This post is part five in a 10-part series on care model innovation.
A Fragmented System, With Some Fragments Missing
In the literature, we see care model innovation held up as the solution to fragmentation. According to a Commonwealth Fund report:
Fragmentation fosters frustrating and dangerous patient experiences, especially for patients obtaining care from multiple providers in a variety of settings. It also leads to waste and duplication, hindering providers’ ability to deliver high-quality, efficient care.
We see this kind of fragmentation in maternity care. For example, most electronic medical record systems are poorly integrated between ob-gyn offices and hospitals, so the standard way to get information to the hospital is to fax or email a copy of the prenatal record in the third trimester. This means women who present in preterm labor may not have any record available at all, while those who present at term may lack the last few weeks of data. As for provider continuity, a 2012 national survey found that one-third of new mothers reported having never met or only met briefly the provider who cared for them at birth. If no one taking care of you knows you, and your health record is missing, how are you going to get appropriate – or even safe – care?
But fragmentation is not just about disorganized and duplicative services. It is also about services that are missing altogether, like prenatal education, which has been squeezed out of the prenatal visit in favor of tests and procedures, or labor support, squeezed out by the machines and documentation that draw nurses’ attention away from the woman.
It is also about fragmenting health from family and community. We see this in how childbirth is managed as an “acute episode” requiring hospitalization. Once an intimate part of a family’s home life, childbirth has been plucked out of history’s long-honed human experience and put inside the four walls of a delivery room – or an operating theater. Although we gained access to some life-saving treatments, it is hard not to imagine that we gave something up in the process.
So, to transform the care model, we need first to understand what exactly has has been fragmented. What makes up the package of care that childbearing women want and need? How does this package vary across women, or across time for any particular woman? How do we preserve a meaningful and family-centered experience of birth while delivering safe, effective, and equitable care? Once we answer these questions, we must then figure out how to tool up the system with the right people, facilities, and information systems.
American Style Maternity Care: The No-Model Model
The United States has not adopted a “model” of maternity care per se. How we organize and deliver care has been rather haphazard, responding to cultural and economic forces over the last century that diminished women’s power, moved birth into the hospital, and converted a physiologic process into a decidedly medicalized one. As a result, there are no principles or policies that guide who delivers care, how care is coordinated, how information is shared, or how effectiveness is measured.
In contrast, policy makers and system stakeholders in other industrialized countries have given considerable attention to these questions. And the majority have adopted midwife-led models.
Evidence supports this approach. A Cochrane Systematic Review of 13 trials across 5 countries showed better maternal and infant outcomes, less resource utilization, and better maternal satisfaction when midwives lead and coordinate maternity care.
The UK is one of many countries where midwives are women’s point of entry into the maternity care system, and the obstetrician’s role is as a consultant for medical concerns, or to lead care of women with high-risk pregnancies. Recently, NICE, the independent body that issues evidence-based guidelines for the NHS, affirmed that midwife-led care should extend into labor and birth for most women, and that low-risk women benefit from midwifery care at home or in birth centers.
These guidelines reflect the findings of The Birthplace in England Study, a national effort to prospectively collect data on every single birth in midwife-led maternity services, and a stratified sample of births in obstetric-led units – nearly 65,000 births in all. Results showed better maternal outcomes and lower costs in midwife-led settings. Newborn outcomes were equivalent across settings, with the exception of first-time mothers planning home births, whose newborns face a slight but significant increased risk of morbidity or mortality.
From my perch as a midwife and a woman-centered care advocate, these guidelines are “NICE” indeed. Unfortunately, in the United States we have neither the evidence nor the care model the UK has. While midwives deliver plenty of maternity care, attending about 10% of births, they often work under physician supervision or practice under hospital policies that are not evidence-based. And our payment models discourage putting midwifery care to effective use, because midwives can reduce cesareans, anesthesia use, and length of stay, and these are where the money comes from with fee-for-service payment. Their contribution to outcomes and to patient satisfaction are hidden in physician- and hospital-centric data systems. So it is nearly impossible to assess the effects of different collaborative care models.
With these forces in play, we have a long way to go before we have widespread access to evidence-based, midwife-led care. But what we do have in the U.S. is the demand.
Although still a very small proportion of births, the number of midwife-attended home births has grown 7% per year over the last decade, while midwife-led birth center births have grown more than 20% per year since 2010. These trends seem likely to continue or accelerate, especially if we are to believe data from Listening to Mothers III, a national survey of new mothers. More than half of women said they would consider having their next baby in a birth center, and one in four said they definitely would want to. Interest in home birth was substantial, too.
Baby+Co: Scaling Midwife-Led Care in the United States
Baby+Co. is a company poised to meet this demand, and to redefine how technology is used to continuously improve the care delivery model and personalize the experience. Founder Cara Osborne is a midwife and Harvard-trained epidemiologist with a mission to scale up the birth center model, and a “data” tattoo on her arm that suggests how she’ll do it.
With plans and financing to build dozens of birth centers over the next few years, Cara and her team are going after the Triple Aim of better outcomes, better experiences, and lower costs, and are placing their bets on relationship-based, woman-centered care as the “secret sauce” for achieving all three. With Maternity Neighborhood as the “intel inside” their birth centers, Baby+Co. is engaging women as part of the care team, gathering data on outcomes and experiences, and gleaning insights to drive better care. They are also partnering with physicians and hospitals in each community to be sure the transition is seamless when women need a higher level of care.
I spoke to Cara and asked what Baby+Co. is offering that is different from mainstream maternity care, and how she is measuring it. She told me,
We are offering a nurturing partnership between the provider and the family. This is the secret sauce. Women need a trusting relationship to be able to talk about the things that are going to be important for them, and midwives need this to deliver good care because what people want and need varies from person to person. Midwifery training is so relationship-based, and that is what I’m really coming back to. That relationship is so central to having trust. And feeling safe is about trusting your surroundings and trusting the people you’ve enlisted to help you through something.
What gets measured gets managed, and what gets measured in our current system is reimbursement. We want to measure value. This means in addition to tracking outcomes we need to measure the experiential variables, and frankly we don’t know what these are. Nobody does. We need a round of real observation and listening to figure out what the right questions are. We need a drastic reboot that starts with, who are the women having babies today and what are they looking for? What are their fears and concerns and desires? What resonates for them? What of the messaging that is already out there means something and what doesn’t?
Financing the “Humanisation” of Birth
The Cochrane reviewers analyzing midwife-led care concluded,
“Policy makers who wish to achieve clinically important improvements in maternity care, particularly around normalising and humanising birth and preventing preterm birth should consider midwife-led continuity models of care and consider how financing of midwife-led services can be reviewed to support this.”
As the U.S. rolls out healthcare reform, introducing new ways of paying for care that reward value, midwives and midwife-led services should be poised to play a more prominent role in our maternity care system. In the second half of my series, I will explore in more depth the opportunities and barriers to financing midwife-led care. But first, I will look at one more Care Model That Works. Not surprisingly, the model has its roots in midwifery, and it doubles down on the relationship-based care element. Next week I will look at CenteringPregnancy, a group visit model where women deliver some of their care to each other…