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Why Maternity Care Quality MattersIs health care quality a problem in the United States? Is maternity care quality a problem in the United States? Why is maternity care quality important to me? How can we define maternity care quality? Why do we need a single national set of high-quality maternity care performance measures? What is transparency in maternity care, and why is it important? What maternity care procedures are being overused in the United States? What safe and effective maternity care practices are underused in the United States? Why do mothers and babies benefit from physiologic childbirth? Is health care quality a problem in the United States?Try asking your friends and family—or a politician running for office—about the U.S. health care system. Any one of them will likely come up with a long list of problems, including
Experts agree that our health care system needs work. A recent report in the Journal of the American Medical Association stated, “Serious and widespread quality problems exist throughout American medicine.” The Institute of Medicine, part of the National Academy of the Sciences, concluded, “In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves.” And a 2008 report from PricewaterhouseCoopers estimated that 1.2 trillion dollars of the 2.2 trillion spent annually on health care in the United States are wasted. Is maternity care quality a problem in the United States?While everyone agrees that the U.S. health care system needs improvement, the Listening to Mothers II survey indicates that most women believe maternity care quality in the United States is very good. Are they right?Well, first think about how you might judge maternity care quality. One way is to compare U.S. performance with other countries. A World Health Organization report identified 29 countries in the year 2000 with lower maternal mortality rates than the United States, while 33 countries had lower neonatal mortality rates. Another study found that maternal mortality rates in the U.S. in 2005 were higher than those in 33 other countries. The U.S. had higher low-birthweight rates than 23 other countries. Yet the U.S. spends more on health care, per person, than any other nation. Others have carefully examined the best available research on safe and effective care for mothers and babies. More and more rigorous systematic reviews analyzing the effects of maternity practices are available. Unfortunately, these reviews are rarely used to guide practice or policy. Many low-tech beneficial practices are underused, while highly-medicalized procedures are overused. The tendency in the United States to provide expensive, procedure-intensive maternity care without improving the health of mothers and babies has been coined the “perinatal paradox: doing more and accomplishing less” (Rosenblatt 1989). Why is maternity care quality important to me?Maternity care is the second most common reason for admission to a hospital, with more than four million childbirth-related hospital stays per year. Yet, as a pregnant woman, you have vastly different needs than others who are hospitalized. This is because pregnant women are neither ill nor injured. In fact, most childbearing women in the United States are healthy and have no reason to expect complications from childbirth. Then why, each year, do millions of healthy mothers and babies experience care similar to that of patients in intensive care units?Optimal maternity care should follow the principle of “effective care with least harm.” Instead, nearly all women who give birth in U.S. hospitals experience high rates of interventions, with risks of adverse effects. Procedures appropriate for a relatively small number of mothers, such as episiotomy and continuous electronic fetal monitoring, are common. Meanwhile, numerous beneficial practices that support women's own innate capacities or the "physiologic" process of childbirth, such as labor support, are underused. As an expectant mother, and later as a new mother, you want the best quality of care for you and your baby. High-quality care will
How can we define maternity care quality?The Institute of Medicine (IOM), a part of the U.S. National Academy of Sciences, defines quality of health care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” In its landmark 2001 report Crossing the Quality Chasm, the IOM called for large-scale changes to the U.S. health care system and laid out six national aims for improvement: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.We can define maternity care quality in the context of these six aims. Optimal maternity care will be:
Why do we need a comprehensive set of high-quality nationally recognized maternity care performance measures?Poor quality maternity care can lead to medical errors or to unnecessary interventions and complications, longer hospital stays, and infants needing intensive care services. These problems, in turn, increase costs and short- and long-term health problems in mothers and babies. With over four million expectant mothers admitted to hospitals each year, maternity care quality affects a large number of women, newborns and families.Up to now, there has been very little focus on quality measurement and reporting for maternity care. No nationally recognized set of maternity care performance measures existed, and few used the measures that did exist. Only sporadic public reporting on maternity care quality occurred. Similarly, public access to information about maternity care quality was limited. Nationally recognized maternity care performance measures will help improve maternity care quality by:
