Addressing our maternity care crisis

April 30th, 2018

Becoming a parent is supposed to be one of the most exciting and happiest days in one’s life. But as the stories of Serena Williams, Lauren Bloomstein, and many others published over the past year show, the very real threat of complications has made giving birth in America more scary than exciting.  

The US has the highest rate of maternal mortality in the developed world; in 2015, 26.4 out of every 100,000 live births resulted in maternal mortality. That’s more than three times the rate in Canada, four times the rate in Japan, and nearly five times as high as Australia’s. Further, women in certain states and regions of the US, and especially African American women, face extremely high rates of maternal mortality. 

What factors are behind the maternal health crisis, and what can we do about it? At the 2018 Lown Conference earlier this month, clinicians and health policy experts led a breakout panel on right care in maternal health, to discuss the reasons behind the problem and evidence-based solutions. (You can view the powerpoint slides for this breakout session on our website.)

The session featured Dr. Carol Sakala, Director of Childbirth Connection Programs at the National Partnership for Women & Families; Nan Strauss, Director of Policy and Advocacy at Every Mother Counts; Dr. Steven Calvin, Medical Director of the Minnesota Birth Center; and Dianna Jolles, faculty at Frontier Nursing University and practitioner at El Rio Community Health Center.

Overuse and underuse in maternity care

The panelists pointed out that both overuse and underuse are prevalent in maternity care. Many women, especially those in rural areas, do not have easy access to maternal care. Additionally, high rates of obesity, diabetes, and high blood pressure (which are often untreated) create a greater risk of complications for American mothers. 

But at the same time, too many unnecessary interventions are being done during childbirth. The rate of cesarean sections in the US is about 32%, much higher than the rate recommended by the World Health Organization. C-section rates also vary widely across states. Why is there so much geographical variation? Diana Jolles explained that whether a mother has a c-section is not always dependent on medical need, but can depend on the hospital or clinic’s access to resources, payer source, and provider practice styles.

Carol Sakala echoed this point in her presentation of the NPWF “State of the Science” on maternity care. Much of the obstetrics field is focused on the “rescue” of high-risk pregnancies, but this misses the chance to prevent complications in the first place, said Sakala. At the same time, we use specialized care for low-risk pregnancies unnecessarily, which can be harmful. 

Putting the person in the center

In many of the stories of preventable maternal harm or near-harm, there is a prevalent theme of the patient not being heard. There are stories where the patient was highly educated, knew exactly what was wrong, had the same complication before, or even had a medical degree themselves, and doctors still ignored the patient when she insisted that something was wrong.

One way to combat this dangerous and frustrating problem is by integrating support from a midwife and doula, said Nan Strauss. Midwives and doulas provide different but complimentary services (midwives are licensed health care providers that provide prenatal, labor, and post-partum support, while doulas provide non-clinical physical and emotional support during birth).

Having continuous, one-on-one support from another person is associated with increased likelihood of spontaneous vaginal birth, reduced likelihood of a cesarean birth, and reduced negative feelings about childbirth, compared with just having physician care. “The goal is to put the person at the center of the equation,” said Strauss.

Turning the tide

The US is lagging behind other countries in maternal care, but several states are taking steps to change that. Recently, governor Andrew Cuomo of New York announced a pilot program allowing Medicaid to reimburse patients for doula services, making New York the third state to expand Medicaid coverage for doulas. 

Post-partum care is another serious issue women’s health professionals are starting to address. Many of the stories of harm or near-harm to new mothers show a gap in care in the first few weeks after they give birth. Dr. Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine put it bluntly in an NPR interview: “The baby is the candy; the mom is the wrapper. And once the candy is out of the wrapper, the wrapper is cast aside.”

Stuebe and others recently released a statement from a task force of the American College of Obstetricians and Gynecologists, urging doctors to make postpartum care an “ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs.” Statements like these are long overdue, as are steps to facilitate continuous support and reduce unnecessary interventions during birth.