This post is part two of a 10-part series on care model innovation.
I’ve written extensively about the need to change how we deliver maternity care in the United States, so I wasn’t sure I really needed to read up on the need for new care models. But most of what I have written has focused on birth, and I wanted to expand my scope to encompass the entire maternity “episode,” as it is known in healthcare parlance. I also knew this project was going to take me deeper into the issue of health disparities than I have previously explored, and that I would end up spending most of my time thinking about what happens in women’s lives, families, and communities, and how this intersects with what our maternity care system offers. So I chose the following three readings:
- Why we need a vastly expanded version of maternity care, a presentation by Paula Braveman, Director of the Center on Social Disparities in Health at UCSF;
- The Cost of Having a Baby in the United States, a report by Truven Analytics commissioned by Childbirth Connection, Catalyst for Payment Reform, and the Center for Healthcare Quality and Payment; and
- Transforming the costly travesty of U.S. maternity care, an article in JAMA Forum by Diana Mason, President of the American Academy of Nursing
Because of my background, I’m quite familiar with the statistical soundbites. Almost any way we look at it, maternal and infant health outcomes in the United States are far worse than they should be. Our infant mortality rate is on par with Poland, our maternal death rate just above Iran. We’re one of just eight countries in the world with rising maternal death rates, a distinction we share with Chad and Afghanistan. Our preterm birth rate has nudged down in recent years, but it’s hardly much to celebrate when we rank behind 53 other countries and still have a point to go to return to where we were in 1990.
What is driving these poor outcomes?
To figure out how to retool the system, we need to ask what is driving these poor outcomes. It is not enough to know the most common pregnancy and birth complications, but these provide some clues. For mothers, the main culprits are embolism, hypertensive disorders, and hemorrhage. For newborns, the major factor is prematurity. With advances in technology, it would seem that our ability to detect and treat these problems would be getting better, not worse.
This paradox is familiar. We just saw it last week in our broader exploration of pathogenesis and its “missing complement,” salutogenesis.
Healthcare isn’t really what creates health. Social care is. And this week’s reading, Why we need a vastly expanded version of maternity care by Paula Braveman, makes a strong case that social care is lacking for pregnant women. Braveman reported outcomes of a state-wide survey, looking at stressors and sources of support by payment source and income level. Among pregnant women with Medi-Cal (Medicaid), the researchers found:
- More than 1 in 8 experienced intimate partner violence in pregnancy
- More than 1 in 5 had symptoms of depression during pregnancy
- More than 1 in 9 had moved during pregnancy because they couldn’t pay the rent or mortgage
- 1 in 20 had no regular place to sleep
- Almost 1 in 3 were food insecure
These stressors were also common, although less frequent, in low-income women with commercial insurance, and present even among the remaining population of commercially insured pregnant women.
In addition to the direct effect on safety, nutrition, and healthcare access, these and other chronic stressors can “get into the body” via neurobiologic pathways that are becoming better understood, according to Braveman. This predisposes women and fetuses to mood disorders and chronic disease, and there is growing consensus that they are the predominant factor driving poor birth outcomes.
Are we investing in the right solutions?
While the root causes of poor maternal and infant health stretch well before the birth (indeed, before pregnancy), maternity care expenditures are another story. Our largest investment, by far, is in the day or so around the birth. According to Truven data, payments for care during the intrapartum hospitalization dwarf what is spent on other phases of care (prenatal and postpartum): more than three-quarters of the total spend on maternal and newborn care covers intrapartum care. In fact, more than 60% of the total spend goes to just one part of the bill: the hospital facility fee.
Our considerable investment in intrapartum care is driven up further by cesareans, now performed for one-third of births in the United States – and more than half in some hospitals. Truven data show that cesareans cost payers 50% more than vaginal births. In her JAMA Forum commentary, Mason argues that our investment in hospitalization and the cesarean epidemic are linked. She makes the case for a new investment to scale up birth centers as part of the solution. (We’ll explore this service redesign in Week 5.) This would reduce both the facility overhead and the cesarean rate, as birth center care safely reduces cesarean risk in well screened women.
Although the Cost of Having a Baby report doesn’t address social services, we know from last week’s reading that spending on social services in the United States is just a fraction of what is spent on healthcare, and I’m not aware of any evidence to the contrary during pregnancy and infancy. We are the only industrialized country without paid maternity leave (strange bedfellows again: our peer countries with this distinction are Lesotho, Swaziland, and Papua New Guinea). Supplemental food assistance is available through WIC, but the average program investment is just $43/month/woman during pregnancy. Access to mental health treatment is poor. Despite the importance of connectedness and support, the predominant experience for many new mothers is isolation.
Are we creating health?
This is all rather depressing, but I remain optimistic and increasingly determined. Since last week, I can’t stop thinking about a part of Don Berwick’s IHI address when he talks about the health creating effects of prosocial behavior. Prosocial (or helping) behavior reduces stress, and even changes the brain in structure and function. These changes help create health.
Connecting to and helping others creates health.
It turns out the main hormone involved in prosocial behavior is oxytocin, and birthing women and newborns are bathed in the stuff. It makes sense evolutionarily that women ought to grow stronger and more resilient during pregnancy and after birth, and that as we attach and bond with our infants, these instincts and effects increase. Survival of our species literally depends on it. As a midwife, I have seen it. In the right conditions, pregnancy and birth can absolutely be a tipping point for better health.
Since the start of this project, I have been obsessing on the notion that if we can reorient our maternal and infant care system, we can truly create health. Biology is on our side. Right now, we have a system that squanders this potential, but as we will begin to see in the coming weeks, innovative care models are out there, still largely under the radar. And these care models align perfectly with the themes Berwick finds from the pioneers in salutogenesis (see discussion beginning around 26:00 in H4.)
- The practitioners embrace a positive view of health.
- The resources to support positive health reach beyond the current boundaries of healthcare.
- The effect sizes we see from these wellness efforts are significant and affect the entire person, not just the “disease.”
- The interventions warrant systemic changes in how we live.
- The pioneers reconnect the idea of personal health to connectedness and interpersonal interactions.
- Loving kindness is central to these efforts, and to our wellbeing.
I’m looking forward to exploring these care models in depth starting next week.