Transforming Maternity Care -- A Blueprint for Action

An Expert Interview With Carol Sakala, PhD, MSPH

Katharine M. Hikel, MD


March 12, 2010

Editor's Note:

The healthcare reform discussion now includes the problem of increasingly expensive maternity care in the United States, and troubling outcomes for women and newborns. Childbirth and birth-related conditions are the most common reasons for hospital care, accounting for one-fourth of hospital discharges in 2007. In that year, cesarean delivery was the most common operative procedure in the country, comprising 31.8% of births. Meanwhile, the incidence of vaginal birth after cesarean (VBAC) has declined to 9.7% (from 35.3% in 1997).[1,2]

In the past 2 decades, rates of preterm birth have increased to 12.7%, and low birth weight to 8.2%. In 2006, charges for "mother's pregnancy and delivery" and "newborn infants" were $86 billion -- far exceeding charges for any other hospital condition.[3,4]

Childbirth Connection, founded in 1918 as Maternity Center Association, is a national not-for-profit organization whose mission is to improve the quality of maternity care through research, education, advocacy, and policy. The organization has provided leadership in areas such as care of underserved women, maternity nursing, nurse-midwifery education, childbirth and parenting education, and care in freestanding birth centers. In the 21st century, Childbirth Connection has promoted evidence-based maternity care and quality improvement through policy and health system change. In 2008, organizational leaders authored "Evidence-based Maternity Care: What It Is and What It Can Achieve," a Milbank report that takes stock of the US maternity care system and identifies a wealth of opportunities for improving quality, outcomes, and value.

For the past 2 1/2 years, Childbirth Connection has carried out the Transforming Maternity Care project to collaborate with stakeholders from across the healthcare system to identify values, principles, and attributes of a high-performing maternity care system and strategies for achieving such a system, culminating in 2 direction-setting reports: "2020 Vision for a High-Quality, High-Value Maternity Care System" and "Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System." The new reports are published in a special issue of Women's Health Issues.[5] Carol Sakala, PhD, MSPH, Director of Programs for Childbirth Connection, and co-author of Evidence-Based Maternity Care, spoke with Medscape about childbirth in the United States, and the Transforming Maternity Care project.

Medscape: In the recent documentary film, The Business of Being Born, Marsden Wagner, MD, says, "Maternity care in the United States is in crisis."[6] In the discussion of healthcare reform, what is the current awareness of the state of maternity care?

Dr. Sakala: Maternity care is a major segment of the healthcare system. Many people don't realize that 25% of patients discharged from US hospitals are childbearing women and newborns; hospital charges for their combined care far exceed those for any other hospital condition. These 2 conditions are the most common and costly hospital conditions for Medicaid, and for private insurers, they are the most common, and the first and third most costly hospital conditions.

It's really important to remember that maternal and newborn care affects everyone at the beginning of life, and about 85% of women give birth at least once. With such a major role in the nation's healthcare system, and the current interest and focus on healthcare reform, one would expect a high degree of interest in understanding how we're doing on maternity care quality, outcomes, and value -- what are we getting for this major investment?

But this has not been the case. Quality initiatives have largely been directed elsewhere -- for example, to the Medicare population, or to people with chronic diseases. More and more, however, policymakers and the general public are starting to realize that the challenges in other clinical areas also apply to maternal and newborn care.

Fundamental concerns include the considerable overuse of interventions that may pose risk and expense without benefit, underuse of beneficial practices, and broad practice variation that largely cannot be explained by needs and preferences of childbearing women and their newborns.

Medscape: In your report, "Evidence-based Maternity Care: What It Is and What It Can Achieve," published in 2008, you say "A large, growing body of systematic reviews is available to help clarify effects of maternity practices, yet these valuable resources are grossly underutilized in policy, practice, education, and research in the United States." Can you talk about interventions that are considered to be "overused" vs "underused" in US maternity healthcare?[7]

Dr. Sakala: The field of maternity care is special in that we have an abundance of high-quality evidence to help guide decision-making. Beginning in the 1970s, Iain Chalmers and his colleagues identified randomized controlled trials about care during pregnancy and childbirth, and carried out systematic reviews to assess the effectiveness of a whole host of interventions in this clinical area. In 1989, they published the landmark "Effective Care in Pregnancy and Childbirth" and companion resources that inspired the establishment of the Cochrane Collaboration to carry out systematic reviews in all fields of health and medicine.

Because of this head start, an estimated 2000-3000 systematic reviews now exist in this field alone. And this is probably a conservative estimate. We can understand overuse and underuse by comparing results of up-to-date, well-conducted systematic reviews with knowledge about current practices, from sources such as birth certificates or Childbirth Connection's national "Listening to Mothers" surveys. And we can also look at benchmarks from high-performing segments of the maternity care system.

