A new nationwide scorecard ranks the state of women’s health and reproductive care. The results reveal a deep geographic divide in women’s healthcare access and outcomes.
The state-by-state rankings were released by the Commonwealth Fund. Its goal was to assess the state of women’s health in the wake of the Supreme Court's Dobbs decision that overturned the right to abortion and the proliferation of state abortion bans that followed. The report used 32 performance indicators to evaluate each state's healthcare access and affordability, quality of care and outcomes for women. It generally drew these measures from publicly available data sources and used the most current data where possible.
For health outcomes, researchers measured all-cause mortality, maternal and infant mortality, preterm birth rates, syphilis among women of reproductive age, infants born with congenital syphilis, self-reported health status, postpartum depression, breast and cervical cancer deaths, poor mental health and intimate partner violence.
It found “significant” disparities between states and deepening racial and ethnic gaps in outcomes. The findings suggest these gaps could widen further, especially for women of color and those with low incomes in states with restricted access to reproductive care, per the report.
The states ranked the best overall in healthcare system performance for women were Massachusetts, Vermont, Rhode Island, Connecticut and New Hampshire. Those that ranked the worst included Mississippi, Texas, Nevada, Oklahoma and Arkansas.
Higher performing states, the report found, have invested in health insurance coverage for nearly all residents, made reproductive healthcare legal and accessible, and achieved lower maternal mortality rates through a stronger workforce as well as frequent check-ups and screenings. All-cause mortality for women of reproductive age was highest in southeastern states, with the highest rates of maternal mortality located in the Mississippi Delta region.
“One thing is absolutely clear: women’s health in the U.S. is in a fragile state,” Commonwealth Fund President Joseph Betancourt, M.D., told reporters in a media briefing Wednesday. He encouraged anyone reading the women’s health scorecard to also look at other previous rankings, such as one on primary care, for greater context.
Much of the briefing focused on the importance of insurance coverage and the availability of maternity care providers for access. Both of those are tied to state policies around the expansion of Medicaid and abortion.
For instance, a woman’s inability to afford needed care is most pronounced in states that have not expanded Medicaid. The lowest rates of coverage among reproductive-age women were also generally within Medicaid non-expansion states. Women of reproductive age had the highest uninsured rates in Texas, Georgia and Oklahoma, while women in Massachusetts, D.C. and Vermont had the lowest.
Due to federal and state rules, uninsured rates do drop when women become pregnant. However, this doesn’t guarantee good health outcomes, as a lack of coverage means one is sicker over their lifetime, Sara Collins, senior scholar and VP at the fund, said during the briefing.
“It means that women enter their pregnancy having had less access to healthcare, particularly if they’re poor or low income,” Collins said. “It’s pretty clear that having health insurance that’s adequate… is really necessary to access the healthcare system.”
But coverage alone is not sufficient. Other factors, like out-of-pocket expenses and provider capacity, also matter. Women who are under-insured may still face prohibitively high costs, Collins noted, have poor provider networks or not be able to get a timely appointment.
States with abortion restrictions often had fewer maternity care providers overall. Arkansas, Oklahoma, Alabama and Idaho had notably fewer maternity care providers compared to D.C., Vermont and Connecticut.
When it comes to postpartum depression among women who recently gave birth, states with some of the highest rates of self-reported symptoms were also those least likely to screen women for the condition—including Mississippi, Arkansas and Alabama. Conversely, states with the highest rates of screenings had the lowest rates of self-reported symptoms, like Massachusetts and Vermont.
For data on postpartum depression, the report relied on the maternal health surveillance database PRAMS, which some major states like California and Texas don’t participate in. Still, 33 states do participate. “It was too important of a dataset to pass up,” David Radley, a senior scientist at the fund, told reporters. However, he urged lawmakers to push for states to participate in order to get better data. “There may be really great things happening in California that we can’t see,” Radley noted.
Ultimately, care access is about more than the number of providers. It also means the availability of support like social workers and behavioral healthcare. PRAMS data doesn’t necessarily capture that. “Accessing care is not just about the number of docs you have access to,” Radley said.
The fund hopes the scorecard can help inform federal and state policymakers and healthcare system leaders in their efforts to bolster women’s healthcare. It expects to update the report over time to track how ongoing state policies, such as abortion restrictions, impact women’s health.