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Advancing Health Equity

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Community-Based Models to Improve Maternal Health Outcomes and Promote Health Equity

Doulas demonstrating how a birthing person can be supported while in hte bathroom

Stephanie Dixon, left, and Deundra Hundon, a mother-daughter doula duo and owners of Bare With Me, demonstrate how a birthing person can be supported while in the bathroom. Bare With Me is part of a new partnership with the San Francisco Department of Public Health aimed at providing doulas to low-income Black and Pacific Islander women. Photo: Carlos Avila Gonzalez/San Francisco Chronicle via Getty Images

Stephanie Dixon, left, and Deundra Hundon, a mother-daughter doula duo and owners of Bare With Me, demonstrate how a birthing person can be supported while in the bathroom. Bare With Me is part of a new partnership with the San Francisco Department of Public Health aimed at providing doulas to low-income Black and Pacific Islander women. Photo: Carlos Avila Gonzalez/San Francisco Chronicle via Getty Images

Abstract

  • Issue: In the United States, high spending on maternity care does not translate to better maternal health outcomes. People of color, particularly Black and Indigenous women, are at heightened risk for negative outcomes.
  • Goal: To examine models for delivering maternity care that could improve outcomes and reduce racial inequities in maternal morbidity and mortality.
  • Methods: Review of research literature on the maternal health outcomes associated with community-based, perinatal care models.
  • Findings and Conclusions: Research shows a wide range of community-based approaches could improve maternal health outcomes and patients’ experiences while also potentially reducing costs. Such approaches could especially benefit those most at risk for poor outcomes, particularly people of color and those with low income. One policy option is expanding reimbursement for providers like doulas and midwives, whose care has been associated with improved maternal and infant health outcomes in some research. Other options include enhancing patient access to a broader range of services and incentivizing health systems and providers to adopt evidence-based, equity-centered models of care.

Note: We at times use “women” and “mothers” when referring to people who are pregnant or recently gave birth. We acknowledge that not all people who become pregnant or give birth identify as women.

INTRODUCTION

The United States has one of the highest rates of maternal mortality among high-income countries, with nearly 17.4 deaths for every 100,000 live births, despite significantly higher spending on maternity care.1 Further, risks for maternal mortality are disproportionately higher among Black women, who have a pregnancy-related mortality ratio more than double that of white women, regardless of educational level (see exhibit). Similarly elevated risks of maternal mortality are also reported for Indigenous women.2

Zephyrin_community_based_maternal_health_exhibit_1

Transformation of the maternity care system will require new models of health care delivery developed with input from community stakeholders and designed to reduce racial health inequities.3 Such models are being examined not only for their overall effectiveness and cost-savings potential but specifically for their likelihood to improve maternity care for people of color and those with low income. The need for new approaches has perhaps never been greater: as the coronavirus pandemic continues to rage in the U.S., evidence shows that Black, Hispanic, and Indigenous women are being disproportionately affected by COVID-19 during pregnancy.4

In this issue brief, we review the evidence for new maternity care models and discuss how policymakers, payers, providers, and health care systems can help to advance them.

INCORPORATING DIVERSE GROUPS OF HEALTH CARE PROVIDERS

Community-based doulas and nurse-midwifery care are rooted in the centuries-old practice of women receiving help from other women during childbirth, and a growing demand from women to have greater agency during their own birth process.5

Community-Based Doulas

What They Are and What They Do: Community-based doulas are trusted individuals, often from local communities, who are trained to provide psychosocial, emotional, and educational support during pregnancy, childbirth, and the postpartum period.6 They are particularly critical in labor and delivery, serving as patient advocates, and providing comfort and coaching. Community-based doula programs build on the strong relationship doulas establish with mothers throughout pregnancy, birth, and the postpartum period to promote ongoing care and support.7

Evidence of Effectiveness: Doulas can improve perinatal and postpartum outcomes while being cost-effective, particularly for those facing inequities in birth outcomes.8 For example, those at high risk for adverse birth outcomes receiving care from doulas, compared with those not receiving care from doulas, are:

