Continuing Education Module Transforming Maternity Care: Implementing the Blueprint for Action

Abstract

In January 2010, Women’s Health Issues published two direction-setting reports from the Transforming Maternity Care (TMC) Project: “2020 Vision for a High-Quality, High-Value Maternity Care System” and “Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System.” This guest editorial summarizes highlights of the implementation phase of what is now known as the TMC Partnership. Major progress has been made in elevating maternity care quality to a national policy priority, increasing the availability and use of maternity care performance measures, and developing shared decision making tools for childbearing women.

In January 2010, Women’s Health Issues published two direction-setting reports from the Transforming Maternity Care (TMC) Project: “2020 Vision for a High-Quality, High-Value Maternity Care System” (Transforming Maternity Care Vision Team et al., 2010) and “Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System” (Transforming Maternity Care Symposium Steering Committee et al., 2010). Convened by Childbirth Connection, the TMC Project brought together leaders and stakeholders to envision and chart the path toward a system that reliably delivers safe, effective, woman-centered maternity care to all childbearing women in the United States. The reports galvanized improvement efforts and helped elevate maternity care quality to a major national priority. Childbirth Connection continues to engage multiple stakeholders as we foster implementation of key Blueprint recommendations. This article summarizes highlights of the implementation phase of what is now known as the TMC Partnership.

Lamaze International has created a continuing education homestudy based on this article. Visit the Online Education link under the “Education” heading at the Lamaze for Professionals website (www.lamazeinternational.org) for detailed instructions regarding completion and submission of this homestudy module for Lamaze contact hours.

MATERNITY CARE IS ON THE NATIONAL AGENDA

After years of inadequate and poorly coordinated attention by policymakers and others, maternity care quality has become a priority in health-care reform efforts. In 2011, obstetric adverse events became one of 10 priority areas for the Partnership for Patients (P4P), a national initiative to dramatically improve patient safety across the country (U.S. Department of Health and Human Services, 2011). In 2012, P4P joined with the National Priorities Partnership, a collaborative of 51 federal health agencies and national organizations, to establish a Maternity Action Team, reflecting maternity care as a major priority across agencies and stakeholders. Childbirth Connection’s Executive Director, Maureen Corry, was invited to cochair the Maternity Action Team, which will focus national efforts on eliminating early elective births and reducing the cesarean surgery rate in low-risk women.

After years of inadequate and poorly coordinated attention by policymakers and others, maternity care quality has become a priority in health-care reform efforts.

To learn more about Childbirth Connection and its numerous resources and programs, visit the organization’s website (www.childbirthconnection.org).

Medicaid pays for over 40% of the births in the United States and, thus, has a major potential role in driving improvements in the quality and value of maternity care (Markus & Rosenbaum, 2010). After a multistakeholder meeting convened by the Centers for Medicare and Medicaid Services in 2011 to identify priorities for improving perinatal outcomes, the federal government announced the Strong Start initiative in early 2012 (Centers for Medicare and Medicaid Services, 2012). Unveiled by U.S. Department of Health and Human Services Secretary Kathleen Sebelius at the Family Health and Birth Center in Washington, DC, Strong Start will fund and evaluate evidence-based models of enhanced prenatal care, including CenteringPregnancy group prenatal care, birth center care, and woman- and family-centered maternity care homes—three models recommended in the consensus Blueprint for Action. The program will also support efforts to eliminate early elective births, including coordinated public awareness campaigns among major national partners.

Finally, the time since the 2020 Vision and Blueprint for Action were issued has brought unprecedented legislative activity to support maternity care quality improvement. Multiple maternity-related bills have been introduced in the House and Senate, including one that Childbirth Connection and the American Congress of Obstetricians and Gynecologists worked jointly on: the Quality Care for Moms and Babies Act of 2011 (S. 1969 / H. R. 3620), sponsored by Senators Debbie Stabenow and Robert Menendez and Representative Eliot Engel. The bill would support the development of a maternity care quality measurement program, evaluation of maternity care home models, and expansion of maternity care quality collaboratives. Other bills pending in Congress address additional high-priority Blueprint recommendations, including ameliorating maternity workforce issues, promoting evidence-based maternity care, and improving health-care provider education. In addition, the Patient Protection and Affordable Care Act, passed in 2010, includes many provisions that address other Blueprint recommendations.

PROGRESS CONTINUES TOWARD TRANSPARENT REPORTING OF OUTCOMES

The Institute of Medicine defines health-care quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Lohr, 1990, pp. 128–129). Performance measures are data that can be used to design and evaluate quality improvement programs and to align payment incentives with high-quality care. When reported transparently to the public, performance measures can increase consumer engagement in health care.

