Broken Continuity: Insurance Fragmentation and the Structural Roots of America's Maternal Health Crisis

The United States spends more per capita on healthcare than any other high-income nation, yet its maternal mortality rate remains a persistent outlier among peer countries. According to the Commonwealth Fund, the US recorded approximately 23.8 maternal deaths per 100,000 live births in 2020—a figure more than three times higher than Germany's and nearly five times that of the Netherlands. While clinical factors such as hemorrhage and hypertensive disorders account for a portion of these deaths, a growing body of policy research points to a more systemic culprit: the structural fragmentation of American health insurance and its corrosive effect on continuity of prenatal care.

For pregnant women navigating the US system, insurance is not a passive backdrop. It is an active determinant of whether they see the same obstetrician from the first trimester to delivery, whether a recommended anatomy scan is approved without bureaucratic delay, and whether a midwife or maternal-fetal medicine specialist remains in-network after a plan change. The cumulative weight of these disruptions does not merely inconvenience patients—it produces measurable clinical harm.

The Mechanics of Disruption

The employer-sponsored insurance model, which covers roughly 54 percent of non-elderly Americans, creates an inherent tension with the longitudinal nature of pregnancy. A woman who changes jobs during her second trimester—or whose employer switches insurance carriers during open enrollment—may find that her established obstetric provider is no longer covered under her new plan. The choice then becomes either paying out-of-pocket to maintain the relationship or transferring care to an unfamiliar provider at a point in the pregnancy when clinical history and trust have already been built.

Network restrictions compound this problem. Even within a single insurer's portfolio, provider networks vary significantly between plan tiers. A woman who selects a lower-premium plan at enrollment may not anticipate that her preferred hospital's labor and delivery unit sits outside her network—a discovery that can arrive as a surprise bill following an emergency delivery. The No Surprises Act of 2022 addressed some aspects of unexpected billing, but it does not resolve the upstream problem of network design that structurally fragments maternal care pathways.

Medicaid, which finances approximately 42 percent of all US births, introduces a different but equally consequential disruption. Eligibility for Medicaid is income-dependent and subject to periodic redetermination. Women who experience modest income changes during pregnancy can cycle on and off coverage, interrupting not only their provider relationships but also their access to the care coordination services that Medicaid managed care organizations are nominally required to provide. Research published in the American Journal of Public Health has documented that Medicaid coverage gaps during pregnancy are independently associated with inadequate prenatal care utilization, even after controlling for socioeconomic variables.

Delayed Screenings and the Clinical Cost of Administrative Friction

Prenatal care is not a monolithic service—it is a sequenced series of screenings, consultations, and interventions whose clinical value depends substantially on timing. Cell-free DNA testing for chromosomal abnormalities is most informative between 10 and 13 weeks of gestation. Anatomy ultrasounds are typically performed between 18 and 20 weeks. Glucose tolerance testing for gestational diabetes occurs in the second trimester. Each of these interventions has a narrow window of maximum utility, and each is subject to prior authorization requirements under many commercial and managed Medicaid plans.

When a woman loses coverage, changes plans, or encounters a network disruption, the administrative process of establishing care with a new provider—verifying insurance, obtaining referrals, scheduling appointments in a system with chronic specialist shortages—can consume weeks. In obstetrics, weeks are not a neutral quantity. A delayed anatomy scan may miss a structural anomaly that, if detected earlier, would have permitted timely intervention. A delayed gestational diabetes diagnosis deprives both mother and fetus of weeks of glucose management that directly affects birth outcomes.

The American College of Obstetricians and Gynecologists has issued repeated guidance emphasizing that continuity of care with a known provider is associated with improved outcomes across a range of maternal and neonatal metrics, including preeclampsia detection, preterm birth rates, and cesarean delivery rates. Insurance-driven provider discontinuity works directly against this evidence base.

A Comparative Policy Lens

The contrast with integrated European models is instructive, though not without nuance. In the Netherlands, a tiered midwifery-led system provides continuous care coordination from early pregnancy through the postpartum period, with risk stratification determining when obstetric specialists are engaged. Coverage is universal and not contingent on employment status, eliminating the mid-pregnancy disruptions that characterize the American experience. Germany's statutory health insurance system similarly ensures that a woman's provider relationship is not severed by job change or income fluctuation.

The United Kingdom's National Health Service assigns each pregnant woman a named midwife responsible for care continuity across the antenatal, intrapartum, and postnatal periods—a model that NHS England's own evidence reviews have linked to reductions in preterm birth and maternal mortality. These systems are not without their own pressures, including workforce shortages and access inequities in rural areas. Nevertheless, the structural guarantee of coverage continuity removes an entire category of risk that American women must absorb.

Direct policy transplantation from European systems into the US context is constrained by institutional, political, and financing differences that this journal has examined in prior issues. However, the European evidence does illuminate which structural features produce better outcomes—and those features are not culturally specific. Continuity of coverage, continuity of provider, and elimination of mid-pregnancy administrative disruption are policy objectives achievable through multiple financing mechanisms.

Toward Structural Reform

Several evidence-based policy interventions warrant serious consideration within the American context. First, extending continuous Medicaid eligibility through 12 months postpartum—a provision included in the American Rescue Plan Act of 2021 as a state option—should be made a federal mandate rather than an elective state decision. As of early 2024, a substantial minority of states had yet to adopt this extension, leaving postpartum women in those jurisdictions vulnerable to coverage loss at precisely the moment when postpartum depression, hemorrhage, and hypertensive complications most commonly present.

Second, federal network adequacy standards for obstetric and maternal-fetal medicine providers should be strengthened and made enforceable across both commercial and Medicaid managed care plans. Current standards are inadequate and inconsistently applied, allowing insurers to maintain nominal compliance while offering effective access to a narrow range of providers.

Third, prior authorization requirements for evidence-based prenatal screenings should be categorically prohibited. The clinical protocols governing prenatal care are well-established; there is no evidence-based rationale for subjecting time-sensitive screenings to administrative review processes that routinely introduce delays of one to three weeks.

Finally, care coordination requirements for high-risk pregnancies should be standardized and adequately reimbursed. Medicaid managed care organizations are currently required to offer care coordination, but reimbursement rates are often insufficient to sustain meaningful programs, and quality oversight is inconsistent across states.

Conclusion

America's maternal mortality crisis is not reducible to clinical variables alone. It is, in substantial measure, a policy-constructed crisis—one in which the architecture of insurance financing actively undermines the continuity of care that evidence identifies as protective. The women most exposed to these structural failures are disproportionately Black, low-income, and rural, reflecting the compounding inequities that insurance fragmentation both reflects and reinforces.

Reforming the conditions under which pregnant women access and retain coverage is not a peripheral concern in maternal health policy. It is foundational. Until the structural disruptions embedded in the American insurance system are addressed, clinical interventions—however well-designed—will be working against a current that policy itself has created.