Our Milbank report on evidence-based maternity care has a chapter on overuse, and another on underuse. Two major interventions that are overused are labor induction and cesarean section. Many of these procedures are carried out for indications that are not supported by best evidence, such as "the fetus seems large." A series of systematic reviews is consistent in clarifying that this is not a valid reason for undertaking these interventions. These procedures are also carried out without any indication in the current environment.

We argue that epidural analgesia is overused, because it often is the first line of help with labor pain before trying other approaches that women have given high marks to and that have minimal or no known side effects, such as tubs and showers, birth balls, and doulas. Unlike epidurals, those interventions don't slow labor, increase the likelihood of hypotension, immobilize women, require continuous fetal monitoring and frequent blood-pressure monitoring, or increase the use of bladder catheters, labor augmentation, and other interventions.

The Milbank report also presents data on overuse of continuous electronic fetal monitoring, artificial rupture of membranes, and episiotomy.

Quite a few beneficial practices would contribute to improved outcomes if they were more consistently used; these underused interventions include things such as smoking cessation interventions for pregnant women; external version to turn babies to a vertex position at term; continuous support during labor (such as from a doula); use of hydrotherapy to promote comfort and labor progress; nonsupine positions for giving birth; early skin-to-skin mother-baby contact; interventions to increase initiation and duration of breastfeeding; and psychosocial and psychological interventions to relieve postpartum depression. Our Milbank report summarizes evidence to support these interventions. We tried to focus on practices that apply very broadly to large segments of the 4.3 million pregnancies and births that take place every year in the United States.

Medscape: You mention in your report that part of the problem seems to be that current maternity practice guidelines are "excessively reliant on opinion." You also identify a concern -- for example, in the case of cesarean birth -- with single studies that "focus on a small set of outcomes and fail to bring into view the full range of effects that are relevant to decision making."[7] Can you elaborate on these concerns?

Dr. Sakala: In the evidence-based paradigm, "expert opinion," unless carefully grounded in rigorous research, is often unreliable. It's at the bottom of most evidence hierarchies that have been developed. We refer, in the Milbank report, to a study that Chauhan and colleagues[8] published in the American Journal of Obstetrics and Gynecology. They assessed the type of evidence that supported recommendations in obstetrics practice bulletins from the American College of Obstetricians and Gynecologists, and found that 42% of recommendations were Level C, which is "based primarily on consensus and expert opinion." Thirty-five percent were supported by Level B evidence, which is defined as "limited or inconsistent" scientific evidence; and just 23% were Level A -- "based on good and consistent - scientific evidence."[8]

Furthermore, just 3% of the recommendations in the practice bulletins were supported by a meta-analysis. We would like to see a much higher proportion of recommendations that are supported by the abundant, Level A systematic reviews in our field. This is very important, because these bulletins are used for practice, policy, and liability purposes -- for example, as the basis for developing performance measures. So it's crucial to have solid recommendations that are supported by the best available evidence.

The second part of the question describes what has often happened in discussions about vaginal birth after cesarean (VBAC). Outcomes relating to the uterine scar and the possibility of uterine rupture in the present pregnancy have received the most attention. In surveys, including our own "Listening to Mothers" surveys, childbearing women repeatedly want to know most or all of the risks involved. With VBAC, little attention has been paid to other outcomes that come into play for pregnant women who have undergone a previous cesarean.

For example, these include many other shorter-term outcomes in mothers and newborns that favor VBAC, such as the likelihood of maternal infection and blood clots and of newborn respiratory and breastfeeding problems; and a host of serious scar-associated risks in future pregnancies, such as placenta accreta and cesarean-scar ectopic pregnancy. The other thing we know very clearly is that, as scars accumulate with multiple repeat cesareans, the risks for many of these outcomes rise exponentially.

We have concerns with just shining the light in a single area, when so many other factors are also involved. We will welcome the new federal evidence report on VBAC, which will be released in March 2010. It takes a broader view of outcomes of interest, and addresses shortcomings of previous work that was done in that area.

Medscape: All phases of the "Transforming Maternity Care" project involved members of the obstetrics community. What are obstetricians doing to evaluate their discipline with a more critical eye, and what level of reform can we expect from within the field?

Dr. Sakala: Because of the persistent underuse of the wealth of systematic reviews in our field, Childbirth Connection has been focused on changes to the maternity care system that would lead to more reliable delivery of care consistent with the best evidence. Just having, publishing, and publicizing it have not proved to be enough to get it into practice.

