⁹ Canada, Switzerland, and Australia have approximately twice the proportion of mental health workers. To expand its mental health workforce and integrate mental health care with primary care, the U.K. implemented its talk therapy program, Improving Access to Psychological Therapies, free of charge at clinics throughout the country.³⁰

The Biden administration has proposed investments to increase the supply of mental health workers in underserved communities, including funding for proven behavioral health training programs and funding to expand the availability of evidence-based community mental health services.³¹

Conclusion

The U.S. health care system too often fails women of reproductive age. The COVID-19 pandemic has unveiled the true extent of health and racial inequities in U.S. health care and exacerbated its many weaknesses, including underinvestment in primary care and mental health.³² Across the U.S., women increasingly face threats to reproductive health care access, including abortion services, which could have a lifelong impact on physical and mental health.³³ While the nation awaits the outcomes of legal challenges to state restrictions on these services, U.S. policymakers have a number of options to improve health and health care for women of reproductive age.