Maternal Health Matters: Why the U.S. Ranks Last

Why the U.S. Ranks Last On This Most Important Healthcare Issue: Maternal-Child Health. How We Can Fix It

“Children are our future, and their mothers are its guardians. We must make every mother and child count, because we value every human life.  And they count because healthy mothers and children are the bedrock of healthy and prosperous communities and nations.” Kofi Annan – United Nations Secretary General, 2005

Maternal-child health is the foundation for the future health of any nation. No healthcare policy maker, healthcare provider or employer would deny that healthy mothers are important, or that a healthy pregnancy, a positive birth outcome and a healthy baby are foundational to a healthy population. I would argue that healthy mothers and children are the single most important key performance indicators of public health and of the overall effectiveness of the healthcare system in delivering high quality and cost-effective care. If we were to score the U.S. healthcare system on its maternal health outcomes defined in terms of maternal mortality and morbidity (or reduction in these bad outcomes), the US is failing miserably.

A report by Amnesty International entitled “Deadly Delivery: The Maternal Health Crisis in the USA” provides overwhelming evidence that the US has the worst maternal health outcomes at the highest cost.

Examining Maternal Health Outcomes: The Data

It would likely surprise most Americans to know that the United States is one of the most dangerous Western countries in which to give birth1  American women are more than twice as likely to die in pregnancy or childbirth as women in Canada and at higher risk of dying than mothers giving birth in China, Saudi Arabia, Iran, Libya and Turkey.2  The World Health Organization ranks the US 46th in maternal mortality worldwide and stands among only a handful of countries — including Zimbabwe and North Korea — where the mortality rate has risen since 1990. The US Center for Disease Control (CDC) data show our maternal mortality rate has more than doubled in the past few decades (12 to 28 maternal deaths per 100,000 births)) while more than a third of all U.S. women – 1.7 million women each year – experience a pregnancy-related complication that has an adverse effect on their health.

An expose by CNN and Every Mother Counts titled Giving Birth in America raises the profile and issues of maternal health outcomes in the United States. Produced by Every Mother Counts, with executive producer and founder Christy Turlington Burns, the film chronicles the surprising journey of four women as they give birth in America.

Says Turlington Burns: We face medical-legal, hospital and insurance barriers that are out of sync with women’s needs, like lack of support for vaginal births after C-sections (or VBACs) and mandatory C-sections for conditions that can often be managed safely by vaginal birth. 

Outcomes Data: Complex Reasons for Declining Maternity Outcomes

Dr. William Callaghan, the chief of the Maternal and Infant Health branch at the CDC concedes that maternal mortality rates are too high in the U.S. as quoted in this Huffington Post article on rising mortality rates: Maternal Death Rates Are Decreasing Everywhere But The U.S.

“It reflects, in many ways, the health of our population,” Callaghan continued. “We have a birthing population that is on average older [than before], and more people are coming into pregnancy with obesity, high blood pressure and other cardiovascular risk factors.”

The graph below shows percentages of pregnancy-related deaths in the United States in 2011:

Cardiovascular diseases, 15.1%.
Non-cardiovascular diseases, 14.1%.
Infection or sepsis, 14.0%.
Hemorrhage, 11.3%.
Cardiomyopathy, 10.1%.
Thrombotic pulmonary embolism, 9.8%.
Hypertensive disorders of pregnancy, 8.4%.
Amniotic fluid embolism, 5.6%.
Cerebrovascular accidents, 5.4%.
Anesthesia complications, 0.3%.
The cause of death is unknown for 5.9% of all 2011 pregnancy-related deaths.

Many pregnancy-related deaths and complications are caused by chronic diseases and conditions including advanced maternal age, diabetes and heart disease. More than half of women are above the recommended BMI prior to becoming pregnant. The costs on our healthcare system amount to hundreds of millions of dollars. The cost of pre-term labor and premature infants alone amount to billions of dollars in unnecessary and avoidable healthcare costs and immeasurable adverse impact on the long-term health of mothers and children born too soon.

