Despite paying more for health care, American women are less healthy, more likely to die in pregnancy, and have higher rates of emotional distress than women in other wealthy countries, a new study from the Commonwealth Fund says.

The new study, released on Wednesday, shows how far behind other wealthy nations the United States is when it comes to health care. Researchers compared health data for women in 11 wealthy, developed countries — the US, Canada, Germany, Australia, France, Norway, the Netherlands, New Zealand, Sweden, Switzerland, and the UK. The study found that despite higher health care costs, women in the US have worse health outcomes than women in the other 10 countries examined.

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The study intended to measure the impact of the 2010 Affordable Care Act on women’s health, according to Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, who helped create the report.

“We wanted to take an assessment of where women are on healthcare and, particularly, insurance coverage. Women are indisputably in a better place than they were in 2009,” Collins told NBC News. 

Approximately 16% of Americans did not have health insurance in 2009. Nearly 10 years later, only 8.8% lack coverage, NBC News reports. But while access to health care has improved, the US still has a long way to go. 

The US is the the only country out of the 11 studied that does not have universal health care coverage. The 10 other countries included in the study all have national health insurance systems or laws that require everyone to have health insurance.

A federal health care spending report shows that the US spends $10,739 per person on health care, which is more than any other country in the world and almost double the average cost per person for developed countries. Approximately 40% of American women have forgone medical treatment  because of high costs. This is significantly higher than  the other countries examined in the study; only 5% of women in the UK said they skipped medical care due to costs.

A new study comparing U.S. women’s health care experiences with those of women in 10 other high-income countries found that U.S. women were more likely to report problems paying or disputing medical bills or spending time on related paperwork. https://t.co/QgO6O73F87pic.twitter.com/skSI6IkKfr

— Commonwealth Fund (@commonwealthfnd) December 20, 2018

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The report showed that 1 in 5 American women said they have two or more chronic conditions, including asthma, arthritis, diabetes, heart disease, and high blood pressure — double the amount reported by women in Australia, Germany, and the Netherlands. 

American women’s mental health has also suffered. About 34% of the women studied reported experienced emotional distress, higher than any other country studied, which in turn can negatively impact physical health.

In addition to this, women in the US pay more money during pregnancy to other high-income countries, yet suffer the highest maternal mortality rate of the countries studied. Both vaginal deliveries and caesarian sections in the US cost about double the price of the same procedures in Australia, according to the report. 

The US also has the third highest rate of caesarean sections with 320 per 1,000 births. This is second to Australia and Switzerland. Caesarean births are often more expensive because of the cost of the operating room, medical personnel, and hospital stay during the extended recovery time.

In the US, 14 in every 100,000 women die from childbirth-related causes, according to UNICEF. In comparison, Sweden, the country with the lowest maternal mortality rate in the study, has just four deaths per 100,000 births.

U.S. women are more likely to die in pregnancy and childbirth and to skip care because of costs, a study of high-income nations finds. https://t.co/QgO6O73F87pic.twitter.com/mCu0l6VQH1

— Commonwealth Fund (@commonwealthfnd) December 19, 2018

According to a report last year from the CDC, at least half of all pregnancy-related deaths are preventable.

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The one area in which the researchers noted that American women had strong health outcomes was breast cancer prevention. Women in the US had some of the highest breast cancer screening rates and were less likely to die of breast cancer than other countries according to the report, but on the whole, women in the US reported being highly dissatisfied with their medical care.

Out of the countries studied, American women were the least likely to rate their health care quality as “excelled or very “good,” with only 25% satisfied with health conditions.  

Collins said that expanding Medicaid without restrictions that limit enrollment and providing federal support to help people manage health insurance premiums could help to improve the country’s health overall.

“There is just a long list of small changes that could be made to the ACA [Affordable Care Act],” said Collins. “We don’t need to throw out the law and start again. There are small, relatively low-cost changes that Congress could tackle.”