The Cure for An Ailing Maternity Care System

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The Cure for An Ailing Maternity Care System

Amie Newman

Maternity care is big business in the U.S...$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. Not so.

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
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
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.

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“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

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

“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

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!