The National Institute of Health published a study titled “Effectiveness of patient education to reduce preterm delivery among ordinary risk patients” demonstrating that patient education and birth preparation was highly effective in reducing preterm delivery among ordinary risk patients and therefore the costs of maternal-child healthcare:

“In evaluating the outcome of pregnancies in patients not at high risk for preterm delivery (ordinary risk patients) we found that patients who received instruction to recognize early signs of preterm labor had babies with a higher birthweight (3255 +/- 548 gm) than patients who were not so instructed (3200 +/- 599 gm, p = 0.03). Average length of gestation in the instructed and noninstructed patients was 276 +/- 15 days and 275 +/- 18 days (p = 0.12), respectively. The preterm delivery rate among patients receiving the instruction was 9.5% compared with 11.5% among those who did not receive it. We conclude that specific prenatal education about early warning signs of preterm labor is an important component ofpreterm birth prevention programs that can be demonstrated to have an independent contribution to prenatal care.”

The Impact of Obesity on Maternal Child Health

Science shows overwhelming evidence that obesity affects pregnancy outcomes:

The increasing rate of maternal obesity provides a major challenge to obstetric practice. Maternal obesity can result in negative outcomes for both women and fetuses. The maternal risks during pregnancy include gestational diabetes and preeclampsia. The fetus is at risk for stillbirth and congenital anomalies. Obesity in pregnancy can also affect health later in life for both mother and child. For women, these risks include heart disease and hypertension. Children have a risk of future obesity and heart disease. Women and their offspring are at increased risk for diabetes. Obstetrician-gynecologists are well positioned to prevent and treat this epidemic. Source: The Impact of Maternal Obesity on Maternal and Fetal Health. Department of Research, The American College of Obstetricians and Gynecologists, Washington, DC†Department of Psychology, American University, Washington, DC

Callaghan noted that women with lifelong poor nutrition and long histories of type 2 diabetes are also at risk of maternal medical complications — issues Ward attributed to a lack of health insurance.

Examining Costs: Why Do US Births Cost the Most?

A New York Times article from 2013 is one of many articles shedding light on the healthcare dollars spent both out of pocket and by insurance companies including Medicaid in American Way of Birth “The Costliest in the World”. The U.S. has the highest per capita health care expenditures on maternity care (twice that of most developed countries) with hospitalization related to pregnancy and childbirth costs of over US$86 billion per year.

Maternity and newborn care comprise the highest hospitalization costs of any area of medicine and the leading profit-center for most for-profit hospitals. U.S., with costs related to pregnancy and childbirth reaching over $86 billion per year as reported by the New York Times in American Way of Birth “The Costliest in the World”. 

Impact on Fee-for-Service: Money Motivates Doctors To Do More C-Sections

Providers make more money from Cesarean births. The National Bureau of Economic Research and health care economists Erin Johnson and M. Marit Rehavi calculated that doctors might make a few hundred dollars more for a C-section compared to a vaginal delivery, and a hospital might make a few thousand dollars more.  An NPR article titled “Money May Be Motivating Doctors to Do More C-Sections” states, “Obstetricians in many medical settings are paid more for C-sections. 

Professor Gerard Anderson of the Johns Hopkins Centre for Hospital Finance and Management says that the fee for service “a la carte” payment system puts more money into the hands of doctors, which drives up the number of tests ordered, “If you can make more money as a doctor by ordering more tests, you are going to order them and therefore patients end up getting more tests,” he says. Patients receiving more tests pay great out-of-pocket costs and cost insurers more money.

Patients Need Education to Reduce Cesarean Birth

Johnson and Rehavi examined the reasons for the increased number of surgical childbirth procedures via an unusual tack: They hypothesized that obstetricians would be less likely to be swayed by financial incentives when patients themselves had significant medical expertise and knowledge. By contrast, the researchers figured, such incentives might play a larger role in medical decision-making when patients knew very little.”