The National Quality Forum (NQF) is a non-profit organization working to improve the quality of American health care by setting national priorities and goals for performance improvement, and endorsing national consensus standards for measuring and publicly reporting on performance. In October 2008, the National Quality Forum released important new tools for improving the quality of maternity care: a set of 17 national measures for assessing the quality of care from the end of pregnancy until mothers and babies are discharged. The measures address care provided by clinicians, including physicians and midwives, as well as care provided by facilities, such as hospitals and birthing centers. What is transparency in maternity care, and why is it important?Transparency is the opposite of privacy. Transparency means making information about maternity care practices and outcomes of caregivers and institutions fully available to the public. Transparency is essential to evaluating the quality of maternity care, and it helps promote quality improvement.Rates of medical interventions during labor and birth, including labor induction, cesarean section, and episiotomy, vary widely from caregiver to caregiver and place to place. In 2005, cesarean section rates of New York City hospitals varied from 17.3% to 44.6%. In upstate New York, induction rates varied fourfold across hospitals and sevenfold across caregivers. The wide variation has little to do with differences in the needs or preferences of women. The variation is primarily due to differences in styles of practice, maternity markets and other factors that should not influence care. A woman’s choice of caregiver, and her choice of where to give birth, are major factors in determining the kind of care she will experience during childbirth. Many women wish to avoid routine, unneeded childbirth interventions. How can a woman find a caregiver and place of birth with, for example, relatively low episiotomy or cesarean rates? Right now, it is difficult since in most states, caregivers and maternity care facilities are not required to publicly report intervention rates or other performance measures. However, this type of information is increasingly collected and reported. In addition to helping women make informed decisions, transparency improves the quality of maternity care. Several studies have shown that public reporting of performance leads to higher quality care. For example, one study looked at a number of hospitals that had received low maternity care quality scores. The hospitals whose low scores were reported publicly made more effort to improve their maternity care quality than hospitals without public reporting—and their efforts were successful. What maternity care procedures are being overused in the United States?Optimal maternity care follows the principle of “effective care with least harm.” Yet many interventions with harmful side effects are widely used in the United States, even when there is little or no expected benefit for mother or baby. Numerous maternity practices designed to address specific needs of a small segment of mothers are now used frequently — even routinely — in healthy women. Some practices that are widely used despite lack of evidence of clear benefit include some routine prenatal tests and treatments, continuous electronic fetal monitoring, rupturing membranes during labor, and episiotomy.Labor induction is another important example of an overused maternity practice. While induction may occasionally be necessary in certain circumstances, induction for convenience — the mother’s convenience, the caregiver’s convenience, or both — is becoming increasingly prevalent. Increases in labor induction are leading to more babies born before they reach 40 weeks of gestation, despite evidence that fetal brain development continues up through the 40th week and that mortality rates are higher for babies born at 38 or 39 weeks. Drugs used to induce labor may decrease a mother’s chance of successfully breastfeeding her newborn. In addition, labor induction leads to an increased chance of c-section in first-time mothers. Epidural analgesia is also used more widely than necessary. Mothers are given epidurals routinely as the “first line of defense” against labor pain. Not only is this routine use of epidural analgesia expensive, an epidural decreases women’s ability to move during labor, and later to push, decreasing the chance of a "spontaneous" vaginal birth with no vacuum extraction, forceps or cesarean. Using labor support, tubs, and other pain relief measures first, then administering epidural analgesia as needed, makes more sense for the health of mothers and babies. The rate of cesarean section in the U.S. has been increasing steadily for the past decade, and now reaches a new record level each year. Both the rate of "primary" or first-time cesareans and the rate of repeat cesareans are rising. Recent research reaffirms earlier World Health Organization guidance that optimal national cesarean rates are in the range of 5% to 10% of all births, while rates above 15% are likely to do more harm than good. However, our national rate is above 30%. Women are often told they need a c-section due to “failure to progress.” However, numerous available methods for promoting labor progress could be used before turning to c-section. When choosing between a repeat c-section and a vaginal birth after cesarean (VBAC), there are incentives for caregivers to encourage c-section, because a planned c-section can be quick and convenient for professionals or because caregivers may be concerned about lawsuits if complications arise during a VBAC. Often, women are not