Three Deadly Delays: How Medicaid Policy in Iowa Is Risking the Lives of Childbearing People

Three Deadly Delays" have been identified by the World Health Organization as contributors to maternal death. 1 These include a delay in (1) deciding to seek care, (2) identifying and reaching a health care facility, and (3) receiving appropriate treatment after arrival.Evaluating care through the lens of these 3 delays can help identify barriers at the household, community, and health care systems level.This solution-based approach has been used frequently in low-and middle-income countries, 2 but not high-income countries like the United States, where services are assumed to be more robust and available.2 But how true is that assumption?At 18 deaths per 100,000 live births, 3 the 2024 US maternal mortality ratio is a fraction of sub-Saharan Africa (442 deaths per 100,000 live births), yet drastically higher than other high-income countries, which are near or below 10 deaths per 100,000 live births.4 Disparities in the United States are extreme.The 2024 maternal mortality ratio among Black women, at 45 deaths per 100,000 live births, was triple that of White women, 4 and it exceeded neighboring countries of Mexico (42), El Salvador (39), and Cuba (35).5 Evaluating perinatal care in the United States through the lens of the 3 delays may reveal factors that contribute to these disparities.This story demonstrates how Medicaid policy led to the shuttering of a vibrant local midwifery practice and created perilous delays for one woman in Iowa.Ruth is a 41-year-old woman from Ames, Iowa.She first entered care in Ames in 2021, shortly before the birth of her second child in 2022.In 2024, she became pregnant with her third child.Due to her immigration status, Medicaid provided coverage for only 2 of the 9 months of her pregnancy.6 When it came time for the birth, Ruth's only option was to apply for emergency Medicaid that would cover a 3-day hospitalization.6 Ruth knew her coverage would be limited, but she considered herself low risk.However, the certified nurse-midwives caring for Ruth were concerned.Standard prenatal care spans 12 to 14 appointments from the first trimester through the end of pregnancy.This schedule of care includes assessment for infections, genetic abnormalities, fetal growth, and emerging problems like diabetes, hypertension, and depression.The midwives recom-