  • Two times less likely to experience a birth complication
  • Four times less likely to have a low birthweight baby
  • More likely to breastfeed
  • More likely to be satisfied with their care.9

Capacity to Advance Equity: The evidence suggests doulas are beneficial particularly for women of color, low-income women, and other marginalized communities. For example, a study of Medicaid beneficiaries receiving doula support found lower rates of C-sections and preterm births, compared with other pregnant women enrolled in Medicaid.10 Similar findings were reported for a community-based doula program serving predominantly Black and Latinx neighborhoods in New York City.11 Additionally, a recent study in California found that doulas have the potential to provide a “buffer” against racism in health care for pregnant women of color by providing patient-centered, tailored, and culturally appropriate care.12

To enable community-based doulas to provide care for Medicaid beneficiaries, fair compensation for doula work is critical. At least five states (Indiana, Minnesota, New Jersey, New York, and Oregon) have passed legislation implementing third-party reimbursement for doula services through Medicaid.13 Unfortunately, during the COVID 19 pandemic, certain states have had to pull back their focus on these programs. Low reimbursement rates as well as expensive, time-consuming licensure processes may also need to be addressed, as they create barriers to entry into community-based doula work.

Midwives

What They Are and What They Do: Midwives provide reproductive health care and attend births in multiple settings including at home, in a birth center, or in the hospital. They oversee the spectrum of maternity care, helping birthing people to identify their labor preferences and the appropriate site of delivery. Many individuals prefer working with midwives over M.D.s.14

Evidence of Effectiveness: The positive impact of midwifery on maternity care outcomes is well documented. An extensive literature review shows midwife-led maternity care results in substantially higher rates of vaginal delivery and lower rates of C-sections, as well as significantly lower rates of preterm births and low-birthweight infants compared with other maternity models.15

Although integration of midwives into health systems is demonstrated to be a key determinant of optimal maternal–newborn outcomes, only 8 percent of births nationally are delivered by certified nurse midwives.16 Rates vary significantly by states, in part because of differences in scope of practice laws that may limit what services midwives are permitted to provide independently.

Capacity to Advance Equity: There is less evidence on the success of midwifery at reducing racial inequities, perhaps because of the shifting demographic makeup of midwives themselves.17 In 2019, 49 percent of births in the U.S. were to people of color, but the nurse midwifery workforce remained 90 percent white.18 This reflects the historical exclusion and denigration of the long tradition of Black midwifery in the U.S. Prior to the early 20th century, the majority of U.S. births were attended by Black or immigrant lay midwives.19

For nurse midwifery to effectively address racial disparities in birth outcomes, one policy option is intentional investment in pipelines to train a racially and culturally diverse midwifery workforce. This may be especially valuable, as evidence suggests that racial concordance between provider and patient can improve satisfaction and quality of care.20

OFFERING NON-HOSPITAL-BASED CARE

Freestanding Birth Centers

What They Are and What They Do: Birth centers are stand-alone facilities that provide prenatal and labor and delivery care. They emphasize relationship-building between providers and pregnant people, and patient-centered birth planning and labor. Unlike costly hospital-based labor and delivery, birth centers are midwifery-led and typically do not employ anesthesiologists, obstetricians, and pediatricians. Because of this, birth centers are only recommended for low-risk labors.21

Evidence of Effectiveness: Birth centers reduce the number of interventions used in the course of labor and delivery while improving patient experience and lowering costs — saving more than $1,000 per birth.22 A review of 32 studies of birth centers found positive health outcomes for women, including lower rates of C-sections compared with women delivering in hospitals.23 Few severe maternal outcomes and no maternal deaths were reported in any of these studies, and overall, women were satisfied with the comprehensive, personalized care that they received. Another recent study of more than 15,000 birth center labors found only 6 percent resulted in C-sections with no maternal deaths.24 Although less consistent, some research also suggests improved infant outcomes.25

