Maternity care is a prime example of how our dysfunctional health care system leads to waste and poor outcomes. The birth process has become completely medicalized; women’s bodies are held to a single physiological standard that ignores the normal range of variation; women are often given unnecessary interventions to speed up birth; adequate prenatal and maternal care remain out of reach for many women in rural areas; and women in certain states and regions of the US, and especially African American women, face extremely high rates of maternal and infant mortality.
These problems are complex and systemic; there is no “quick fix” to improve maternal health. Fortunately, there are lots of health professionals and policy experts working to address the maternal health crisis. More impressively, these experts are working together, across disciplinary lines, to attack the problem from multiple angles using a holistic view.
How can we change the maternity care system so that all women who want to and are able to experience the benefits of a natural birth can do so?
The National Partnership for Women & Families convened a team of 17 experts from a variety of organizations and disciplines to create a blueprint for a higher-performing maternity care system. (You may have seen a sneak peek of the blueprint if you attended the Lown Conference panel on maternity care.)
The goal of this coalition is to identify policies that will enable all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences. In short, how can we change the maternity care system so that all women who want to and are able to experience the benefits of a natural birth can do so?
Co-author Carol Sakala, who leads maternity care programming at the National Partnership, said, “We can turn around the substandard performance and excessive expenditures of our current maternity care system. Rapid gains are within reach, and our team’s thoughtful new Blueprint points the way.”
Here are the major strategies and policies outlined in the blueprint to transform maternity care:
The fee-for-service model of payment can be especially problematic in maternity care, because clinician and hospital payments typically do not reflect whether good care was provided, leading to widespread overuse of unnecessary interventions, underuse of beneficial practices and worsening outcomes for many indicators. Too few health plans, health systems and Medicaid programs are moving toward an episode payment system (one payment per episode of care rather than paying for each service).
The traditional payment system doesn’t actually hold providers accountable for outcomes, because it doesn’t include performance measures with a downside risk if providers don’t meet the targets. Making separate payments to clinicians, facilities and others across different phases of care without accountability provides no incentive for the entire care team to work toward shared aims by doing the most impactful things. Paying each provider separately has also made maternity care very expensive, and the costs are steadily increasing.
The blueprint recommends switching to episode payment programs that cover women and newborns from prenatal to postpartum care, with both upside rewards and downside risks based on high-impact performance measures. (See Section 1 of the blueprint for lots more detail on how we can structure EPPs for maternity care.)
The blueprint also suggests more research and pilots of maternity care homes – a single person (most often a nurse, social worker, or community health worker) coordinating care for pregnancy, birth, and postnatal care. This person provides continuity of care throughout the episode, is available to the woman through multiple channels for advice and support, and coordinates with other providers in a care team, as well as needed community and social services.
We know that the US has poor maternal care outcomes compared to other developed countries. But when it comes to measuring performance more specifically across hospitals and clinics, we are behind. We need nationally-endorsed standardized measures by which to evaluate providers and more rigorous collection and reporting of performance data. We also need to measure more outcomes across demographics, to hold providers accountable for disparities in maternity care outcomes.
The lack of shared decision-making in maternal care can lead to miscommunications, traumatic experiences, and poor outcomes. The authors encourage providers to engage in “shared care planning” – where patients and providers set goals together, make informed decisions together, and make the care plan available to all members of the care team (including women and families) throughout the pregnancy and birth process.
Maternity care professionals – obstetricians, nurses, midwives, doulas, social workers, and others – all have unique but incredibly important roles to play in the birthing process. However, these professionals do not often have the chance to interact with each other and learn from each other outside of the delivery room. We need more opportunities for medical students and other health professionals to learn about and participate in physiologic labor, and to learn about the roles and skills of everyone on the care team.
Currently there are many areas of the country where there are few or no medical professionals with training in maternity care, making it difficult for pregnant women to get the medical attention they need. The NPWF blueprint suggests using federal funding to increase residency slots for obstetricians in states with a shortage of these professionals, as well as increasing the number of midwives, encouraging Medicaid reimbursement of certified professional midwives and giving family medicine doctors more training in maternity care during their residencies and fellowships.
They blueprint also emphasizes conducting more research and pilot programs of laborist models, which involve a physician or midwife being physically available 24 hours a day for only labor and delivery responsibilities. So far laborist performance has been uneven, but the authors see potential for this model to develop clinicians’ skills in supporting natural birth.
Even though the process of childbirth has been studied for hundreds of years, there are still a lot of things we don’t know about the natural birth process. Why does labor start when it does? What are the long-term effects of common interventions used during birth, such as inducing labor, for mothers and children? What are the benefits and harms of giving births in a hospital compared to a birth center or home? Filling in these research gaps would help prioritize resources and policies even more.