Summary: A number of new initiatives take aim at longstanding problems with maternity care, including excessive rates of cesarean sections and the practice of electively delivering babies before 39 weeks, both of which pose risks for mother and babies. In some health care facilities, these initiatives have lowered neonatal intensive care admissions by as much as 25 percent.
By Martha Hostetter and Sarah Klein
Historically, much of the discussion around health care quality improvement has focused on the Medicare population—a bias that stems in part from the relative abundance of data on the quality and costs of care for this group.1 Less attention has been paid to expectant mothers, who account for 20 percent of all hospital discharges annually.
This has remained true despite evidence of widespread problems with maternal care, many of which reflect broader issues with the health care system—including its overemphasis on interventions and costly procedures and its underuse of evidence-based practices. In the U.S., rates of cesarean section—long increasing despite evidence that the procedure is often unnecessary and increases the risk of complications—rose to a high of 32.9 percent in 2009, more than double the rate recommended by the World Health Organization.2 Labor inductions, episiotomies, ultrasounds after 24 weeks, and continuous electronic fetal monitoring are also often overused while simple but beneficial practices—such as use of non-medical comfort measures during labor, smoking cessation programs for pregnant women, and breastfeeding support—are underutilized.3
A number of advocacy groups and leading health care providers have been pushing for change by highlighting the consequences of current practices—including the high emotional and financial costs of adverse birth outcomes—and identifying strategies for attending to the root causes of poor maternal care, which include poor access to care, unwarranted variations in practice, and perverse payment incentives that discourage the use of less medically intensive services. At long last, this work seems to be paying off.
Several state Medicaid agencies, which cover more than 40 percent of births in the U.S., are now developing policies to reduce early elective deliveries (EEDs), which pose risks to mothers and their babies. Similarly, the National Quality Forum's National Priorities Partnership has made reduction of preterm births via EEDs and reduction in the number of cesarean sections national goals. In addition, the Choosing Wisely campaign has just added early elective deliveries to its list of procedures that patients and providers should question. This work is being reinforced by public and private health care purchasers, which are beginning to require reporting on measures assessing providers’ adherence to best practices, and by several health systems and regional collaboratives, which are targeting maternal health care quality improvement. Together, these programs are building momentum for change. “I have been working for 35 years in the maternity space and I have never been more hopeful than I am now about our ability to achieve rapid gains in maternity care quality, outcomes, and value,” says Maureen Corry, M.P.H., executive director of Childbirth Connection, a nonprofit advocacy group working to improve the quality and value of maternity care.
Targeting Inappropriate Care: EEDs
The most prominent of recent maternal care improvement initiatives are those that seek to curtail the practice of electively delivering babies before 39 weeks, either through inductions or cesareans, without a medical indication. Mothers who are induced early have a higher risk of cesareans, anemia, and infection while babies born before 39 weeks are at higher risk for neonatal intensive care unit (NICU) admission, respiratory distress syndrome, sepsis, feeding problems, and other complications.4 The practice is still common even though the American Congress of Obstetricians and Gynecologists recommended against the practice more than 30 years ago and The Leapfrog Group, a national organization of health care purchasers, has estimated $1 billion could be saved each year if the U.S. rate of deliveries between 37 and 39 weeks dropped to 1.7 percent from 14 percent in 2011.5 (Just this month, the organization reported the EED rate fell to 11.2 percent in 2012—evidence that recent efforts are gaining traction.6 )
Health care organizations are using different methods to successfully reduce EEDs. Health systems such as Utah-based Intermountain Healthcare used education, data feedback, and care guidelines, while Trinity Health System in Michigan, reduced its EED rate from an estimated 15 percent in 2009 to 0.1 percent in 2012 using a similar approach while also instituting a hard-stop policy preventing clinicians from scheduling deliveries before 39 weeks without a medical reason. A similar hard-stop policy put in place by Tenn.-based Hospital Corp. of America (HCA), which delivers 5 percent of all babies in the U.S., resulted in a 10 percent to 15 percent drop in NICU admissions.
Many of these improvement efforts reach beyond institutional walls.7 Florida’s perinatal quality collaborative enabled six pilot hospitals to reduce EEDs from 39 percent of births to less than 5 percent. (Non-medically indicated cesarean sections also dropped from 53 percent to about 9 percent, according to data from the Centers for Medicare and Medicaid Services.) And as reported in a previous issue of Quality Matters, CMS' Hospital Engagement Networks are targeting reductions in EEDs, among other quality and safety issues.
After achieving success with larger hospitals, some collaboratives are extending their work to smaller hospitals that, according to Carole Lannon, M.D., M.P.H., the Ohio Perinatal Quality Collaborative’s lead improvement advisor, face challenges because they have fewer obstetrical providers and with that less of an ability to alter schedules and workload.
In addition to asking hospitals to examine their policies around EEDs, the St. Louis, Mo.–based Midwest Health Initiative sought to develop community-level consensus against the practice of early deliveries. After an educational and outreach effort led by this regional health care improvement organization, all but one area hospital, as well as physician groups, employers, health plans, and government agencies, signed on to a public statement against early elective inductions and cesareans. "Policy alone doesn't drive behavior," says Octavio Chirino, M.D., chair of the obstetrics and gynecology department at St. Louis' Mercy Hospital. "You need to first use education to develop buy-in that this is evidence-based."