Access to Affordable Maternity Care is Essential

The first step for patients begins with access to affordable preconception and pregnancy care. While the Affordable Care Act has certainly improved access to pregnancy care, there are still millions of uninsured and part-time women who do not get prenatal care. Rachel Ward, the director of research for Amnesty International USA and the author of the 2011 report “Deadly Delivery: The Maternal Health Care Crisis in the USA.” writes:

The way in which the health care system in the USA is organized and financed is failing to ensure that all women have access to affordable, timely and adequate maternal health care services. As a result, women, and in particular women of color, women living in poverty and immigrant women, are more likely to enter pregnancy with untreated or unmanaged health conditions; to receive little or no prenatal care because of delays in receiving coverage; to face crippling debt following labor and delivery; and to have limited access to postpartum care.

Do we value mothers and children so little that we believe that parents should go bankrupt for bringing a child into our society? Does it make sense that parents who lack insurance are subject to higher costs because they don’t have insurance companies negotiating fees on their behalf?

Data Prove Ongoing Birth Support Improves Outcomes

Data shows that proper childbirth education and preparation for birth improves birth birth outcomes. Evidence also shows that labor and birth support from trained care providers such as birth doulas (women that provide birthing women with ongoing emotional, physical and psychological support) improve birth outcomes and reduce costs.

Source: Every Mother Counts, Overdue: Medicaid and Private Insurance of Doula Care

Ongoing Birth Support Lowers Cesarean Section Rates

In 2012, Hodnett et al. published an updated Cochrane review on the use of continuous support for women during childbirth. They pooled the results of 22 trials that included more than 15,000 women. These women were randomized to either receive continuous, one-on-one support during labor or “usual care.”

The authors concluded (and the evidence shows) that outcomes are improved from doula support, “Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.”

“Overall, women who received continuous support were more likely to have spontaneous vaginal births and less likely to have any pain medication, epidurals, negative feelings about childbirth, vacuum or forceps-assisted births, and C-sections. In addition, their labors were shorter by about 40 minutes and their babies were less likely to have low Apgar scores at birth.”

Providers Should Cover Doula Support to Lower Cesareans and Improve Costs

Why are birth support providers not covered by healthcare insurers who have financial incentives to reduce Cesarean sections and the cost of birth? Why are there no universally available, provider-covered health plans to help women reduce their chances for Cesarean birth? Because doulas are not currently a covered expense, insurance companies have little tracking data on the efficacy and cost-effectiveness of doula support. Because insurers don’t have this data, they can’t justify coverage. A Catch-22 situation.

Access To Doula Services and Income Disparity

“Given the strength of the evidence and the endorsement of doula care by professional associations, it’s important to consider why only 6 percent of U.S. women who give birth have support from a doula. First, hiring a doula is expensive. Most private doulas charge $700-$1,500 per birth, putting doula care outside the financial reach of many mothers.”

Secondly, doulas are not evenly distributed geographically, and many women in rural areas of the United States—where half a million babies are born each year—don’t have a doula nearby. Finally, there is limited diversity within the doula workforce, which can create cultural barriers to access. Most doulas are white upper-middle class women, and most of their clients are white upper-middle class women.

Low-income women and women of color, which are the groups of women at highest risk of poor birth outcomes, are also the most likely groups to report wanting, but not having, access to doula services. The major evidence gap for policymaking is not whether doula care supports positive outcomes but rather how policy efforts can best ensure access to evidence-based doula support and whether and how particular policy strategies more effectively produce value and potentially reduce disparities in birth outcomes.”

The Role of Medicaid in Promoting Access to High-Quality, High-Value Maternity Care: The Case for Medicaid Coverage of Doula Support

More than 50% of births are covered by government-funded Medicaid. A report titled “Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform” published by the Jacobs Institute of Women’s Health states “The Medicaid program is a major source of public financing for health care services provided to pregnant women, infants, and children in the United States.”

