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Health Care Reform Priorities for High Quality, High Value Maternity Care
A Statement from Childbirth Connection
September 2009
The Childbearing Population and Maternity Care in the United StatesLarge population affected. There are 4.3 million births/year; 85% of women give birth.
Considerable health implications. Rapidly developing fetuses/newborns are vulnerable to lifelong health impacts. Many childbearing women experience new-onset, often persisting, health concerns. Health before and between pregnancies impacts pregnancy outcomes.
Major position in health system. 23% of those discharged from hospitals are childbearing women or newborns. 6 of the 15 most common hospital procedures in the entire population involve childbirth. Cesarean section is the most common operating room procedure.
Costly condition. Maternal and newborn hospital charges ($86 billion in 2006) far exceed those of any other condition. Private insurers pay for 49% of births; Medicaid covers 43%.
Crucial opportunities. Repeated contact with the health care system in pregnancy is a unique opportunity to help a large, young, motivated population improve lifestyle, prevent chronic disease, make informed decisions, and become savvy health care consumers.
Current maternity care deficiencies can and must be improved. Deficiencies include overuse of many practices (and associated harm and waste), underuse of beneficial practices that would improve outcomes, unwarranted often manyfold practice variation, and indicators that have moved in the wrong direction for many years (e.g., low birthweight, c-section). A new Milbank Report identifies opportunities for improvement and elaborates upon barriers and solutions described below. See www.childbirthconnection.org/ebmc/
Eight Steps to High Quality, High Value Maternity Care
Ensure access for all
All pregnant women should have access to quality affordable care. It is unacceptable to exclude pregnancy as a pre-existing condition and use past birth experiences (e.g., c-section) to justify ineligibility or higher charges. There should be no delays in entering care.
Guide policy, practice, education, and improvement with comparative effectiveness
Evidence-based health care began with Effective Care in Pregnancy and Childbirth (1989) and companion resources that led to establishment of the Cochrane Collaboration. A large continually updated and expanded body of an estimated 2,000 to 3,000 Cochrane and non-Cochrane systematic reviews is available to guide maternity practice. Grossly underutilized in the U.S., these resources should be the foundation of clinical guidelines and practice, health professions and public education, reimbursement policy, performance measurement, and identification of gaps and comparative effectiveness research priorities. Needed are:
- an up-to-date, comprehensive database of completed pregnancy and childbirth systematic reviews to help all stakeholders access and use these invaluable resources
- state or regional maternity quality collaboratives using effective improvement strategies
Make primary maternity care the standard with optimal caregivers and settings
Most childbearing women and fetuses/newborns are healthy and at low risk. They are best served by access to safe, low-intervention primary maternity care that supports their innate capacities for birthing, breastfeeding and attachment, avoids overuse, and gives priority to prevention, wellness, and appropriate referral and treatment as needed. Primary maternity care also offers improved value for payers over present approaches. Foster it by:
- expanding the supply of midwives with national credentials (CNM, CM, CPM) and family physicians (FPs) who provide maternity services, as comparative effectiveness research comparing midwifery or FP maternity care to specialist care of similar women has consistently found that differences in process and outcome favor midwives and FPs
- recognizing that as surgical specialists obstetricians are optimal for women who have or are at high risk for serious health problems
- expanding access to freestanding birth centers, as healthy women who give birth in U.S. hospitals experience much high rates of labor induction, continuous electronic monitoring, episiotomy, cesarean section and other procedures
- ensuring that women who choose home birth have access to CPMs or other licensed caregivers with training and experience in this setting and to excellent care coordination
Measure and report maternity care performance, and use results to improve care
To foster maternity care quality improvement via performance measurement, use multi-disciplinary, multi-stakeholder processes, including substantial consumer involvement, to:
- identify, develop, test and disseminate a core maternity measure set, including measures of outcome, vaginal birth after cesarean (VBAC), normal birth (an established UK measure), postpartum care, informed decision making, and care coordination
- as feasible, apply measures to clinicians, groups, facilities, health plans, other entities
- adapt Consumer Assessment of Healthcare Providers and Systems (CAHPS) clinician, facility and health plan surveys for assessing maternity providers, settings and care
- develop Uniform Maternity Care Data Set for interoperable electronic health records that foster high-quality clinical care and performance measurement and reporting, building on ongoing initiatives (e.g., of American Association of Birth Centers)
- require states to report on core maternity care measures
- develop, test and disseminate standard reporting format for core maternity measures
- assist states and other entities with best practices and technical assistance for maternity measurement and reporting, including reporting for consumers and providers
- monitor, improve and expand the core maternity measure set, including measurement of access to and use of performance reporting
Align quality and payment
The payment system fosters costly procedure-intensive maternity care that is inappropriate for most women and newborns (e.g., labor induction, c-sections, repeated ultrasound imaging), while not reliably delivering effective priority preventive services. Needed are:
- pilots to assess bundled, risk-adjusted payments for the full episode of maternity care, to limit overuse, deliver effective preventive services, and improve outcomes and value
- Maternity Care Home payment for primary maternity care and care coordination to physicians and midwives meeting National Committee for Quality Assurance standards
- coverage of effective priority services, including smoking cessation programs for pregnant women, breastfeeding support programs before/after birth, labor doula care, and mental health services for postpartum depression
- incentives for women to choose high-performing maternity providers and facilities
- direct financial rewards to high-performing maternity providers and facilities
Improve Medicaid maternity care; demonstrate quality improvement strategies