Just a few years ago, there was no set of nationally endorsed measures of maternity care quality; but this has changed rapidly, with efforts gathering steam since the 2020 Vision and Blueprint for Action were issued. An initial set of endorsed performance measures is now in use by the Joint Commission for accrediting hospitals; although few hospitals currently report on these voluntary measures, multiple stakeholders have called for incentives and other means to increase reporting. New measures for both clinicians and hospitals are in various stages of the endorsement process, and Childbirth Connection staff have leadership roles in both of the major national measure endorsement programs. While we work with and monitor all perinatal measures in the endorsement pipeline, we have particularly championed measures that are applicable to the large proportion of childbearing women who are healthy. These include measures addressing spontaneous labor and birth; healthy term newborns; cesarean surgery in low-risk, first time mothers; and elective birth before 39 weeks.

Childbirth Connection has also focused our efforts on supporting more widespread reporting of appropriate maternity care measures. In 2011 and 2012, TMC Partner, The Leapfrog Group, published rates of early elective birth as part of their annual hospital survey. This represents the largest maternity care public reporting effort and has helped spur action toward elimination of this harmful practice. The Leapfrog Hospital Survey and other publicly reported hospital data are available through the TMC Data Center (http://transform.childbirthconnection.org/resources/datacenter/).

A growing list of landmark reports and consensus statements have prioritized shared decision making in maternity care.

LEADING ORGANIZATIONS MAKE A MAJOR NATIONAL COMMITMENT TO MATERNITY SHARED DECISION MAKING

Shared decision making is a process that takes into account the best available scientific evidence, as well as the individual’s values and preferences, to determine the right course of care (Coulter & Collins, 2011). Evidence-based decision aids can support shared decision making, and systematic reviews of their use have shown a remarkable range of benefits. The current Cochrane review found that decision aids increase knowledge, reduce feelings of being uninformed about options and of being unclear about personal values, reduce passivity in decision making, improve patient–provider communication, reduce postintervention uncertainty about choice, increase the likelihood of choosing less invasive options, and involve similar or greater decision satisfaction (Stacey et al., 2011). A systematic review of the emerging evidence for decision aids applied to maternity care includes trials showing improved knowledge, reduced decisional conflict, increased perception of having made an informed choice, reduced anxiety, and improved satisfaction (Say, Robson, & Thomson, 2011).

A growing list of landmark reports and consensus statements have prioritized shared decision making in maternity care, and include the following: the TMC Blueprint for Action; the National Institutes of Health (2010) Consensus Development Statement on Vaginal Birth After Cesarean; “Quality Patient Care in Labor and Delivery: A Call to Action” (2012), issued jointly by seven health professional organizations; and the Home Birth Consensus Summit (2011) Common Ground Statements, among others.

In 2011, Childbirth Connection and the Informed Medical Decisions Foundation brought together our expertise and national leadership in maternity care and shared decision making, respectively, to launch Expecting More, the first national maternity care shared decision making initiative. Applying the foundation’s tested approach to developing evidence-based decision support tools free of conflicts of interest, the collaboration will, over the next several years, produce a suite of high-quality, publicly available decision aids for a broad range of preference-sensitive decisions in maternity care (see Table 1). The Expecting More team also will produce multimedia content to inform women about evidence-based care and help them navigate the maternity care system as empowered, knowledgeable consumers.

TABLE 1. Preference-Sensitive Decisions in Maternity Care.

Every maternity care intervention presents possible benefits and possible harms. Where rigorous evidence does not point to a single care pathway as the “right” choice, the decision is considered “preference-sensitive.” That means the right choice depends on what is most important to the woman. Some examples include •where and with whom to give birth, •prenatal screening options, •vaginal birth after cesarean (VBAC) or repeat cesarean, •options for comfort and pain relief in labor, •prevention and treatment options for conditions such as gestational diabetes and preterm labor, and •induction of labor for conditions where tradeoffs are uncertain.

The Expecting More team will partner with hospitals, health plans, employers, and other system stakeholders to disseminate decision support tools and other educational content to childbearing women and to develop and evaluate models of shared decision making in maternity care clinical settings. In addition, maternity decision support tools and related content will be freely available on a user-friendly, multimedia website (www.expectingmore.org) and integrated with other technologies as appropriate.

RAPID GAINS IN MATERNITY CARE QUALITY, OUTCOMES, AND VALUE ARE WITHIN REACH

The 2020 Vision and Blueprint for Action seem to have helped focus and galvanize efforts among all stakeholder groups to improve maternity care quality and value in the United States. A national climate of health-care reform, increasing innovation in health care, and investment in improvement strategies have bolstered implementation efforts. Rapid gains in maternity care quality and value are within reach, but none of us can do it alone. Every system stakeholder has an important part to play in helping achieve a system that reliably delivers safe, effective, and woman-centered maternity care.

Rapid gains in maternity care quality and value are within reach, but none of us can do it alone.

Biography

AMY M. ROMANO has worked in the maternity care field as a clinician, research analyst, educator, and consumer advocate since 2001. In 2010, she joined Childbirth Connection, where she directs the Transforming Maternity Care Partnership and works on a broad range of program activities. Prior to joining Childbirth Connection, Romano spent 6 years as a perinatal research and advocacy consultant to Lamaze International, during which she analyzed, summarized, and critically appraised research for the Lamaze community and launched Lamaze’s award-winning research blog, Science & Sensibility.