Medicaid covers more than 1 in 3 US children and over 40% of births, including infants, as well as a significant number of deliveries across the nation according to the Kaiser Commission on Medicaid and the Uninsured, 2013. With four million births per year, Medicaid covers 1.3 million births.

Medicaid Coverage Reduces Income Disparity

Medicaid is a bedrock source of coverage for children. Medicaid, together with the smaller Children’s Health Insurance Program (CHIP), covers more than 1 in every 3 children and more than half of all low‐income children. Medicaid is particularly important for children with disabilities and special needs. Because of Medicaid and CHIP, the uninsured rate among children has declined substantially over the last decade.” 

Source: Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform

“As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health, as well as birth outcomes. Improved birth outcomes could translate into substantial cost savings, because the costs associated with preterm births are estimated to be 10 times greater than those for full-term births.”

Financial Incentives for Medicaid Coverage of Doula Support 

Medicaid has a direct financial incentive to cover doula support as well as national childbirth education to reduce the cost of birth nationwide, which totals more than $80 billion.

The George Washington University School of School of Public Health and Health Services known as the Jacobs Institue on National Health published an abstract titled The Role of Medicaid in Promotion Access to High Quality, High-Value Maternity Care which analyzed and described the role of Medicaid in facilitating access to care for pregnant women and ensuring high-quality maternity care that is affordable:

“Health care reform may provide an opportunity to revisit key issues around access to and quality of maternity care, including the benefit package, the content of services covered in the package, the frequency with which these services should be furnished, and the development of meaningful measures to capture whether women of childbearing age, including pregnant women, regardless of insurance status, indeed receive efficient, timely, effective, safe, accessible, and woman-centered maternity care.”

How Medicaid Coverage For Doula Care Could Improve Birth Outcomes, Reduce Costs, And Improve Equity” states

“At a time of growing pressures toward cost-containment within the health care system, the search for solutions to achieve the triple aim (quality improvement and better population health, at a lower cost) [within maternal-child health] is increasingly urgent.”

Efforts to expand Medicaid coverage to include doula services have the potential to improve access to low-intervention, physiologic birth and also to reduce costs of maternity services for all women.

“In 2013, Minnesota passed legislation requiring Medicaid payment for doula services. We (the authors of this post) are currently studying the effects of this law in partnership with community- and hospital-based organizations that provide doula services.

“If states consider this route, Minnesota’s lessons may inform their efforts. It is possible to create policy change that heeds the call of Goldstein to “empower women in their birth experience whenever possible,” and of Glied and colleagues to “improve productivity, producing the same services with fewer, or less costly, labor inputs.”

The Case for Nationwide Financial Coverage for Prenatal Education and Doula Support: Improved Outcomes and Lower Costs

Patient education is sorely lacking for women both before and during pregnancy. There are no nationally-published guidelines for how to prepare for a healthy pregnancy and birth. There is no trusted health or medical authority for pregnancy education in the US that adequately prepares women for the most costly, scary and high-stakes medical event of their lives: childbirth. There is no government-mandated national coverage for prenatal and childbirth education, yet financial incentives exist to adequately prepare pregnant mothers and provide ongoing birth support to reduce costs and improve outcomes, including reduced Cesarean births as evidenced above and below:

“In childbirth, Johnson and Rehavi figured, this meant that obstetricians would perform fewer C-sections when their patients were themselves doctors. 

“We found that doctors are about 10 percent less likely to get C-sections,” Johnson says. “So obstetricians appear to be treating their physician patients differently than [they treat] their non-physician patients.”

“The idea is that physicians have medical knowledge,” Johnson says. “If the obstetrician is deviating from the best treatment because of their own financial incentive, the patient [who is a] doctor would be able to push back against the obstetrician. But that might not be the case for non-doctors because they simply do not have the medical knowledge to know whether or not this C-section is the appropriate [method of delivery] for them.”

