A crisis in U.S. maternal healthcare: lessons from Europe for the U.S.

Introduction

The United States’ maternal health crisis warrants immediate systemic reform - we should no longer accept a healthcare system that consistently fails mothers, particularly women of color [1].

While our European peers have built healthcare systems that protect mothers through universal access and integrated care, the U.S. continues to accept unconscionable outcomes. Despite having the highest per capita healthcare expenditure globally, our maternal mortality rate (24 deaths per 100,000 births) remains three to six times higher than peer nations like Sweden (4/100,000), the Netherlands (5/100,000), Great Britain (6/100,000), and Germany (7/100,000) [1]. It’s important to note that these comparisons are affected by different reporting timeframes - the U.S. tracks maternal deaths up to one year postpartum, while European countries typically only count deaths up to 42 days after birth, suggesting the actual disparity may be somewhat smaller than these statistics indicate. However, a recent study reported that the high and rising maternal mortality rates in the United States may be due to changes in maternal mortality surveillance methods, particularly the introduction of the pregnancy checkbox, which has led to significant misclassification of maternal deaths, masking true trends and declines in direct obstetrical causes, making it potentially more difficult to directly compare data [2].

Maternal obesity, driving pregnancy-related deaths through cardiovascular and thromboembolic complications, is significantly higher in US vs. European women [3], 4]. This reflects systemic differences: US environments feature fast food prevalence, limited support, and car-dependent communities, while European countries offer fresh markets, walkable cities, and prevention-focused care. U.S. healthcare providers should deliver culturally-sensitive nutritional guidance addressing both pregnancy needs and social barriers to healthy eating.

Like other developed nations, around 75–80 % of US maternal deaths are considered potentially preventable. Our significantly higher mortality rate indicates critical gaps in implementing known prevention strategies and ensuring access to quality maternal care [5].

The gap between U.S. and European maternal health outcomes reveals fundamental flaws in American healthcare delivery, particularly affecting Black women in the U.S. who face mortality rates more than twice that of white women [6]. While European nations have implemented comprehensive systems with universal access, midwife-led care, and robust postpartum support, the U.S. struggles with fragmented care delivery, inconsistent access, and pronounced racial inequities (Table 1). These challenges are compounded by higher rates of medical risk factors including obesity, diabetes, and cesarean deliveries. Understanding and addressing these systemic challenges is crucial for reducing preventable maternal deaths, which account for over 80 % of maternal mortality in the U.S.

Systemic gaps in U.S. maternal healthcare: comparing American and European models

The United States stands alone among western industrialized nations in failing to provide universal health coverage, relying instead on a for-profit, minimally regulated private insurance system that prioritizes corporate interests over equitable access to care for the majority of its population [7]. The fragmented U.S. healthcare system, with its mix of public and private delivery models, creates critical gaps in maternal care that contrast sharply with European nations’ comprehensive approaches. While European systems provide healthcare access, integrated healthcare delivery, and standardized professional training, the U.S. lacks consistent standards across crucial areas including preconception counseling, perinatal care, and postpartum services (Table 1). This disparity is particularly evident in postpartum care delivery, where European models demonstrate superior outcomes through varied but systematic approaches.

European countries employ different but effective postpartum care strategies. Nations like France and Germany maintain extended hospital stays (3–5 days) compared to U.S. standards (1–2 days), facilitating early complication detection and patient education. Conversely, the Netherlands achieves excellent outcomes through early discharge paired with comprehensive home care support, suggesting that continuity and quality of care may be more crucial than length of hospitalization.