Medicaid programs pay for at least 43% of the country's births, and their share is growing. State Medicaid programs, funded jointly with federal dollars, have not adequately implemented key strategies for maternity quality improvement. Needed are:
- demonstrations and waivers to encourage Medicaid programs to become leaders in maternity care quality improvement through 1) use of performance measurement, 2) alignment of payment and quality, and 3) innovation in culturally competent maternity care, effective health communication and maternal health literacy
- statutory clarification that birth center care is an essential Medicaid covered service and requirement for Medicare and Medicaid reimbursement of midwives with national credentials at 100% of the rate provided to other licensed health care professionals
- Medicaid and CHIP Payment and Access Commission (MACPAC) oversight, analysis, and proposals for Medicaid maternity quality, payment, and performance measurement
Engage consumers
To help pregnant women develop healthier lifestyles, prepare for childbirth and parenting, make informed maternity decisions, and become savvy health care consumers:
- develop up-to-date education and decision aids about comparative effectiveness of key maternity interventions, reflecting best evidence about effective health communication
- incorporate education and decision tools into HIT; make print, online versions available
- with education and decision aids, inform women as early as possible about the important choices of maternity caregivers and place of birth, and ensure access to reported results of maternity performance measures and decision support
- with education and decision aids, support women's key pregnancy decisions
- with education and decision aids, inform women well before birth about the most common decisions women face at that time, and again as relevant at the time of birth
Improve maternity health professions education and maternity care guidelines
To provide the maternity care workforce with primary maternity care skills and knowledge to support innate birthing, breastfeeding and attachment capacities of mothers and newborns:
- provide opportunities for nursing and medical students and residents to observe and foster physiologic childbirth by including experienced midwives in teaching roles
- provide incentives to include in medical school and residency programs core proficiencies for vaginal breech and vaginal twin birth, vacuum extraction and forceps, external version to turn fetuses to a headfirst position, diverse ways to facilitate labor progress and comfort, safe VBAC practice, and intermittent fetal monitoring
- develop, incorporate into HIT clinical decision support tools reflecting best evidence
- create a transparent multi-stakeholder process for developing clinical guidelines with meaningful participation of all relevant clinical disciplines, researchers, consumers and advocates, modeled on Canada's Family-Centred Maternity and Newborn Care: National Guidelines and the UK's National Institute for Health and Clinical Excellence
About Childbirth ConnectionChildbirth Connection, a national not-for-profit organization, has been a leader in maternity care quality improvement since 1918. Childbirth Connection promotes safe, effective and satisfying maternity care through research, education, advocacy and policy, and is a voice for the needs and interests of childbearing women and families.
Most recent page update: 9/22/2009
© 2010 Childbirth Connection. All rights reserved.
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.
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News and Features
"2020 Vision" and "Blueprint for Action" Reports Available
Leaders from across the U.S. health care system have prepared several reports for improving the maternity care system.
Learn about Transforming Maternity Care project 
Read the "2020 Vision"
Read the "Blueprint for Action"
Read the Consumer Workgroup report
Help implement Blueprint recommendations
Rising Maternal Mortality
Analysis of maternal mortality data for the state of California, with 14% of the nation's births, strongly suggests that maternal mortality is increasing in tandem with rising rates of cesarean section and obesity.
Read article about maternal mortality in California
Read companion Q&A
Maternity Care Fact Sheet Available
A new fact sheet (12/09) summarizes U.S. maternity care trends and figures from the latest federal reports. The fact sheet updates background information in the 2008 Milbank Report on Evidence-Based Maternity Care.
Get the fact sheet
Read Evidence-Based Maternity Care
US Cochrane Center (USCC)/Consumers United for Evidence-based Healthcare (CUE)
Visit the USCC/CUE website for the latest pregnancy and childbirth systematic reviews.
Maternity Care, a Major Segment of Health Industry, Must Be Overhauled for Health Care Reform to Succeed
As competing interests work out the particulars of health care reform, Childbirth Connection reminds the nation that rapid gains in the quality, cost, and value of maternity care are achievable.
Read the press release (PDF)
National Policy Symposium Honors Childbirth Connection's 90th Anniversary
Nearly 250 leaders deliberated about Transforming Maternity Care in Washington DC in April 2009.
Learn about symposium, next steps 
See 90 years of milestones for women and families (PDF)
Seton Family of Hospitals Receives First Maternity Quality Matters Award
Childbirth Connection presented its inaugural Maternity Quality Matters Award to an organization that is achieving significant gains for women and newborns.
Learn more about award winner
Maternity Care Priorities in Health Care Reform
Childbirth Connection has issued a statement about health care reform priorities for a high quality, high value maternity care system.
Read the statement (PDF)
Evidence-Based Maternity Care Report Released
A major new report takes stock of the U.S. maternity care system and finds great opportunities for improvement. Childbirth Connection collaborated with the Reforming States Group and the Milbank Memorial Fund to develop the report.
Learn more, get the report
Read companion USA Today article
Read the USA Today article
Read the Consumer Reports story
Take the Consumer Reports quiz
Read Our Bodies Our Blog entry
Help Transform Maternity Care! Please join our efforts to make quality maternity care a top national priority. Your support will help make the transformation possible. View 2009 Supporter Roster
New Mothers Speak Out National Report ReleasedThe 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)
"I feel my doctor put too much stress on me during the later stages of my pregnancy by trying to force me into another c-section."
-Listening to Mothers® survey participant
Every woman has the right to receive full advance information about risks and benefits of all reasonably available methods for relieving pain during labor and birth, including methods that do not require the use of drugs. She has the right to choose which methods will be used and to change her mind at any time.
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