Johnson suggests that one solution to the disparities lies in better patient knowledge and empowerment, which is a result of improved patient education and universal access to childbirth preparation (and therefore financial coverage for childbirth education).

The average childbirth class is about $150, yet the potential reduction in healthcare costs as a result of improved prenatal and birth education and thereby reduced Cesareans is more than the average childbirth class (given Cesareans births cost on-average about $10,000 and in some cases up to $20,000 per birth depending on the hospital).

Prenatal preparation and ongoing, compassionate labor support in the form of birth doulas, which are on-average cost between $500-$1000 provides clear financial incentives for both Medicaid and private insurers to reduce the overall cost of birth, which is phenomenally high and only getting more expensive:

“According to the same Kaiser Family Foundation report, the average hospital delivery cost was $6,520. This cost is steadily rising; it was $3,983 in 1987 and $5,464 in 1997. According to the American Academy of Family Physicians (AAFP) the average costs of a vaginal birth and C-section delivery are:

Without Complications
Vaginal delivery: $6,200
C-section: $11,500

With Complications
Vaginal delivery: $8,200
C-section: $15,500

These are hospital fees only. Doctor’s fees are usually charged on top of this and average $1,500. 

Wouldn’t you rather pay $150 for a childbirth class, even if your payment is out-of-pocket, along with the services of a doula, costing $500-1000 for a total of $650 to $1150, given it’s statistically likely to reduce your chance of a $11,500 to $15,500 Cesarean birth by on-average 22.3% or by 31.5% among Medicaid beneficiaries nationally? The data provides incontrovertible evidence that doula-supported births were 40.9% less likely to result in a C-section compared to births that did not have the benefit of ongoing emotional, physical and educational support not typically provided by obsteticians:

“After controlling for factors associated with high-risk pregnancies and C-sections, such as gestational diabetes, race/ethnicity, hypertension and age, the U of M researchers found that doula-supported Medicaid births were 40.9 percent less likely to result in a C-section.

They also found that states could reap significant savings by paying doulas to support Medicaid mothers during pregnancy and delivery. Minnesota, for example, would have saved $3 million in 2009 by reimbursing doulas $300 to assist Medical Assistance women during childbirth, according to the researchers’ estimates.

Prenatal education and knowledge of basic childbirth procedures, comfort measures and coping techniques can help every woman and mother have a better birth experiment. How can we provide access to these essential health education programs and maternal support services?

Google certainly doesn’t replace the advice of a certified physician, and community health forums are full of misinformation and bad medical advice from women who are untrained in professional birth support and prenatal education.

Access to trained providers such as birth doulas and compassionate, effective, outcomes-driven obstetricians and midwives can and do improve outcomes and reduce costs by the thousands. It is time we provide our mothers the prenatal education support and ongoing birth and labor support that every women deserves.

If you are a first-time pregnant woman, please educate yourself on how to best prepare for childbirth, reading evidence-based guides to childbirth, such as Ina May’s Guide to Childbirth, which follows a midwifery model of care and continuous labor support known to improve outcomes while reducing costs. Childbirth preparation through books and classes provide first-time mothers with inspiring birth stories and practical advice, such as:

  • Reducing the pain of labor without drugs–and the miraculous roles touch and massage play
  • What really happens during labor?
  • Orgasmic birth–making birth pleasurable
  • Episiotomy–is it really necessary?
  • Common methods of inducing labor–and which to avoid at all costs
  • Tips for maximizing your chances of an unmedicated labor and birth
  • How to avoid postpartum bleeding–and depression
  • The risks of anesthesia and cesareans–what your doctor doesn’t necessarily tell you
  • The best ways to work with doctors and/or birth care providers
  • How to create a safe, comfortable environment for birth in any setting, including a hospital

Take a childbirth class at your local hospital, through your obstetrician or midwife or an independent childbirth professional certified through the International Childbirth Association so you are aware of all the various procedures, tests and expertise which will need budgeting for.  A prepared and educated pregnant mother is less likely to make uniformed choices or suffer a negative birth experience.

