American women are still struggling to get good health care compared to women in other advanced nations, a new study finds.

U.S. women are sicker, spend more on medical bills, have to work harder to get good care and are far more likely to die in pregnancy and childbirth than women in other rich nations, the report out Wednesday from the Commonwealth Fund finds.

The only areas where the U.S. comes out ahead? Women are less likely to die of breast cancer here, and have better access to medical specialists.

But in most other measures, the U.S. falls short when compared to 10 other wealthy countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and Britain.

The Commonwealth Fund’s Sara Collins, who helped write the report, said the aim was to see if the 2010 Affordable Care Act had made a difference for women’s health. “We wanted to take an assessment of where women are on health care and, particularly, insurance coverage,” Collins said.

And compared to 2009, when 16 percent of Americans had no health insurance, now just 8.8 percent of Americans go without a way to help pay medical bills.

“Women are indisputably in a better place than they were in 2009,” Collins told NBC News.

But the benefits of the Affordable Care Act — expanded health insurance coverage, rules that stop health insurers from charging women more, rules forcing insurers to cover pre-existing conditions, and coverage guarantees — have done little to narrow gaps between American women and women in other rich nations.

Compared to the 10 other wealthy countries, the U.S. still has the highest rate of maternal mortality. The U.S. maternal mortality rate is 14 deaths out of every 100,000 women who give birth, according to statistics from UNICEF. That’s comparable to the rate in Uruguay, where the maternal mortality rate is 15 per 100,000, and Turkey, where it’s 16 per 100,000.

“Women in the U.S. had the highest rate of maternal mortality because of complications from pregnancy or childbirth; women in Sweden and Norway had among the lowest rates,” the report reads.

“High rates of caesarean sections, lack of prenatal care, and increased rates of obesity, diabetes and heart disease may be contributing factors to the high rate in the U.S.”

The report gets at some of the possible reasons: close to 40 percent of women say they’ve taken a pass on health care because of cost.

“This is the highest rate among the 11 countries in our analysis," the report reads. Just 5 percent of British women said they skipped care because of cost.

The Commonwealth team surveyed 9,254 women aged 18 to 64 in the 11 countries, and also used health data from the Organization for Economic Cooperation and Development, as well as UNICEF’s maternal deaths database.

More than a quarter of U.S. women said they spent $2,000 or more of their own money for medical treatment. That compares to 2 percent of women in Britain, Sweden and the Netherlands. Only in Switzerland did more women — 28 percent — spend more.

And 44 percent of American women complained about trouble with medical bills. That includes being unable to pay a bill, struggling to pay, arguments over bills or having to pay more than expected. That compared to 35 percent of women in France and 2 percent in Britain.

American women are also sicker, in general. In the U.S., 20 percent of women have two or more chronic conditions, such as diabetes, asthma or heart disease. That’s the highest rate out of the 11 countries. In Canada, 16 percent of women have two or more chronic conditions; in Germany, just 7 percent do.

And Americans spend more to get less. The latest federal health care spending report shows the U.S. spends $10,739 per person on health care, more than any other country and about twice the average for developed countries.

“Women are indisputably in a better place than they were in 2009."

The team did tease out some benefits. They looked at breast cancer in particular and found women in the U.S. are more likely to get mammograms and are more likely to survive breast cancer than women in other countries. Women in the U.S. had among the lowest rates of breast cancer–related deaths, after Norway, Sweden, and Australia. Women in the Netherlands and Germany had the highest rates.

“Breast cancer survival is a bright spot,” Collins said.

American women are unhappy with their health care. Just 24 percent of U.S. women said their medical care was excellent or very good, by far the lowest percentage. More than 60 percent of British women said their care was very good or excellent; 61 percent of Swiss women did and 59 percent of Australian women did.

The U.S. is the only country among the 11 that does not have a system of universal health care coverage, either through a national insurance system or a law requiring everyone to have health insurance. But Collins said it would be possible to improve the health outlook for women without moving to a European or Canadian-style health system.

“There are ways to do this,” Collins said.

“All states should expand Medicaid without restrictions that limit enrollment.” Currently, 37 states have expanded Medicaid to more people, or plan to, while 14 states have not. Arkansas, Kentucky, New Hampshire and Indiana either have or plan to impose work requirements for Medicaid.

Providing federal support to help more people pay their health insurance premiums would also help, Collins said.

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

The ruling earlier this month by a federal judge in Texas, who said the ACA is unconstitutional, adds some uncertainty, Collins said. She and many other scholars predict the ruling will be turned back at appeal. “But it throws a lot of confusion into the health care system,” Collins said.