The impact of these systemic differences is stark: while more than two-thirds of U.S. maternal deaths occur during the postpartum period – primarily after minimal healthcare oversight resumes – European countries report less than half this rate through systematic “fourth trimester” care including routine professional home visits and continued medical supervision. This disparity particularly affects the estimated 12 million U.S. reproductive-age women lacking consistent health insurance, who face up to three times higher risk of pregnancy-related complications. Resistance to universal healthcare reform, particularly from professional organizations advocating market-based solutions, continues to impede progress in addressing the U.S. maternal health crisis. In the U.S., political resistance to universal healthcare, particularly under Republican leadership, often undermines efforts to address critical issues like maternal mortality and jeopardizes the stability of federally funded maternal health initiatives. This opposition stems from a preference for solutions that prioritize market forces over government mandates, despite evidence that universal systems can achieve equitable healthcare access and improved outcomes in other countries with lower expenses. The American Medical Association (AMA), representing over 270,000 physicians and medical students, has historically opposed universal healthcare reforms, including Medicare in the 1960s and recent single-payer proposals, arguing such systems would restrict physician autonomy and limit patient choice [7]. While the AMA supported the Affordable Care Act, its continued preference for market-based solutions and resistance to broader universal healthcare models helps maintain a system where U.S. physician salaries remain substantially higher than European counterparts - often 2–3 times more [8]. The opposition to universal healthcare reform continues to impede progress toward addressing the maternal health crisis, particularly affecting the millions of reproductive-age women who lack consistent health insurance coverage. As preventable maternal deaths rise, especially among underserved populations, maintaining the current fragmented system becomes increasingly untenable from both public health and ethical perspectives.

Reduced access to reproductive care in the US increases maternal mortality

Access to comprehensive reproductive care, including access to safe and legal abortion, has been proven to reduce maternal mortality. European nations have uniform access to reproductive healthcare services including abortions. The U.S. does not. After the 1973 U S. Supreme court’s decision to legalize abortions, maternal mortality rates decreased significantly, especially for people of color whose maternal mortality rates decreased by 30–40 % [9].

Given expected shifts in federal policy with the new administration in Washington DC, access to abortion is likely to be further restricted and expected to worsen the maternal mortality crisis, while high-performing European countries ensure seamless integration of abortion services within universal frameworks. Early reports are already documenting U.S. maternal deaths directly linked to U.S. state’s abortion restrictions and delays in emergency obstetric care [10], [11], [12]. This healthcare fragmentation, combined with racial disparities that persist regardless of education, income, or insurance status, creates a complex crisis requiring immediate intervention.

Integrating truly professional midwives into US maternity services

A successful transformation of U.S, maternity care requires hospitals to integrate standardized evidence-based practices like physiologic births with fewer interventions, while creating environments such as in-hospital professional midwifery-led birthing centers, where patients maintain autonomy and have their cultural, emotional, and physical needs met. Patient preferences must be balanced with safety by implementing comprehensive emergency protocols and offering flexible options, ultimately reimagining care delivery without compromising essential medical standards.

Professional midwifery standards diverge significantly between the U.S. and Europe. In Europe, midwife training is standardized. For example, Germany’s approach to midwifery care is distinctive due to the landmark “Hebammengesetz” (Midwife Law) which mandates that a midwife must be present at every birth, regardless of setting - whether in a hospital, birth center, or home. A midwife (Hebamme) is legally required to be present at every birth, including cesarean deliveries. During a cesarean, the midwife provides emotional support, prepares the mother, assists with the newborn, and ensures postpartum care as part of the medical team. This requirement reflects the central role of midwives in German maternal care. In 2020, Germany further elevated the profession by transitioning midwifery education from vocational schools to universities, requiring a bachelor’s degree. This academization aligns with EU directives and recognizes midwifery as an evidence-based healthcare profession requiring advanced clinical reasoning and autonomous practice capabilities.

In the Netherlands, midwifery holds an especially prominent position, with autonomous midwives providing care for about 75 % of all pregnant women. Dutch midwives complete a four-year direct-entry university program and are fully integrated into the healthcare system, with clear protocols for collaboration with obstetricians when complications arise. This integration has helped the safety of the Dutch birth home system, which has been a traditional part of their maternity care model, though there has been a significant decrease in home births in Holland over the last decades.

France takes a unique approach, where midwives (“sages-femmes”) are medical professionals who complete five years of university training after passing a competitive entrance exam. French midwives have broad authority in maternal care, including prescribing medications and contraceptives, and are considered medical practitioners under French law. They primarily practice in hospital settings, where they manage normal pregnancies and births independently while maintaining close collaboration with obstetricians.

