Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing

Abstract

The Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing charts an efficient pathway to a maternity care system that reliably enables all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences. The authors are members of a multistakeholder, multidisciplinary National Advisory Council that collaborated to develop this document. This approach preventively addresses troubling trends in maternal and newborn outcomes and persistent racial and other disparities by mobilizing innate capacities for healthy childbearing processes and limiting use of consequential interventions. It provides more appropriate care to healthier, lower-risk women and newborns who often receive more specialized care, though such care may not be needed and may cause unintended harm. It also offers opportunities to improve the care, experience and outcomes of women with health challenges by fostering healthy perinatal physiologic processes whenever safely possible.

The full Blueprint and separate files for the six strategy sections can be found at http://www.NationalPartnership.org/blueprint/

© 2018 National Partnership for Women & Families. Reproduced with permission.

Executive Summary

The Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing (hereafter Blueprint) aims to chart an efficient pathway to a maternity care system that reliably enables all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences.¹ The authors are members of a multistakeholder, multidisciplinary National Advisory Council that collaborated to develop this document.

Fostering healthy physiologic processes whenever possible is a preventive approach to health and safety for childbearing women and their newborns.

Knowledge about the importance of perinatal physiologic processes for healthy maternal-newborn outcomes has come into sharper focus and garnered growing attention in recent years. Fostering healthy physiologic processes whenever possible is a preventive approach to health and safety for childbearing women and their newborns. Promoting, supporting, and protecting these processes contributes to healthy outcomes in women and their fetuses/newborns. These processes facilitate such crucial matters as fetal readiness for birth and safety in labor, labor progress, reduced stress and pain in labor, safe maternal and newborn transitions and adaptations after birth, effective breastfeeding, and secure maternal-newborn attachment. Growing evidence of longer-term effects of care around the time of birth also underscores the importance of fidelity to optimal maternal-newborn care. Leading professional organizations increasingly provide guidance for promoting, supporting, and protecting these processes.

A focus on benefits of healthy perinatal physiologic processes aligns with the health system shift to providing high-value care, addressing the unintended consequences of fee-for-service payments and improving health outcomes and experiences with wiser spending.

The recommendations and action steps reflect unprecedented opportunities for innovation in the rapidly evolving health-care environment.

Increased use of this approach has the potential to preventively address troubling trends in maternal and newborn outcomes and persistent racial and other disparities in care and outcomes by mobilizing innate capacities for healthy childbearing processes and limiting use of consequential interventions that can be safely avoided. This approach is a way to provide more appropriate care to the majority of healthier, lower-risk women and newborns who often receive more specialized care, though such care may not be needed and may cause unintended harm.

The Blueprint identifies six widely accepted improvement strategies to transform maternity care and a series of specific recommendations within each strategy (see Appendix). Each recommendation is presented with immediate action steps to directly or indirectly increase access to healthy perinatal physiologic processes. The recommendations and action steps address many barriers to optimal care in the current maternity care system. The recommendations and action steps reflect unprecedented opportunities for innovation in the rapidly evolving health-care environment. To realize system transformation, innovation must be accompanied by continuous evaluation and publication of results, refinement, and the scaling up and spreading of effective approaches.

This Blueprint’s six improvement strategies and the focus of the associated priority recommendations are:

1. Improve maternity care through innovative care delivery and payment systems and quality improvement initiatives.

   1. Implement episode payment programs.
   2. Implement maternity care homes.
   3. Expand high-performing elements of care.
   4. Incorporate quality-improvement initiatives.
2. Advance performance measurement for high-value maternity care.

   1. Fill measure gaps.
   2. Measure for quality improvement.
   3. Measure for accountability.
   4. Leverage specific measures.
3. Meaningfully engage all childbearing women and families.

   1. Develop system enhancements.
   2. Expand communication and education.
   3. Incorporate birth preferences care planning and shared decision making.
4. Transition to interprofessional education that supports team-based care for maternity care professionals.

   1. Educate using an interprofessional model.
   2. Educate on safety and quality.
5. Foster an optimal maternity care workforce composition and distribution.

   1. Better deploy and retain of obstetricians.
   2. Expand family physician maternity care participation.
   3. Grow the midwifery workforce.
   4. Implement effective laborist care models.
   5. Expand Maternity care in rural and underserved areas.
6. Conduct priority research to advance the science of physiologic childbearing and its impact on maternal and child health outcomes.