Hospital-affiliated birth centers may be particularly effective because they ensure higher levels of care are available in an emergency.26 For example, birth centers may be colocated with hospitals, with midwives maintaining admitting privileges. Some states also are leveraging the birth center model during the COVID-19 pandemic as a safe alternative to overcrowded hospitals and to prevent infection for birthing parents.27

Capacity to Advance Equity: Black-owned, culturally sensitive birth centers are a promising means of reducing racial disparities in maternal morbidity and mortality.28 However, while there are more than 384 birth centers in the United States, it is estimated that only about 20 are led by people of color.29 Limited access to capital and resources is a significant barrier to people of color starting and owning birth centers. Another obstacle to the growth of birth centers is Medicaid’s limited, or sometimes lack of, reimbursement for the services they provide.

EXPLORING INNOVATIVE MODELS OF MATERNITY CARE

Group Prenatal Care

What It Is and What It Does: Group prenatal care has been widely tested as an alternative to traditional, individualized care. Under the model, providers offer the same physical health care services for individual patients, who also convene as a group for facilitated discussions on topics ranging from preparations for parenthood and stress management to breastfeeding and nutrition.30

Evidence of Effectiveness: Preliminary, observational studies on the impact of group prenatal care demonstrate reduced rates of preterm birth (upwards of 41%), neonatal intensive care unit (NICU) admissions, low birthweight, and emergency department use during pregnancy, as well as increases in breastfeeding, patient and physician satisfaction, and parental knowledge of childbirth and child-rearing.31 A study of a group prenatal care program for pregnant Medicaid beneficiaries in South Carolina found the model was cost-effective; by preventing premature births, group prenatal care resulted in cost savings of $2.3 million for the state. However, some studies, particularly randomized clinical trials, found no differences in health outcomes like preterm births between women in group versus individual prenatal care.32 Whether group prenatal care programs were able to successfully move online during the COVID-19 pandemic, and the impact of that transition, remains an open question.

Capacity to Advance Equity: There is evidence that group prenatal care is particularly helpful for improving health outcomes among Black people with low income, suggesting the model could help reduce racial disparities in maternal and infant mortality.33 Despite the promising evidence, the use of this model is not widespread.34 Some have been piloting diverse, culturally centric models to increasing awareness and interest. One group program, EMBRACE, was developed to provide prenatal care integrated with intentional racial consciousness to Black mothers and Black pregnant people.35 Group prenatal care models can be culturally responsive and aware and have diverse staff and leadership that represent the community served.

Pregnancy Medical Homes

What They Are and What They Do: The pregnancy medical home (PMH) provides comprehensive perinatal health care. PMHs provide early prenatal care in the first trimester, expand patient access through increased office hours, and engage patients in shared decision-making.36 Teams are financially incentivized for achieving specific milestones toward these goals and for meeting program requirements, such as screening for risk, collaborating with a care coordinator, and using data and analytics to monitor their own performance.

Evidence of Effectiveness: A medical home pilot in Texas resulted in better outcomes, fewer emergency department visits, and fewer C-sections, while pilots in Wisconsin and Texas increased likelihood of attending a postpartum visit.37 North Carolina formed a PMH model in which teams of maternity care providers aim to prevent preterm births and reduce C-sections for individuals enrolled in Medicaid. The program resulted in a nearly 7 percent decrease in the low-birthweight rate among the state’s Medicaid population.38

Several states that have implemented PMHs have realized savings from decreased hospitalizations and emergency department visits.39 However, some evidence suggests PMH models are not as effective as other models like group prenatal care at preventing maternal and child mortality and morbidity, and reducing overall health care costs.40

Capacity to Advance Equity: There is promising evidence that the PMH model, with its integrated care teams that address behavioral health and social needs, could play a role in reducing racial disparities in maternity outcomes. For example, North Carolina had the second-lowest rate of maternal mortality of all 25 reporting states, according to 2018 data from the Centers for Disease Control and Prevention. The state’s success in part may be the result of its PMH model, which was implemented among 95 percent of prenatal care providers who accept Medicaid payment.41