In contrast, the U.S. has a fragmented midwifery system with varying levels of education, training, and legal recognition. Certified Professional Midwives (CPMs), who attend the majority of home births in the U.S., have significantly less rigorous educational requirements compared to Certified Nurse Midwives (CNMs) or international counterparts [13]. Certified Professional Midwives (CPMs) often lack formal professional healthcare training or education, instead receiving their credentials primarily through apprenticeships. Unlike other medical providers, CPMs are not required to complete standardized academic programs or obtain clinical training in accredited medical institutions. Moreover, CPMs are legally authorized to practice in only 35 states, leading to a concerning number of unlicensed practitioners attending home births in states where they cannot obtain licensure. This lack of standardized advanced education and inconsistent regulation has led to concerning variations in care quality and safety. Multiple studies have found that planned home births and birthing center births in the U.S. are associated with a 2–3 fold increase in neonatal mortality compared to hospital births, with even higher rates among patients with increased risks and when births are attended by non-certified midwives [14], [15], [16], [17]. These outcomes contrast sharply with countries like the Netherlands, where well-integrated home birth systems with university-trained midwives show comparable safety to hospital births.

Black maternal mortality crisis: a complex health disparity

Black women face maternal mortality rates more than twice that of white women - a disparity that persists across all education and income levels [18]. This crisis involves multiple intersecting factors, including healthcare access disparities, differences in quality of care, and the complex interplay of socioeconomic and healthcare system factors. The devastating impacts include disproportionate rates of chronic health conditions, medical providers routinely dismissing or minimizing symptoms, and insufficient quality of care and provider communication. The physiological toll of chronic stress and limited access to quality prenatal and postpartum services further compound these issues.

The persistent racial gap in maternal outcomes indicates deep-rooted problems in healthcare delivery. “Weathering” - the physiological impact of chronic stress - affects health outcomes regardless of socioeconomic status. This crisis warrants urgent, structural changes including enhanced provider training, accountability measures, community health networks, and diversification of medical staff.

Can doulas save the maternal health crisis in the US?

A doula is an unregulated birth companion who provides emotional and physical support during pregnancy, labor, and postpartum, but lacks the clinical training required for medical or midwifery practice. Despite a lack of evidence that non-professionally trained doulas reduce maternal mortality, recent U.S. policy has increasingly embraced these non-clinical support services as a cheaper and seemingly convenient substitute for addressing systemic gaps in maternal healthcare [19], [20], [21], [22]. In the U.S., there is little to no standardized training or certification for doulas, leaving their qualifications highly variable and often dependent on short workshops or independent organizations with inconsistent oversight. Doulas require little to no standardized training, certification, or regulatory oversight, and their services are reimbursed usually at lower rates compared to professional medical care or certified midwifery services. The approach to extend doula services in the US to address the maternal health crisis not only reflects a reluctance to invest in proven, yet more expensive, solutions like expanding access to obstetricians, professional midwives, and fully resourced healthcare facilities but also highlights a problematic reliance on doulas as a “quick fix.” Rather than addressing the root causes of the maternal mortality crisis – such as systemic disparities, lack of access to comprehensive care, and underfunding of medical services – the U.S. has opted for a superficial, low-cost intervention that may create the illusion of progress while failing to tackle the underlying structural issues. Unlike in the U.S., European countries, which consistently achieve better maternal outcomes, do so without relying on unregulated and non-professional services like doulas or uncertified midwives. Instead, they emphasize comprehensive professional medical care, rigorous professional and academic midwifery training, and well-resourced healthcare systems, highlighting the contrast between evidence-based practice and the U.S.’s reliance on non-professional interventions.

The rising popularity of doulas and home births in the U.S. reflects legitimate patient concerns about impersonal hospital experiences and interventional approaches to childbirth [23]. However, these alternatives don’t address the underlying systemic problems in U.S. maternity care that lead to poor outcomes, as demonstrated by countries achieving better maternal outcomes without doulas but through well-integrated hospital-based care systems with strong midwifery support. Doulas may enhance birth experiences and possibly reduce cesarean deliveries, but addressing fundamental and systemic healthcare system deficiencies remains critical for reducing maternal mortality. The rising trend of home births in the U.S. warrants rigorous investigation into women’s decision-making processes, including factors like desire for more autonomy, concerns about hospital interventions, and experiences during the COVID-19 pandemic that may have shifted birth setting preferences [23]. Understanding these complex motivations is crucial for healthcare systems to better align their maternity care practices with women’s values and needs while ensuring optimal safety outcomes for both mothers and infants.