   1. Conduct perinatal physiologic research.
   2. Conduct perinatal clinical epidemiologic research.
   3. Conduct perinatal implementation research.
   4. Address structural factors influencing needed research.

The growing emphasis on the reliable provision of high-value maternity care creates unprecedented opportunities to ensure that most women and their fetuses/newborns have a healthy, uncomplicated labor, birth and transition in the days and weeks after birth. The present environment also offers opportunities to improve the care, experience, and outcomes of women with health challenges by fostering healthy perinatal physiologic processes whenever safely possible.

It is important to build on the growing consensus and meaningful professional leadership that have occurred in recent years. Systemic, transformational change is essential for achieving a maternity care system in the United States that restores respect for the biological capacities and contributions of women and their fetuses/newborns and maximizes benefits of these capacities. This Blueprint was developed to move expeditiously toward this more balanced, coherent, preventive, and complete maternity care system by offering specific improvement strategies, recommendations, and action steps that are directly tied to the current health policy and practice environment.

Systemic, transformational change is essential for achieving a maternity care system in the United States that restores respect for the biological capacities and contributions of women and their fetuses/newborns and maximizes benefits of these capacities.

Maternity care stakeholders—including policymakers, clinicians, administrators, health plans, employers, researchers, birth workers, advocates, and women and families themselves—are deeply interested in improving quality and safety. We encourage all stakeholders to identify and implement the priority recommendations and action steps that they can advance—on their own and in collaboration with others. With this clear set of priorities, we can collectively transform care, improve outcomes and experiences, reduce disparities, and rein in outlier costs. We face an exciting opportunity to achieve a full, high-performing maternity care system for all women, newborns, and families.

Biographies

MELISSA D. AVERY is a Professor in the School of Nursing at University of Minnesota and Past President of American College of Nurse-Midwives.

AMY D. BELL is Director of Quality for Women’s and Children’s Services in Atrium Health.

DEBRA BINGHAM was Vice President for Research, Education and Practice at Association of Women’s Health, Obstetrics and Neonatal Nurses (during Blueprint work), and currently she is Executive Director of Institute for Perinatal Quality Improvement and an Associate Professor at University of Maryland School of Nursing.

MAUREEN P. CORRY is Senior Advisor for Childbirth Connection Programs at National Partnership for Women & Families.

SUZANNE F. DELBANCO is Executive Director of Catalyst for Payment Reform.

SUSAN LEAVITT GULLO was a Director in the Institute for Healthcare Improvement (during Blueprint work), and is currently Principal, Susan Gullo Consulting.

CATHERINE H. IVORY is Associate Chief Nurse Executive and Vice President for Professional Practice and Care Transformation at Indiana University Health, an Adjunct Assistant Professor at Vanderbilt University School of Nursing, and Past President of Association of Women’s Health, Obstetric and Neonatal Nurses.

JOHN C. JENNINGS is a Professor of Ob/Gyn at Texas Tech University Health Sciences and Past President of American College of Obstetricians and Gynecologists.

HOLLY POWELL KENNEDY is Helen Varney Professor of Midwifery in Yale School of Nursing and a Past President of American College of Nurse-Midwives.

KATY B. KOZHIMANNIL is an Associate Professor at University of Minnesota School of Public Health.

LAWRENCE LEEMAN is a Professor of Family and Community Medicine; Obstetrics and Gynecology at University of New Mexico School of Medicine and a Medical Editor in AAFP Advanced Life Support in Obstetrics Program.

JUDITH A. LOTHIAN is a Professor, College of Nursing at Seton Hall University.

HAROLD D. MILLER is President and CEO of Center for Healthcare Quality and Payment Reform.

TONY OGBURN is a Professor and Chair, Department of Obstetrics and Gynecology at University of Texas Rio Grande Valley.

AMY ROMANO is Senior Vice President, Clinical Programs, Baby+Co.

CAROL SAKALA is Director of Childbirth Connection Programs at National Partnership for Women & Families.

NEEL T. SHAH is an Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School & Harvard T.H. Chan School of Public Health.