ROLE OF PAYMENT AND DELIVERY SYSTEM REFORM

Equity-centered approaches to maternity care may help curb the rising rate of maternal mortality in the United States, particularly among women of color. Several approaches to maternity care have demonstrated that they can improve maternal and infant health outcomes — and, in some cases, reduce costs. To scale and spread these models, payment and delivery system reforms could focus on the following three areas:

  • Expanding and improving reimbursement for the provider types that have helped reduce negative maternal and infant health outcomes, including doulas and midwives. States have a key role in defining scope of practice and allowing these providers to deliver services within their training and ability without physician supervision. The federal government also could financially support accreditation programs and create and expand loan forgiveness and training programs for these provider types to increase access to racially and culturally diverse maternity care providers.
  • Improving access to services. The largest insurer of pregnant people, Medicaid, ends coverage for women 60 days postpartum, which leaves them without critical follow-up care. To reduce the racial inequities in maternal and infant morbidity and mortality, Medicaid coverage could be extended to at least one year postpartum. Additionally, Medicaid and other delivery system models could include more services addressing medical, behavioral, and social health needs.
  • Incentivizing health systems and providers to adopt evidence-based models of care, like pregnancy medical homes, birth centers, and group prenatal care. Additionally, using value-based payments to incentivize use of equity-centered models could promote a more diverse set of providers and services. Creating accountability and incentives would help ensure that these policies and programs are equity-centered and create the desired outcomes.

CONCLUSION

A large and growing body of research suggests that a wide range of approaches could improve maternal health outcomes and the patient experience, while potentially reducing costs. This is especially true for those most at risk for negative outcomes, including people of color and those with low income.

As policymakers, providers, payers, and health system leaders rethink care delivery during the COVID-19 pandemic, they may consider how these evidence-based models can be modified, leveraged, and expanded to ensure access to high-quality maternity care now and in the future.

NOTES

1. Munira Z. Gunja et al., What Is the Status of Women’s Health and Health Care in the U.S. Compared to Ten Other Countries? (Commonwealth Fund, Dec. 2018); and “Maternal Mortality,” National Center for Health Statistics, Centers for Disease Control and Prevention, Nov. 9, 2020.

2. Emily E. Peterson et al., “Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017,” Morbidity and Mortality Weekly Report 68, no. 18 (May 10, 2019): 423–29.

3. Zoë Julian et al., “Community-Informed Models of Perinatal and Reproductive Health Services Provision: A Justice-Centered Paradigm Toward Equity Among Black Birthing Communities,” Seminars in Perinatology 44, no. 5 (Aug. 2020): 151267.

4. Sascha Ellington et al., “Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–June 7, 2020,” Morbidity and Mortality Weekly Report 69, no. 25 (June 2020): 769–75; and Bryant Furlow, “A Hospital’s Secret Coronavirus Policy Separated Native American Mothers from Their Newborns,” ProPublica, June 13, 2020.

5. Katy Dawley, “Origins of Nurse‐Midwifery in the United States and Its Expansion in the 1940s,” Journal of Midwifery & Women’s Health 48, no. 2 (Mar.–Apr. 2003): 86–95.

6. Nora Ellmann, “Community-Based Doulas and Midwives: Key to Addressing the U.S. Maternal Health Crisis,” Center for American Progress, Apr. 14, 2020.

7. Asteir Bay et al., Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities (Ancient Song Doula Services, Village Birth International, Every Mother Counts, Mar. 25, 2019).

8. Mary-Powel Thomas et al., “Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population,” Maternal and Child Health Journal 21, no 1 (suppl. 2017): 59–64.

9. Kenneth J. Gruber et al., “Impact of Doulas on Healthy Birth Outcomes,” Journal of Perinatal Education 22, no. 1 (Winter 2013): 49–58.

