The Cure for An Ailing Maternity Care System

Maternity care is big business in the United States. We’re talking $86 billion big.  With that kind of investment, you’d think women and their newborn babes in this country would be entering the postpartum recovery period universally healthy and happy after being well cared for throughout pregnancy and birth. Unfortunately, the return on investment for maternity care is poor. The U.S. spends more on health care than most – a staggering amount per person in fact - yet lags far behind when it comes to maternal and newborn health and mortality indicators. The United States ranks 41st out of 171 countries when it comes to our maternal mortality rates.  So it makes sense that stakeholders from health care advocates and providers to hospital and insurance company executives, but most importantly women themselves, would want to ensure a much better return-on-investment for maternity care in this country, right?

 

Unfortunately, what has constituted success in terms of a greater ROI among these various stakeholders has not always been uniform.  Where women are growing weary of the increase in unnecessary medical interventions during childbirth that only increase costs and the chance of poorer health outcomes, doctors have taken to routinely encouraging and performing unnecessary c-sections at an exponential rate to keep malpractice claims lower but also because our health care system’s “global fee” method of payment for in-hospital birth promotes a one-size-fits-all type of care which does not lend itself well to vaginal birth but does increase a hospital’s profit; where insurance companies and Medicaid do not provide homebirth coverage across the country, which would bring overall maternity care costs down (for insurance companies, states, those insured and tax-payers across the board), Medicaid funds almost half of all hospital births.

It is precisely because of these issues and more that a team of over 100 national leaders in maternity care, led by maternity care advocacy organization Childbirth Connection, convened two and a half years ago to come up with a shared vision and an action plan for change.

“It was time to act and we called upon key leaders across the health care system to develop a long-term vision for the future of maternity care in the United States,” said Maureen Corry, Childbirth Connection’s Executive Director. The results of this multi-year meeting-of-the-minds, the Transforming Maternity Care Project, are two key reports released today, “2020 Vision For A High-Quality High-Value Maternity Care System” and “Blueprint For Action.”

As we move forward, towards reform of our overall health care system, the problems and solutions identified in these two reports are key to fixing our broken maternity care system and may help birth an entirely new system.

The “2020 Vision” report underscores 11 key focus areas or problems that include: payment reform, disparities in access and outcomes of maternity care, coordination of maternity care, clinical controversies (such as home birth, VBAC (vaginal birth after cesarean) and elective induction), and decision-making and consumer choice. The “Blueprint for Action” report identifies concrete actions to address all of these problems in order to move closer to this shared vision of a high-quality, high-value system.  How do we get the most value – in every possible way that word can be defined – for our money?

Rima Jolivet, Transforming Maternity Care Project Director with Childbirth Connection is optimistic: “The good news is that every challenge is an opportunity for improvement that can benefit millions of mothers and babies annually.” In other words, maternity care is a problem with a solution. And the solution lies in the answers to the questions posed to the work groups involved with these reports:

“Who needs to do what, to, with, and for whom over the next five years to improve the quality care?”

In truth, the answers to these questions are not earth shattering. They seem to echo what women’s health advocate have said for years. We need a system that is woman-centered, evidence-based, safe, timely, efficient and equitable. But how exactly do these concepts translate into in practical approaches to care?

Woman-centered care, according to the “2020 Vision” report is care that “that respects the values, culture, choices and preferences of the woman, and her family, as relevant, within the context of promoting optimal health outcomes. It means that all childbearing women are treated with…respect, dignity and cultural sensitivity throughout their maternity care experiences.”

In effect, we’re talking about personalized care and the understanding that each woman brings a unique vision, perspective, belief system, and cultural identity to their pregnancy and birth experience. Let’s not only respect that but also work with these ideals to promote positive experiences.

The idea that maternity care should be evidence-based, safe, and efficient seems like a no-brainer but one key goal to note is how these imperatives lay the groundwork to minimize “overuse, underuse, and misuse of care practices and services.” We need to make sure we’re providing optimal care to all women by guaranteeing women are able to access the services they need if they need them. However (this is a big one), let’s also start from a place of understanding that pregnancy is a healthy state of being – not an inherently sick state – and so let’s also minimize the amount of unnecessary interventions that now drive up costs and place women and newborns at risk for poorer health outcomes.

As the “2020 Vision” puts it:

“The majority of childbearing women are healthy and have good reason to expect an uncomplicated pregnancy and birth and a healthy newborn. Thus, practice variation for low-risk women is minimized under the principle that any intervention in the physiologic processes of pregnancy and childbirth must be shown to do more good than harm…”

The goal of ensuring greater equitability in access to care is critical in this report. Racial and ethnic disparities run rampant in maternity care. Shockingly, African-American women in the U.S. are four times as likely to die during childbirth as white women. We know, too, that the idea that women can “choose” where to birth and with whom is non-existent for low-income women who cannot afford to pay out of pocket for a homebirth or midwife at a birthing center. The “Blueprint for Action” notes that:

“Non-Hispanic black, Hispanic, and American Indian-Alaskan Natives were more than twice as likely as non-Hispanic white women to receive late or no prenatal care in 2006; as of 2008, nearly 40 percent of low-income women ages 18-44 were uninsured.”

The solutions lie in a host of actions including (what else?) national health care reform legislation, encouraging states to exercise Medicaid’s eligibility option for pregnant women under CHIP and other programs, and expanding public support for maternity care programs, providers and institutions as well.

Another key problem notes the “2020” report is improving the functionality of payment systems. It sounds dry but the truth is that payment reform is key to aligning financial goals with optimal health outcomes. As the “Blueprint for Action” report puts it:

“Volume-driven reimbursement increases cost without improving health outcomes. Providing more services than are needed does not improve health and increases the risk of harm, while driving up spending.”

Not the best use of anyone’s time or money, really.

Of special interest, also, is the section in the “Blueprint for Action” on what are termed “clinical controversies” such as Home birth and VBAC (vaginal birth after cesarean section). The Blueprint acknowledges and reinforces key solutions that grassroots advocates have been working towards for years:

“…developing national clinical guidelines for VBAC, labor induction, vaginal breech and out-of-hospital birth using transparent processes; improving the capacity of hospitals and health systems to meet the needs of women who face these controversial scenarios; improving the capacity of community health systems to meet the needs of women who make an informed choice of planned home birth and, finally, improving cooperation between hospital systems and home birth providers.”

If these reports can be used as actual blue prints for action within health care reform, I can see our maternity care system getting healthier already.

For more on these reports, please check out Amy Romano's post at Lamaze, International's blog Science & Sensibility and Melissa Garvey's post at Midwife Connection, ACNM's blog!