reminded of the numerous risks of c-section, for both mother and baby, or the benefits babies experience as a result of labor. In many cases of medical intervention, including cesarean section and labor induction, one intervention requires many co-interventions to monitor, prevent, or treat side effects of the original intervention. This "cascade of intervention" increases the risk of maternal or newborn harm, as well as greatly increasing costs. What safe and effective maternity care practices are underused in the United States?Optimal maternity care is the safest care that is also effective care. Yet numerous beneficial practices for mothers and babies are underutilized in the United States.For prenatal care, underused beneficial practices include prenatal vitamins, smoking cessation interventions, ginger for treating morning sickness, and caregiver hands-to-belly skills to turn "breech presentation" fetuses to a head-first position before birth to avoid cesarean section. Underused practices around the time of birth that can improve outcomes for mothers and babies include continuous labor support; use of tubs, hypnosis, and acupuncture to relieve labor pain; upright and side-lying positions for giving birth; delayed cord clamping; early mother-baby skin-to-skin contact; various breastfeeding promotion programs; and counseling for women with postpartum depression. For women who have had a previous cesarean section, a vaginal birth after cesarean (VBAC) is often the best option for delivery, with the least chance of short and long term harm to mother and baby. Yet VBAC is both underutilized and, quite often, unavailable. Many pregnant women who have had a previous cesarean section cannot find caregivers or hospitals offering VBAC as an option. Maternity care providers other than obstetricians are also underutilized in this country. Best available research has shown that mothers who choose midwives as their lead maternity caregivers experience reduced likelihood of episiotomy, labor induction, electronic fetal monitoring, pain medications, forceps, artificially ruptured membranes, and low birth weight infants. Studies also show that women who choose midwives as their caregivers are more likely to be satisfied with their care. Yet fewer than 10% of women use midwives as their primary maternity caregivers. Why do mothers and babies benefit from physiologic childbirth?With protection from interference and good support, childbearing women and their fetuses/newborns experience effective innate, hormonally-driven processes that have developed over the course of evolution. These processes begin at the onset of labor, continuing through the birth of the baby, delivery of the placenta, and then through the establishment of breastfeeding and mother-baby attachment. When caregivers give priority to these capacities, most mothers and babies can avoid medical procedures and drugs that push and pull labor along, often with side effects.The great majority of expectant mothers in the U.S. are healthy and at low risk for complications during childbirth. While much attention is given to the important needs of pregnant women with medical problems, or to those women who are at high risk of experiencing problems (about 1 in 6 pregnant women), we also need to give attention to ensuring that healthy childbearing women receive high-quality care that is safe, effective, woman and family-centered, timely, efficient and equitable. Most recent page update: 1/12/2010
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Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Our mission is to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families. |
News and Features : Health Professionals
New VBAC Guidlines
ACOG has just issued new Guidlines for VBAC. What changed? What continues? We've Moved!
On July 1, 2010, the Childbirth Connection office moved to 260 Madison Avenue, 8th Floor, New York, NY 10016. All other contact information is unchanged. "2020 Vision" and "Blueprint for Action" Reports Available
Rising Maternal Mortality
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Updated Maternity Care Statistics Available
US Cochrane Center (USCC)/Consumers United for Evidence-based Healthcare (CUE)
New Mothers Speak Out National Report Released The latest report in Childbirth Connection's Listening to Mothers series is now available. Get an eye-opening look at the reality of life as a mother of young children in the United States, based on national surveys conducted by Harris Interactive. Learn more, get the report Read the Wall Street Journal story and listen to the podcast Download Quick Facts (PDF) Why does the national U.S. c-section rate keep going up? Current research points to an optimal cesarean section rate of 5% to 10%, but 1 pregnant woman in 3 is giving birth by major surgery in the United States. Why the surge and is this safe? A new page - and a PDF handout for journalists, policy makers, students and others - answer these questions. Read more about the rising cesarean section rate New Content!
March/April 2009 evidence column is now available.
Features: National Quality Forum endorses consensus perinatal performance measures; systematic reviews on induction of labor, environmental tobacco smoke and fetal health, and HPV infection and cervical neoplasia Get the column Popular Pages
 Comfort in Labor, by Penny Simkin Penny Simkin, the internationally recognized leader in childbirth education and labor support, shares her wisdom with women, including comfort measures, effective positions, and tips for partners and doulas. Download Comfort in Labor (free PDF) 
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