Serious Problems In Maternity Care Quality And Value, Cesarean Section And Other Interventions Overused

Main Category: Pregnancy / Obstetrics
Also Included In: Pediatrics / Children's Health;  Women's Health / Gynecology
Article Date: 09 Oct 2008 - 3:00 PST

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Over 31% of U.S. births are now by cesarean section although a 5% to 10% rate is best for mothers and babies. The extra cost is well over $2.5 billion per year. The excess cesareans buy no reduction in maternal and newborn deaths. But they cause unneeded exposure to the dozens of adverse effects more common with c-sections. This is just the most striking example of how health care provided to mothers giving birth exposes them to avoidable harm and expense. These conclusions are found in Evidence-Based Maternity Care: What It Is and What It Can Achieve, a report released today by Childbirth Connection, The Reforming States Group, and the Milbank Memorial Foundation.

The report cites an extensive body of evidence to make the case that, despite paying top dollar, American women do not receive the best maternity care. It is the most comprehensive review to date of how maternity care is delivered, financed, and experienced by mothers, families, and health care payers. It concludes that maternity care can be significantly improved using evidence-based care.

Main Recommendations for Improvement

To speed adoption of evidence-based maternity care, the report recommends:

- Develop a standardized evidence-based set of maternity care performance measures to address overuse and underuse.

- Incorporate these measures into Medicaid quality improvement activities, and encourage private insurers and other entities to adopt them.

- Reform the reimbursement system - with such strategies as reducing payment for overused services, increasing payment for underused services, and rewarding high-performing providers and facilities.

- Support more research into evidence-based maternity care, including long-term effects of common maternity practices.

- Increase the use of evidence-based maternity care by educating a wide range of stakeholders.

"If implemented, these recommendations can help close the evidence-practice gap in maternity care," said Maureen Corry, co-author and Executive Director, Childbirth Connection. "There's a role for everyone - clinicians, health systems, payers, policymakers, consumers and the media. It's time to seize the opportunities to ensure that all mothers and babies receive safe, effective and satisfying maternity care."

"The report shows maternity care is one more example of what's wrong with American health care. We're paying too much and getting the worst results in the developed world because of unneeded care," said Reforming States Group Vice Chair, State Senator Charles Scott of Wyoming. "The main causes are that providers earn more from unneeded care while fear of malpractice litigation encourages the same unneeded care. In my state nearly half the births are paid for by the taxpayers through the Medicaid program. If we can implement the recommendations of this report, we can both reduce costs and improve the care our mothers and babies get."

Overused Maternity Practices

Cesarean section is one notable example of frequently overused maternity care interventions documented in the report. C-sections are now the most common operating room procedure in the US. Although clearly beneficial and life-saving in selected circumstances, the absolute indications for cesarean section apply to only a small proportion of births. Yet rates have steadily risen from 20.7% in 1996 to a record high of 31.1% in 2006, a 50% increase.

Wide variation in medical practice exists - for example, differences in rates of performing cesarean section vary across physicians, hospitals, or geographic areas. Just a fraction of these differences are due to differences in the health needs of mothers and babies. Rather, this variation reflects differences in professional styles of practice and other factors such as the number of providers and hospitals offering the surgery, concerns about being sued, and financial incentives that favor surgery. The evidence showed that areas with higher rates of cesareans had more inappropriate care and more surgery in healthier women. The report clarifies that many other common maternity interventions, e.g. labor induction and epidural, are also overused. It can be accessed at http://www.childbirthconnection.org/ebmc/.

Underused Maternity Practices

The analysis also found underuse of many effective practices with few or no known adverse effects. These practices include continuous support throughout labor (such as provided by a doula), numerous measures that increase comfort and facilitate labor progress, upright and side-lying positions for giving birth, delayed cord clamping, and early skin-to-skin contact between mother and baby. More frequent use of these beneficial forms of care would lead to improved outcomes for many mothers and babies. Best available evidence also supports providing access to vaginal birth after cesarean (VBAC) for most women with a previous cesarean, but such access has fallen off sharply in recent years, despite demand from women, and more than nine out of ten women with previous cesareans now have repeat cesareans.

"Hundreds of rigorous systematic reviews of best evidence assess the safety and effectiveness of maternity practices," said Carol Sakala, lead report author and Director of Programs, Childbirth Connection. "Yet, all too often the evidence is ignored."

Maternity Care is Major Segment of Hospital Market

Most maternity care provided to women who give birth in US hospitals - a large and primarily healthy population - is resource and technology intensive. Six of the fifteen most commonly performed hospital procedures in the entire population are associated with childbirth. Hospital charges for maternal and newborn care are greater than charges for any other condition: $79 billion in 2005, jumping to $86 billion in 2006.

Maternal and newborn care are the most costly hospital conditions for both Medicaid (which pays for 42% of all births in the country) and private insurers (shouldering 51%). And, the proportion of Medicaid-covered births is growing, making the quality and cost of maternity care a significant public policy issue. The report finds that lower intensity care, like that provided by midwives, is safe and effective, avoids many procedures with established risks, and is cheaper. Yet, just a fraction of women who give birth in hospitals today receive low intensity care.

And while the US spends much more on health care, its performance lags far behind other developed nations on quality indicators including low birthweight, perinatal and maternal mortality, and cesarean rates. The report spotlights the market influences and other factors contributing to what has been called the "Perinatal Paradox: doing more and accomplishing less" (Rosenblatt 1989).

About Milbank Memorial Fund

Milbank Memorial Fund is an endowed operating foundation that works to improve health by helping decision makers in the public and private sectors acquire and use the best available evidence to inform policy for health care and population health. The Fund has engaged in nonpartisan analysis, study, research and communication on significant issues in health policy since its inception in 1905.

About Reforming States Group

The Reforming States Group (RSG), organized in 1992, is a voluntary association of leaders in health policy in the legislative and executive branches of government from all fifty states, Canada, England, Scotland and Australia.

About Childbirth Connection

Founded in 1918, Childbirth Connection is a not-for-profit organization working to improve the quality of maternity care through research, education, advocacy and policy. As a voice for the needs and interests of childbearing families, Childbirth Connection uses best research evidence and the results of its periodic national Listening to Mothers surveys to inform policy, practice, education and research.

Childbirth Connection