Appendix

Summary Table from Main Body of Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing

Improve Maternity Care Through Innovative Care Delivery and Payment Systems and Quality Improvement Initiatives Implement episode payment programs. Implement, assess, strengthen, scale up, and spread maternity care episode payment programs. Implement maternity care homes. Implement, assess, strengthen, scale up, and spread maternity care home programs. Expand high-performing elements of maternity care. Foster increased access to well-integrated high-performing elements of maternity care that minimize overuse and underuse, and foster physiologic processes. Incorporate quality-improvement initiatives. Implement quality improvement initiatives at national, state, health system, facility, and other levels to increase use of practices that foster healthy perinatal physiologic processes. Work as well to use interventions that disturb those processes judiciously. Advance Performance Measurement for High-Value Maternity Care Fill measure gaps. Develop, test, and seek national endorsement for priority standardized performance measures at the clinician or practice, facility, and health plan levels. Prioritize availability and use of high-impact measures with potential to foster women’s and newborns’ experience of healthy perinatal physiologic processes. Measure for quality improvement. Increase use of performance measurement for maternity care quality improvement within federal, state, and private performance measurement programs, with a focus on fostering women’s and newborns’ experience of healthy perinatal physiologic processes. Measure for accountability. Increase use of performance measurement for maternity care accountability at clinician or practice, facility, and health plan levels, including through public reporting, payment, and recognition. Leverage specific measures. Leverage current and future high-impact maternity care performance measures with greatest potential to foster women’s and newborns’ experience of healthy perinatal physiologic processes. Meaningfully Engage All Childbearing Women and Families Develop system enhancements. Transform the maternity care system to reliably support women in actively engaging in their care. Expand communication and education. Develop and implement social marketing programs to encourage and empower childbearing women to understand, value, and seek maternity care from early pregnancy onward that will enhance healthy perinatal physiologic processes. Incorporate birth preferences care planning and shared decision-making. Create and implement birth preferences care plans, with women and providers engaging in shared decision-making using high-quality decision aids to foster informed decision-making and to build and update their birth care plans during pregnancy. Effectively communicate these preferences to all members of the care team. Transition to Interprofessional Education that Supports Maternity Care Professionals for Team-Based Care Educate using an interprofessional model. At undergraduate, graduate, and continuing levels of education of maternity care clinicians, develop, implement, evaluate and publish results, refine, and scale up interprofessional educational curricula and related educational and credentialing elements that ensure shared foundational knowledge and skills for fostering healthy perinatal physiologic processes and the appropriate use of obstetric interventions. Educate on safety and quality. Develop, implement, evaluate, and publish results and refine prevention-focused professional education programs to improve quality and safety by fostering healthy perinatal physiologic processes and reducing the use of interventions and complications as an essential complement to prevailing rescue approaches, and implement these programs widely. Foster an Optimal Maternity Care Workforce Composition and Distribution Better deploy and retain of obstetricians. Encourage obstetricians and other members of the maternity care team to practice at the top of their licenses. Extend the average duration of maternity care practice of general obstetricians–gynecologists. Evaluate and publish results and refine new care models. Expand family physician maternity care participation. Increase the proportion of family physicians providing comprehensive and advanced maternity care. Evaluate and publish results and refine new care models. Grow the midwifery workforce. Increase the number of midwives with nationally recognized credentials—certified nurse-midwives (CNMs), certified midwives (CMs), and certified professional midwives (CPMs)—in active maternity care practice. Ensure fair reimbursement, and enable them to practice to the full scope of their training and competence. Evaluate and publish results and refine new care models. Implement effective laborist care models. Realize the potential of obstetrical and midwifery laborists to address many core challenges in contemporary maternity care and increase women’s access to high-value care that promotes, protects, and supports healthy physiologic perinatal processes. Evaluate and publish results and refine laborist care models. Expand maternity care in rural and underserved areas. Reverse the trend of loss of maternity services in rural and underserved areas to improve timely access to safe, high-quality maternity care, and avoid unneeded intervention. Evaluate and publish results and refine new care models. Conduct Priority Research to Advance the Science of Physiologic Childbearing and Its Impact on Maternal and Child Health Outcomes Conduct perinatal physiologic research. Strengthen system infrastructure and capacity and expand opportunities for research on priority gaps in understanding of healthy perinatal physiologic processes. Conduct perinatal clinical epidemiologic research. Within perinatal clinical epidemiologic research, study the effects of care practices on healthy perinatal physiologic processes in women and newborns. Select appropriate process and outcome variables. Conduct perinatal implementation research. Carry out research to understand how to reliably implement evidence-based maternity care practices that minimize over- and underuse. Address structural factors influencing needed research. Develop networks and build upon existing infrastructural resources that can evolve or adapt to enable greater access to physiologic childbearing practices.