10. Katy Backes Kozhimannil, Rachel R. Hardeman, and Michelle O’Brien, “Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries,” American Journal of Public Health 103, no. 4 (Apr. 2013): e113–e121.

11. Thomas el al., “Doula Services,” 2017.

12. Amy Chen and Alexis Robles-Fradet, Building a Successful Program for Medi-Cal Coverage for Doula Care: Findings from a Survey of Doulas in California (National Health Law Program, May 2020).

13. Christina Gebel and Sarah Hodin, Expanding Access to Doula Care: State of the Union (Maternal Health Task Force, Jan. 8, 2020); National Partnership for Women and Families, Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and Infant Health (National Partnership, Jan. 2016); and New Jersey Legislature, NJ S1784, Medicaid Coverage for Doula Care, May 22, 2019.

14. American College of Nurse-Midwives, Fact Sheet: Essential Facts About Midwives (ACNM, May 2019).

15. Jane Sandall et al., "Midwife-Led Continuity Models Versus Other Models of Care for Childbearing Women,” Cochrane Database of Systematic Reviews 8 (Aug. 21, 2013): CD004667; and Laura B. Attanasio, Fernando Alarid-Escudero, and Katy B. Kozhimannil, “Midwife-Led Care and Obstetrician-Led Care for Low-Risk Pregnancies: A Cost Comparison,” Birth 47, no. 1 (Mar. 2020): 57–66.

16. Sarawathi Vedam et al., “Mapping Integration of Midwives Across the United States: Impact on Access, Equity, and Outcomes,” PLoS One 13, no. 2 (Feb. 2018); and Georgetown University School of Nursing, How Does the Role of Nurse-Midwives Change from State to State? (Georgetown University, Feb. 5, 2019).

17. Hannah Yoder and Lynda R. Hardy, “Midwifery and Antenatal Care for Black Women: A Narrative Review,” SAGE Open (Jan.–March 2018): 1–8.

18. Jyesha Wren Serbin and Elizabeth Donnelly, “The Impact of Racism and Midwifery’s Lack of Racial Diversity: A Literature Review,” Journal of Midwifery & Women’s Health 61, no. 6 (Nov.–Dec. 2016): 694–706.

19. Serbin and Donnelly, “Impact of Racism,” 2016.

20. Julian et al., “Community-Informed Models,” 2020; Thomas A. LaVeist and Amani Nuru-Jeter, “Is Doctor–Patient Race Concordance Associated with Greater Satisfaction with Care?Journal of Health and Social Behavior 43, no. 3 (Sept. 2002): 296–306; Marcella Alsan, Owen Garrick, and Grant C. Graziani, Does Diversity Matter for Health? Experimental Evidence from Oakland (National Bureau of Economic Research, Aug. 2019); and Brian D. Smedley et al., eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (The National Academies, 2003).

21. American Association of Birth Centers, Standards for Birth Centers (AABC, 2017).

22. Embry Howell et al., “Potential Medicaid Cost Savings from Maternity Care Based at a Freestanding Birth Center,” Medicare & Medicaid Research Review 4, no. 3 (Sept. 2014): mmrr.004.03.a06.

23. Jill Alliman and Julia Phillippi, “Maternal Outcomes in Birth Centers: An Integrative Review of the Literature,” Journal of Midwifery & Women’s Health 61, no. 1 (Jan. 2016): 21–51.

24. Susan Rutledge Stapleton, Cara Osbourne, and Jessica Illuzzi, “Outcomes of Care in Birth Centers: Demonstration of a Durable Model,” Journal of Midwifery & Women’s Health 58, no. 1 (Feb. 2013): 3–14.

25. Sarah Benatar et al., “Midwifery Care at a Freestanding Birth Center: A Safe and Effective Alternative to Conventional Maternity,” Health Services Research 48, no. 5 (Oct. 2013): 1750–68.