The  US National Library of Medicine along with the National Institutes of Health published outcomes data showing that “Personal control during childbirth was an important factor related to the women’s satisfaction with the childbirth experience. Helping women to increase their personal control during labour and birth may increase the women’s childbirth satisfaction.”

What pregnant mother and expectant couple does NOT desire a satisfying childbirth experience and a healthy baby?

Find compassionate birth support by finding a doula in your area, available through certifying doula organizations such as Doulas of North America.

If You Cannot Afford the Cost of Health Insurance, Obtain Medicaid or Look Into Reduced-Cost Prenatal Care

The Affordable Care Act offers pregnant women more options and protection. Women in every State can now get help paying for their medical expenses and care during pregnancy.

To find out about the program in your State:

• Dial 800-311-BABY (800-311-2229). This toll-free phone number will connect you to the Health Department in your zip code.
• Dial 800-504-7081 for information in Spanish.
• Call or contact your local Health Department.

For additional information call:

National Women’s Health Information Center (NWHIC)
Phone: 1-800-994-9662

National Center on Birth Defects and Developmental Disabilities
Phone: (770) 488-7150, (888) 232-6789

Smart Moms, Healthy Babies
Phone: (734) 936-4000

March of Dimes
Phone: (914) 428-7100, (888) 663-4637

The Nemours Foundation
Phone: (302) 651-4046

The Financial Case for Postpartum Care

According to data published by Pediatrics January 1986, VOLUME 77 / ISSUEtitled “Improving the Delivery of Prenatal Care and Outcomes of Pregnancy: A Randomized Trial of Nurse Home Visitation”, a comprehensive program of prenatal and postpartum nurse home visitation designed to prevent a wide range of health and developmental problems in children born to primiparous women who were either teenagers, unmarried, or of low socioeconomic status improved outcomes and reduced costs:

“During pregnancy, women who were visited by nurses, compared with women randomly assigned to comparison groups, became aware of more community services; attended childbirth classes more frequently; made more extensive use of the nutritional supplementation program for women, infants, and children; made greater dietary improvements; reported that their babies’ fathers became more interested in their pregnancies; were accompanied to the hospital by a support person during labor more frequently; reported talking more frequently to family members, friends, and service providers about their pregnancies and personal problems; and had fewer kidney infections. Positive effects of the program on birth weight and length of gestation were present for the offspring of young adolescents (<17 years of age) and smokers. In contrast to their comparison-group counterparts, young adolescents who were visited by nurses gave birth to newborns who were an average of 395 g heavier, and women who smoked and were visited by nurses exhibited a 75% reduction in the incidence of preterm delivery. (P ≤ .05 for all findings.”

Improving Maternal-Child Healthcare as a Matter of Public Health

Whether you’re a healthcare provider, a maternal-child health advocate, public policymaker or employer, we have a collective social, moral and financial incentive to improve the healthcare outcomes for pregnant mothers and babies, while reducing the national and out-of-pocket costs of maternal care.This includes cost-effective programs such as national coverage for childbirth education and ongoing labor support.

Don’t we owe it to American children and their mothers to ensure a safe and satisfying birth? Is there anything more important to our society’s future health than the health of our mothers and children?

“It keeps startling me that at the beginning of this 21st century, at a time when we can . . . explore the depths of the seas and build an international space station, we have not been able to make childbirth safe for all women around the world. … This is one of the greatest social causes of our time.” Thoraya Obaid, Executive Director of the United Nations Population Fund

Denise Terry is CEO of EmbraceFamily Health, a digital maternal-child health company focused on supporting parents during pregnancy, baby and the childhood years. EmbraceFamily provides parents with evidence-based education, health education and expert support to enable the healthiest children and families. In addition to her experience as a technology entrepreneur, Denise supported hundreds of expectant parents during pregnancy, birth and the postpartum period as a birth and postpartum doula and licensed childbirth educator. Denise is a mother of twins.

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