Over the past 2 1/2 years, we have carried out the multi-stakeholder Transforming Maternity Care project to collaborate with leaders from across the healthcare system to determine values, principles, and attributes of a high-performing maternity care system, as well as prioritize steps for attaining such a system. With exceptional contributions from over 100 individuals, we have just released 2 direction-setting reports. The first report, "2020 Vision for a High-Quality, High-Value Maternity Care System," from the project’s Vision Team, clarifies where we need to head. And "Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System," from the project Steering Committee, summarizes priority recommendations for getting there.[5] The blueprint is a synthesis of reports from 5 stakeholder workgroups that deliberated over many months to develop their reports and recommendations. We released these reports at the end of January in Washington DC. They are freely available in a special Transforming Maternity Care issue of Women’s Health Issues[5] and the workgroup reports are available on our Website.

We were gratified with the high level of engagement and support during all phases of our project by obstetricians, other clinicians who provide maternity care, and hospitals, health systems, health plan representatives, consumers and advocates, and other stakeholders involved with maternity care. As we have come to the implementation phase, all of these groups are expressing overwhelming support for the blueprint, and are discussing many possible collaborative projects. We can't do this alone; we hope that all of the relevant organizations and agencies will carefully review the blueprint and find ways to become involved in carrying out its recommendations.

I also want to mention that last year we gave the first Maternity Quality Matters Award to Seton Family of Hospitals for significant, demonstrated maternity care quality improvement. We know that there is a lot of interest in maternity care quality improvement because we received 35 applications for this award, which included many exciting projects from across the country.

Medscape: The importance of evidence-based, or "outcomes" data, is widely discussed in healthcare reform (the US Cochrane Center at the Johns Hopkins Bloomberg School of Public Health, for example, is a leader in this discussion).[9] Your Evidence-Based Maternity Care report lists some of the barriers to evidence-based care in childbearing. What would you say is the most significant barrier?

Dr. Sakala: Having just learned about so many challenges from so many individuals working throughout this complex system, I'm hard-pressed to identify just one problem area. For example, we found that we need to fill in gaps in performance measures. We need to consistently measure performance, and develop ways to feed that information back to providers (even the performance data that are being collected now are not getting back to the clinicians and facilities), and on to consumers, purchasers, and policy makers. We need to find new ways to pay for maternity care that align the financial incentives with quality; and this will take some pilots that evaluate and refine promising strategies such as bundled payments for the full episode of maternity care.

The healthcare home model can and should be extended to a woman and family-centered maternity care home to ensure that care is coordinated and optimized from early pregnancy through the postpartum period. To foster the high-functioning maternity teams that we need to deliver optimal care, we can educate maternity health professionals with a common curriculum and provide students with multidisciplinary learning environments.

We can harness health information technology to provide ready access to electronic health records in all settings of care, to routinely collect information for performance measurement, and to reliably deliver decision support tools to both health professionals and childbearing women. The blueprint contains 3 or 4 priority recommendations in 11 different topical areas. Each of these would provide a more supportive environment for dedicated, hardworking maternity professionals and for childbearing women and newborns. Women, of course, care deeply about what happens to them.

Medscape: Although many women say they want a "natural" birth, most still choose obstetricians for maternity care, rather than midwives or family-practice physicians. Do you think that women are adequately informed about the differences between the obstetrician's view and the midwife's view of birth?

Dr. Sakala: Differences do exist in the practice styles of obstetricians, family physicians, and midwives. It is also important to recognize that practice style can vary greatly within these groups. It's a complicated situation. Consideration must also be given to differences in the make-up of their respective case loads.

That said, most childbearing women are healthy and at low risk and have good reason to expect an uncomplicated childbirth. In the Milbank report, we support providing "effective care with least harm." For healthy women and newborns, this means avoiding invasive interventions with potential adverse effects whenever possible; and promoting, protecting, and supporting women's and newborns' innate capacity for birth, breastfeeding, and attachment.

However, the present maternity care system has quite a few incentives for technology-intensive childbirth. As a result, 6 of the 10 most common hospital procedures are performed on the largely healthy population of childbearing women and newborns. We know from our national Listening to Mothers surveys[10] that this style of childbirth is now the norm for nearly all women who give birth in US hospitals.

Better performance measurement and reporting would help women to understand differences among caregivers, as well as differences among hospitals and between hospitals and birth centers. The United Kingdom has for many years reported a "normal birth" performance measure, and the blueprint for action calls for adaptation and implementation of this measure in the United States. This would help inform many of the stakeholders about variations that exist in care. The blueprint also calls for standardizing the way that health plans inform pregnant women about their choice of caregivers, and for consistently identifying participating obstetricians, family physicians, and midwives who provide maternity care. I don't know of any health plan that does this systematically right now.