26. Victoria G. Woo, Arnold Milstein, and Terry Platchek, “Hospital-Affiliated Outpatient Birth Centers: A Possible Model for Helping to Achieve the Triple Aim in Obstetrics,” JAMA 316, no. 14 (Oct. 11, 2016): 1441–42; and Alliman and Phillippi, “Maternal Outcomes in Birth Centers,” 2016.

27. State of New York, COVID-19 Maternity Task Force: Recommendations to the Governor to Promote Increased Choice and Access to Safe Maternity Care During the COVID-19 Pandemic (NY State, Apr. 2020).

28. Rachel Hardeman et al., “Roots Community Birth Center: A Culturally-Centered Care Model for Improving Value and Equity in Childbirth,” Healthcare 8, no. 1 (Mar. 2020): 100367.

29.Highlights of Four Decades of Developing the Birth Center Concept in the U.S.,” American Association of Birth Centers, May 2020; and Leseliey Welch and Nashira Baril, “Birth Centers Are Crucial for Communities of Color, Especially in a Pandemic,” Rewire News, Apr. 2020.

30. American College of Obstetricians, Committee Opinion: Group Prenatal Care (ACOG, Mar. 2018).

31. ACOG, Committee Opinion, 2018.

32. Christine J. Catling et al., “Group Versus Conventional Antenatal Care for Women,” Cochrane Database of Systematic Reviews 2 (Feb. 4, 2015): CD007622; and Ebony B. Carter et al., “Group Prenatal Care Compared with Traditional Prenatal Care: A Systematic Review and Meta-Analysis,” Obstetrics & Gynecology 128, no. 3 (Sept. 2016): 551–61.

33. Jeannette Ickovics et al., “Group Prenatal Care and Perinatal Outcomes: A Randomized Controlled Trial,” Obstetrics & Gynecology 110, no. 2 (Aug. 2007): 330–39.

34. Allissa Anne Desloge, Scaling Up Group Prenatal Care: Analysis of the Current Situation and Recommendations for Future Research and Policy Analysis (Yale School of Public Health, Jan. 1, 2019).

35.EMBRACE: Group Perinatal Care for Black Families,” University of California, San Francisco National Center of Excellence in Women’s Health, 2020.

36. Jeff Rakover, “The Maternity Medical Home: The Chassis for a More Holistic Model of Pregnancy Care,” Institute for Healthcare Improvement (blog), March 22, 2016.

37. Texas Health and Human Services, Pregnancy Medical Home Pilot Program Final Evaluation Report (THHS, Sept. 2017); and Anisha Agrawal, Case Study: Wisconsin’s Obstetric Medical Home Program Promotes Improved Birth Outcomes (National Academy for State Health Policy, Sept. 2017).

38. Kate Berrien et al., “Pregnancy Medical Home Care Pathways Improve Quality of Perinatal Care and Birth Outcomes,” North Carolina Medical Journal 76, no. 4 (Sept. 2015): 263–66.

39.Expanding Access to Outcomes-Driven Maternity Care Through Value-Based Payment,” Health Care Transformation Task Force, July 2019.

40. Ian Hill et al., Strong Start for Mothers and Newborns Evaluation: Year 1 Annual Report (Urban Institute, Oct. 2014); and Caitlin Cross-Barnet, Strong Start for Mothers and Newborns Evaluation: Year 5 Project Synthesis (Urban Institute, Oct. 2018).

41. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Maternal Mortality by State, 2018 (NCHS, 2018); and Community Care of North Carolina, “Pregnancy Medical Home: Improving Maternal & Infant Outcomes in the Medicaid Population,” accessed Feb. 25, 2021.

Publication Details

Date

Contact

Laurie Zephyrin, Vice President, Health System Equity

[email protected]

Citation

Laurie Zephyrin et al., Community-Based Models to Improve Maternal Health Outcomes and Promote Health Equity (Commonwealth Fund, Mar. 2021). https://doi.org/10.26099/6s6k-5330