Standardizing Care Protocols
Other improvement efforts target unwarranted variation in maternal care by introducing evidence-based guidelines in an effort to reduce risk and improve outcomes. Geisinger Health System in Pennsylvania spent 18 months sorting through the medical literature with its clinicians to identify more than 100 best practices that would serve as a community standard across 22 care sites. The resulting ProvenCare Perinatal program has reduced NICU admissions by 25 percent. “We have made so many changes in such short period, [we are not sure what is driving outcomes],”says Hans Cassagnol, M.D., director of obstetrics and gynecology at Geisinger Wyoming Valley, but he believes better management of patients with diabetes is an important factor.
In similar fashion, Trinity Health System in Michigan brought together physicians, nurses, a risk manager, a pharmacist, and administrators to identify best practices and standardize them across the system—including the circumstances under which a vaginal birth after cesarean should be attempted, the use of oxytocin to induce labor, and procedures for managing the second stage of labor. The system also required all of its nursing and physician staff engaged in maternity care to become certified in appropriate use of electronic fetal monitoring to, among other things, avoid miscommunication between nurses and physicians—a training exercise that cost $1.7 million. That expense was more than offset by the $20 million in liability claims Trinity believes it’s avoided though the implementation of a wide range of new procedures.
Reducing Maternal Mortality
Other improvement efforts have sought to improve the safety of women during pregnancy and delivery. While deaths during pregnancy or childbirth are rare in the U.S., maternal mortality rates crept upward between 1990 and 2008 as global rates fell.8 By 2010, U.S. women were at a greater risk of dying from pregnancy-related complications than women in 49 other nations. Factors such as obesity and advanced maternal age may account for some poor maternal outcomes, but for the vast majority of women better care could lead to much better outcomes.
For example, HCA has implemented a number of mandatory protocols related to the use of high-risk medications and the management of hypertensive crisis and postpartum hemorrhage. After discovering that pulmonary embolism following cesarean section was a leading cause of maternal death, it also instituted a policy of using pneumatic compression for all patients undergoing cesarean delivery. With that, the rate of maternal deaths dropped from 1.5 per 100,000 cesareans to 0.5, a 66 percent reduction that was not statistically significant but was in line with reductions achieved in other forms of major surgery.
The California Maternal Quality Care Collaborative, founded in 2005, discovered through its statewide review that maternal mortality rates had been rising in the state since 1999. While some of the rise may have been due to better reporting, the rates were still higher than they should be, according to Elliott Main, M.D., the group's medical director. "We are considerably higher than similar populations in Europe, particularly in Great Britain, which has a similar multiracial population."
Analysis pointed to a significant number of cases that may have been preventable, including deaths from hemorrhages before or after delivery. A multidisciplinary expert panel developed a toolkit to prepare for and respond to hemorrhages. The toolkit was used in collaboratives involving more than 100 California hospitals over a two-year period and in most hospitals showed a greater than 25 percent reduction in major hemorrhages that required either a hysterectomy or transfusion of multiple units of blood.
"Women shouldn't bleed to death in the U.S.," says Main. "Responding to hemorrhage requires recognizing risk; recognizing the amount of blood lost, which can be tricky; coordinating a team to respond; and having blood available when you need it." Future collaborative efforts are focusing on preeclampsia and cardiovascular disease, two other areas of concern identified in the statewide mortality review.
Better training for OBs and other providers may also help improve care for women who experience rare events such as postpartum hemorrhage and preeclampsia. Steven Clark, M.D., medical director of women and newborn’s services at HCA, believes OB/GYN medical residencies must be restructured to create two separate pathways: one for obstetrics and one for gynecology, thus enabling residents in obstetrics to spend more time learning how to handle high-risk procedures.
Engaging Women in Their Care
Educating women about the risks and benefits of different interventions and procedures may also be key to changing practice patterns. At present, there are few tools to educate women about their treatment options. To fill this void, Childbirth Connection has partnered with the Informed Medical Decisions Foundation on the First National Maternity Care Shared Decision Making Initiative to create shared decision making tools around pregnancy and childbirth, including resources for women with low health literacy.9 The decision making tools, the first of which will be available late this year, will address issues such as where and with whom to give birth, elective delivery, vaginal birth after cesarean or repeat cesarean, and prevention and treatment options for gestational diabetes. Involving women in decision making around childbirth has the potential to reduce interventions such as planned deliveries or cesareans that drive up costs and help avoid procedures such as episiotomies, which many women say they received without having given their consent.10
Corry of the Childbirth Connection also argues for the need for a patient survey tool that takes into account issues that are unique to maternal care, saying that the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) fails to address several important aspects of labor, delivery, and postpartum care. For example, a generic HCAHPS question about pain control does not take into account the trade-offs women may want to make between use of high-dose epidural analgesia and other comfort measures.