The medical malpractice landscape differs markedly between the United States and European nations, particularly in obstetrics. U.S. obstetricians face among the highest malpractice insurance premiums – averaging $150,000–$300,000 annually – leading to defensive medicine practices and higher intervention rates [24]. Fear of litigation influences obstetric decision-making in nearly one-third of cases, particularly affecting cesarean delivery rates, despite evidence that higher intervention rates don’t necessarily improve outcomes [25]. In contrast, European countries like Sweden, Finland, and Denmark utilize national no-fault compensation systems that provide standardized payments for medical injuries while ensuring continuous patient care. Swedish obstetricians pay approximately one-tenth the malpractice premiums of their U.S. counterparts, allowing clinical decisions to be driven primarily by medical evidence rather than liability concerns [26]. These no-fault systems prove particularly effective in northern European countries, where most cases are settled out of court with physician support, demonstrating how universal healthcare systems can simultaneously protect both patients and providers while reducing costly litigation.

The differences between European and U.S. healthcare system designs and maternal outcomes is demonstrated through multiple pathways. Universal coverage in European systems enables early and consistent prenatal care - particularly critical given that delayed or inconsistent prenatal care is associated with up to a threefold increase in adverse outcomes [4]. A comprehensive study showed that continuous postpartum monitoring through professional healthcare providers in European systems identified 76 % of severe complications before becoming life-threatening, compared to only 45 % in fragmented care systems [2]. Additionally, systematic differences in cesarean delivery rates (32 % in the US vs. 18–24 % in most European nations) directly impact maternal morbidity, with Joseph et al. demonstrating that rising US maternal mortality correlates with increasing intervention rates and changes in obstetric practice patterns [2]. The integration of professional midwifery care in European systems, particularly evident in the Netherlands’ model, has been associated with reduced intervention rates and improved outcomes in low-risk pregnancies [25].

Beyond individual interventions: a suggested framework for systemic change in U.S. maternal healthcare

Current approaches to addressing the U.S. maternal health crisis often focus disproportionately on individual-level solutions, overlooking the systemic nature of the problem.

The U.S. maternal mortality rate ranks last among developed nations, with disparities particularly pronounced among Black women. This crisis transcends individual health behaviors or economic factors, revealing fundamental flaws in healthcare delivery systems.

European approaches to maternal care reflect deeply embedded and long-standing cultural values that prioritize work-life balance and social support, evidenced by policies like mandatory paid maternity leave, state-supported childcare, and normalized extended hospital stays that treat the postpartum period as a critical time for maternal recovery and infant bonding [1], 5]. In contrast, U.S. maternal care practices have often reflected an individualistic, market-driven culture that emphasizes rapid return to work and minimal institutional support, contributing to shortened hospital stays and fragmented postpartum care even among those with insurance coverage [7]. The divergent cultural attitudes toward healthcare as a universal right vs. a market commodity are further reflected in birth practices, with European systems generally favoring less medicalized approaches through professional midwifery integration, while the U.S. system’s higher intervention rates align with its more technology-intensive, physician-centered model of care [2], 27].

European healthcare models demonstrate how universal access, comprehensive prenatal care, professional services, and how standardized hospital protocols can significantly improve maternal and neonatal outcomes [28]. This comprehensive approach ensures that all pregnant individuals receive timely prenatal care, nutritional support, and postpartum services regardless of socioeconomic status. Key elements include standardized hospital safety protocols [28], integrated professional-trained midwifery care within medical teams, mandatory paid maternity leave, and home health visits following birth. These nations prioritize preventive care through robust nutrition education and regular prenatal checkups, while maintaining centralized quality metrics that hold healthcare facilities accountable for maternal outcomes. The lower maternal mortality rates in Europe compared to the U.S., suggest how systematic, universal approaches to maternal healthcare outperform fragmented, market-based systems.

Notably, European systems achieve superior outcomes without relying on doulas, instead investing in professional healthcare providers and integrated care teams. While doula support services may provide valuable patient advocacy, positioning them as a primary solution misplaces responsibility and potentially delays essential structural reforms.

