Health Care Reform Priorities for High Quality, High Value Maternity Care

The Childbearing Population and Maternity Care in the United States

Eight Steps to High Quality, High Value Maternity Care

• 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

• 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

• 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

• 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

• 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

• 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

• 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

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