Better Access to Care
Improving the quality of maternal care is also predicated on access to care, and in this respect several provisions in the Affordable Care Act should help. Prenatal, maternal, and newborn care are part of the "essential health benefits" package that insurers must include in individual and small-group plans. And more women should gain coverage through expansions to Medicaid and federal subsidies. Crucially, the legislation also expands maternal, infant, and early childhood home visiting programs for high-risk communities, includes funds for postpartum depression research and treatment, and bars insurers from denying or charging more for coverage for "preexisting conditions," including pregnancy and prior cesarean sections.
The law may also address provider shortages by raising Medicaid reimbursement rates and by making midwives and birth centers more accessible, particularly in medically underserved communities.
Reforming Provider Incentives
But ultimately, one of the greatest levers to improve maternal care may be comprehensive payment reform. Global fees for the physician portion of OB services—including prenatal, delivery, and postpartum care—have been in use by public and private payers for decades. But in some cases these fees create perverse incentives for providers to seek opportunities to get paid for discrete services for which they can charge beyond the global fees.11
For cardiology, orthopedics, and oncology, some payers are moving toward bundled, or episode-of-care payments, that include both facility and physician charges. With growing pressure to improve outcomes and control costs, payers may also begin to push for such fully bundled payments for maternity care, regardless of the type of delivery, neonatal admissions, or other outcomes.12 Indeed, the Affordable Care Act provides funding for both Medicaid and Medicare to pilot episode-of-care payments. This kind of fully bundled payment may encourage providers to rely on less-expensive birthing centers and midwives.
Recognizing that, Steven Calvin, M.D., medical director of the Minnesota Birth Center, a freestanding birth center housed in a renovated Victorian house across the street from a tertiary medical center in Minneapolis, has been negotiating with one local Medicaid care plan for an episode-of-care payment that would be up to 20 percent less than the plan now pays. Moving uncomplicated births out of hospitals and into less costly settings would create some challenges for hospitals that must maintain a neonatal care unit. Harold Miller, executive director of the Center for Healthcare Quality and Payment Reform, believes this could be addressed by increasing payments for complicated births and reducing them for others. Adjusting reimbursement for prenatal care to account for risk factors, such as diabetes or tobacco use, may also encourage physicians to invest time in reducing risks early in a woman’s pregnancy. “This is a huge opportunity for Medicaid programs,” Miller says.
1 R. R. Jolivet, M. P. Corry, and C. Sakala, "Transforming Maternity Care: A High-Value Proposition," Women's Health Issues, 2010 20:S50–S66. 2Deadly Delivery: The Maternal Health Care Crisis in the USA, One Year Update, Spring 2011 (New York: Amnesty International; 2011). Available at: http://www.amnestyusa.org/sites/default/files/deadlydeliveryoneyear.pdf.
3"What to Reject When You're Expecting," Consumer Reports, May 2012, available at http://www.consumerreports.org/cro/2012/05/what-to-reject-when-you-re-expecting/index.htm. M. Corry, "Transforming Maternity Care," Women's Health Issues, January 2010 20(1) Supplement:S2–S3, available at http://www.whijournal.com/article/S1049-3867(09)00147-9/fulltext.
4"Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age," California Maternal Quality Care Collaborative Toolkit, available at http://www.cmqcc.org/_39_week_toolkit.
5"Hospitals Make Progress in Eliminating Early Elective Deliveries: Good News, but More Work Needs to Be Done," The Leapfrog Group, January 25, 2012, available at http://www.leapfroggroup.org/policy_leadership/leapfrog_news/4827337.
6"New Data: Early Elective Deliveries Decline at Hospitals as Health Leaders Caution Against Unnecessary Deliveries," Feb. 21, 2013, The Leapfrog Group, http://www.leapfroggroup.org/TooEarlyDeliveries
7Ohio, California, North Carolina, Tennessee, Massachusetts, New Jersey, Arkansas, New York, Michigan, and Illinois have or are developing statewide collaboratives to improve maternal care and birth outcomes.
8Deadly Delivery: The Maternal Health Care Crisis in the USA, One Year Update, Spring 2011 (New York: Amnesty International; 2011). Available at: http://www.amnestyusa.org/sites/default/files/deadlydeliveryoneyear.pdf.
9A. Romano, The First National Maternity Care Shared Decision Making Initiative, January 2013, http://informedmedicaldecisions.org/wp-content/uploads/2012/05/First_Natl_Maternity_SDM.pdf.
10A. Coulter and A. Collins, Making Shared Decision-Making a Reality: No Decision About Me, Without Me (London, U.K.: The King’s Fund, 2011) and E. R. Declercq, C. Sakala, M. P. Corry et al., Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences (New York: Childbirth Connection, 2006).
11The Transforming Maternity Care Symposium Steering Committee, P. B. Angood, E. Mitchell Armstrong et al., "Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System” Women's Health Issues, January 2010 20(1):S18–49.
12M. W. Painter, Bundled Payments: This Way Toward a Challenging Yet Better Place, Health Care Incentives Improvement Institute.