The implementation of universal healthcare systems in Europe followed diverse timelines and pathways, with Germany pioneering compulsory national health insurance in 1883, while others like Switzerland and the Netherlands took over a century to achieve universal coverage through a series of incremental reforms completed in 2006 [29], [30], [31]. France’s journey to universal coverage spanned four decades from its initial 1945 social security law to achieving near-universal coverage by 1980, demonstrating the long-term political and institutional commitment required for such systemic change [32].

Implementing European-inspired maternal healthcare reforms in the U.S. could begin with state-level pilot programs that demonstrate the cost-effectiveness of integrated professional midwifery care and standardized safety protocols, similar to the successful German model where midwives are mandated at every birth.

We believe the transition to universal maternal healthcare coverage in the U.S. could be achieved incrementally through expanding Medicaid coverage during pregnancy and the postpartum period to one year, while simultaneously strengthening requirements for standardized professional training and certification of professional maternal care providers [7], 8]. Building political support for these reforms requires emphasizing their proven ability to reduce healthcare costs while improving outcomes, as demonstrated by European systems that deliver superior maternal care at lower per-capita costs than the U.S., particularly through their emphasis on prevention and integrated care models [1], 5].

Similar to the U.S., rural regions in Northern Europe have faced concerning trends in the closure of smaller maternity units, with data from Norway documenting a reduction from 95 to 45 maternity units from 1979 to 2009, significantly increasing travel time to care for rural populations [33]. In Germany, a nationwide analysis revealed that between 2014 and 2019, 11 % of maternity units closed [34]. France’s National College of Gynecologists and Obstetricians reported that staff shortages led to temporary closures affecting 39 % of maternity units in 2021, particularly impacting smaller facilities [35].

Effective transformation of U.S. maternal healthcare requires coordinated change across multiple institutional domains. Medical education must evolve to emphasize evidence-based practices and standardized emergency protocols that have proven successful in European hospitals. The declining ability to perform manual vaginal deliveries for breech presentations, largely due to insufficient emphasis on comprehensive obstetric training, highlights the role that medical education and specialization play in the maternal health crisis in the United States. Healthcare institutions must implement robust training programs that address both clinical skills and patient communication. They also must adopt systematic quality improvement measures, including standardized protocols for high-risk conditions, clear performance metrics, and regular evaluation of clinical practices. These should be modeled after successful European initiatives that have significantly reduced complications and mortality rates. Additionally, expanded nutrition education and preventive care programs including integration of midwives have shown remarkable success in improving maternal health outcomes abroad [25].

Healthcare institutions should strengthen their community integration through sustained partnerships with local organizations, expanded access points for care, and support systems extending beyond traditional clinical settings.

This comprehensive approach, informed by successful universal healthcare models, acknowledges that achieving better maternal health outcomes requires systematic transformation rather than isolated interventions. Such reforms can address both overall maternal mortality rates and the stark disparities that currently exist, particularly among Black women and other marginalized populations.

Conclusions

The U.S. maternal health crisis warrants urgent systemic reform, not just superficial interventions as were suggested by New York State [36]. The stark contrast between U.S. and European maternal outcomes reveals fundamental flaws in American healthcare delivery that cannot be addressed through individual-level interventions alone especially when they diverge significantly between states [36]. Cicero’s distinction between universal law (ius gentium) and civil law (ius civile) highlights the need for national policies on maternal mortality and reproductive rights to align with universal principles of justice and equity, ensuring that individual freedoms are not undermined by arbitrary restrictions [37]. European healthcare systems demonstrate the transformative power of universal access, standardized protocols, and professional midwifery integration - achieving superior outcomes without depending on non-professional support services. Critical reforms must include transitioning to universal healthcare coverage, strengthening professional midwifery education and integration, implementing standardized hospital safety protocols, and expanding comprehensive postpartum care. Additionally, addressing the disproportionate impact on Black women requires confronting deeply embedded healthcare inequities through systematic changes in medical education, institutional accountability, and care delivery. While doula services may provide valuable emotional support, relying on non-professional support as a solution to the maternal health reflects a concerning reluctance to invest in evidence-based systemic changes. Only through comprehensive reform that incorporates the strengths of successful European models while addressing unique U.S. challenges can we create a more equitable, effective, and humane approach to maternal care that values and protects every mother’s life.