In the world’s richest country, maternal mortality rates are rising steadily. A 2016 study revealed a drastic increase in U.S. deaths during childbirth from 2000 to 2014, while worldwide rates were dropping. Advanced industrialized countries overall have an average maternal mortality rate of 12 deaths per 100,000 live births, while the U.S. has a rate of 19.9. Measuring up to 42 days after birth, the current rate for the U.K. is 8.9 deaths per 100,000 live births.

There are a number of factors that play into maternal death rates, but given that the vast majority of pregnancy-related deaths are preventable, it is reasonable to conclude that greater availability of medical care could reduce this elevated death rate (and, conversely, a contraction of such care may well lead to higher mortality). This conclusion is borne out in a comparison of two states, Texas and California. Beyond their differences in the expansion of insurance to low-income residents, these states also differed in their attention to maternal medical care.

Texas’s mortality rate has trended up since 2000, increasing from 17.7 at the turn of century to 18.6 in 2010. Between 2010 and 2012, things got far worse: Texas’s maternal mortality rate doubled (Figure 1). In the same period, Texas imposed restrictions on women’s health clinics and cut funding for family planning by $73.6 million in 2012. Those women’s health clinics that stayed open treated only half as many patients as they had prior to budget cuts.

These cuts were compounded by Texas’s refusal to expand Medicaid coverage to its low-income residents. As part of the Affordable Care Act (ACA) legislation, states had this option; eighteen states – including Texas – rejected the offer.

Much of the debate over the Affordable Care Act’s (ACA) merits and demerits has been silent on the real impact of health insurance for saving lives, including those lost in or directly after childbirth. The ACA has reduced uninsured rates by a considerable margin: 44 million people lacked coverage in 2013; at the end of 2016, that figure was less than 28 million. However, Texas claims the highest uninsured rate in the country and a maternal mortality rate of 31.5 deaths per 100,000 live births. Some of this increase may be due to misclassification and over-reporting, but there remains a real and deadly problem of medical care inaccessibility in Texas. In fact, its medical climate is actually dangerous for women.

Figure 1. Texas’s Maternal Mortality Rate. MacDorman, 2016

As of 2017, 16.6 percent of Texas’s population (45 million people) lacked insurance coverage—a full 10 percentage points higher than in those states that expanded Medicaid under ACA. If Texas were to accept the Medicaid expansion, they would reduce the national insurance coverage gap by 27 percent.

Further, of the 638,000 Texans who might benefit from Medicaid expansion, 74 percent are people of color for whom many conditions commonly linked to pregnancy-related deaths exist at greater rates. According to the CDC, cardiovascular diseases and non-cardiovascular (endocrine, hematologic, immunologic, and renal conditions) diseases accounted for 30 percent of pregnancy-related deaths in 2011-2013. Because African-Americans are 1.7 times more likely to develop diabetes than non-Hispanic whites and 1.6 times more likely to have high blood pressure than white women, these conditions impact their pregnancies at disproportionate rates. In an uninsured population largely composed of people of color, the intersection between chronic conditions and maternal mortality is life threatening.

California is a different story. It entered the 2000s with daunting rates of maternal mortality (Figure 2) and a high population of uninsured individuals. With Medicaid expansion and deliberate efforts to reform maternal medical care, those rates have dropped consistently. In 2013, prior to the ACA’s implementation, California’s uninsured rate hit 17.2 percent. After the state opted-in to the Medicaid expansion, the uninsured rate dropped to 7.4 percent in 2016. In the same year, the state reached a maternal mortality rate of 5.9.

One of California’s targeted efforts to improve mothers’ health outcomes came with the 2006 launch of the California Maternal Quality Care Collaborative. In most cases of pregnancy-related deaths, the organization found that better monitoring could have prevented death. Thus the CMQCC created “toolkits” to provide medical professionals with emergency guidance. For instance, to stem obstetric bleeding, which can quickly become fatal, the CMQCC recommends “hemorrhage carts” of necessary medications and supplies be on hand during birth and for nurses to train in measuring postpartum blood—a step that could be widely implemented and has the potential to save lives. The results are telling: since the CMQCC’s inception, California has seen a 55 percent decrease in its MMR. Acknowledging that a variety of factors could be at play, the organization notes that nonparticipating hospitals saw a 1.2 percent reduction in severe maternal morbidity from 2014-2016, compared to a 20.8 percent reduction among participating hospitals. It would be worth considering the demographic makeup of the communities benefitting from these medical reforms to better understand other confounders; however, the impact of attentive maternal care implemented state-wide seems to be real.

Figure 2. California’s Maternal Mortality Rate 1999-2013.

Medicaid expansion is a clear answer for states struggling with high maternal mortality rates, and some Republican legislatures are beginning to reconsider the prospect of implementing it. In a departure from longstanding Obama Administration practice, the U.S. Department of Health and Human Services has permitted Kentucky to add a work requirement for Medicaid beneficiaries. This waiver is likely the first of many for states that had previously rejected ACA funding. By excluding those unable to work, states will increase the total number of people covered while artificially limiting the eligible population.

Medicaid expansions would also make it feasible for states to fund programs like early intervention for heart disease and diabetes, which can eliminate many adverse pregnancy outcomes, and prolonging the post-birth Medicaid coverage period could have a tremendous impact on maternal health outside the delivery room. For women who are covered by Medicaid during their pregnancy in Texas, coverage lasts up to two months after the birth. Given that Medicaid finances 54 percent of births in that state and that most of the deaths occurred more than 42 days after the end of the pregnancy, an additional month of coverage has the potential to improve outcomes for a large portion of the state’s population.

That female bodies have been giving birth for millennia does not obviate childbirth’s risks. When birth occurs in combination with serious underlying conditions and uneven access to health insurance and medical care, tragic outcomes are not an insignificant risk. By taking the common-sense step of expanding Medicaid coverage, states can and should save lives.