The blueprint also calls for adapting the Consumer Assessment of Healthcare Providers and Systems surveys to maternity care to help measure and report differences in women’s experiences of care. The present, generic surveys that hospitals and physicians use have shortcomings when applied to maternity care. We are in discussions with the relevant partners about these shortcomings, and are seeking resources for adapting these for use with childbearing women.

The blueprint recommends that all maternity caregivers be educated to support physiologic childbirth. At present, this approach receives greatest emphasis in midwifery education programs.

Medscape: The obstetric model of active management and intervention seems quite a separate path from the midwifery model of expectant management, or physiologic birth -- especially given the differences in training between obstetrics (a surgical specialty) and midwifery. Are these paths wholly divergent or is there a blueprint for integrating both approaches?

Dr. Sakala: Although these models can be quite divergent, the Transforming Maternity Care project envisions a maternity care system that minimizes divisions and provides seamless care for childbearing women and newborns. This can be facilitated, as mentioned earlier, by grounding all maternity caregiver students in a common core focus on prevention and respect for the physiologic capacities of childbearing women and newborns; and grounding them in the knowledge and skills for supporting these capacities. Throughout the course of Transforming Maternity Care work, the consensus was high that this type of care should be the norm for low-risk childbearing women and newborns. We can also foster a seamless care system by giving all maternity professional students the experience of learning with students from diverse disciplines and from teachers of diverse disciplines. Furthermore, the care coordination section of the blueprint provides recommendations for fostering smooth transitions when women and newborns require a higher level of care.

I think it's important to point out that breaking out of the so-called "silos" in our healthcare system is in fact a major theme of overall healthcare reform and quality improvement. One type of silo would be the different disciplines, which prevent integration and communication between disciplines. We expect them to work as a team when they come together to provide care; but up until that point, they have been learning different ways of viewing the situation with different "languages" and different approaches; so it becomes really hard to ensure high-functioning teams.

Medscape: The effects of a woman's environment on the process of labor and birth are becoming part of the discussion of maternity care reform. The typically busy hospital environment is thought to impede the natural unfolding of labor and birth and partly contribute to our high intervention rates.[9] These considerations are part of the push for out-of-hospital birth -- at home, or in freestanding birth centers. What is your vision for birth places in the future? And how does interprofessional collaboration fit within this vision?

Dr. Sakala: Childbirth Connection was involved in demonstrating, evaluating, and fostering the out-of-hospital birth center model of maternity care during the last quarter of the 20th century. At that time, we were known as Maternity Center Association.

Birth center care, including care measured within the National Birth Center Study of nearly 12,000 women in 84 centers, has consistently been shown to be of high quality of care with excellent outcomes, a high level of satisfaction, and exceptional value. The variation in cost of maternity care, including differences between in-hospital and out-of-hospital care, is very high; we have charts showing this in our Milbank report, and on our Website. In a series of quite consistent studies in North America, low-risk women who gave birth in out-of-hospital settings had more physiologic childbirth experiences with considerably lower rates of intervention than similar women in hospitals. This conservative style of care does not seem to have an adverse effect on outcome. In fact, we need to measure longer-term outcomes, and understand whether more gentle, less invasive approaches might have significant benefits over the long term. We know from Childbirth Connection's New Mothers Speak Out national survey report from 2008[11] that mothers experience a considerable range and extent of new-onset infection, pain, and other morbidities associated with the current procedure- and surgery-intensive style of childbirth. However, we don’t currently have standardized ways of measuring maternal outcomes in the postpartum months.

Undoubtedly, differences also exist between hospitals and out-of-hospital settings and in the expectations and preferences of the women and caregivers in the respective birth settings, and these need to be factored into the results. With respect to well-functioning interprofessional collaboration, it's very clear through our consensus reports that this is a hallmark of a high-performing maternity care system.

Medscape: If you had a wish for the future of maternity healthcare, what would it be?

Dr. Sakala: I’d like to answer this question by paraphrasing the final paragraph from the Transforming Maternity Care Vision paper, and I encourage Medscape readers to read that paper and the blueprint as well, and consider becoming involved in blueprint implementation.

In describing the vision, the Vision Team says that:

The 2020 Vision for a High-Quality, High-Value Maternity Care System will be actualized through concerted multi-stakeholder efforts ensuring that all women and babies are served by a maternity care system that delivers safe, effective, timely, efficient, equitable, woman- and family-centered maternity care. The US will rank at the top among industrialized nations in key maternal and infant health indicators, and will achieve global recognition for its transformative leadership.


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