Transforming Maternity Care


It is increasingly clear that the United States is in a maternity care crisis. Use of interventions is rampant, and the benefit of these procedures is often inversely proportional to the rate at which they are used.1 In 2008 (the most recent year for which data are available), the cesarean rate rose for the 12th straight year to 32.3% of all births, the highest rate ever recorded in this country.2 The problems within the US maternity care system are big, and big problems need big solutions. Enter Childbirth Connection's Transforming Maternity Care project.

Transforming Maternity Care is a sweeping and dynamic project with the goal “to improve the care that is provided to childbearing women and newborns by improving the systems in which care is delivered.”3 Key documents from this project were recently published in a supplement to the January/February 2010 issue of the journal Women's Health Issues. The primary background document for the project is the landmark report Evidence-Based Maternity Care: What It Is and What It Can Achieve,1 which was discussed in a previous editorial in this Journal.4 Be sure to put the supplement and report on your required reading list if you have not yet read them. They are essential and invaluable resources for all midwives and women's health care providers.

The Transforming Maternity Care Project is a collaboration that involves multiple steps and stakeholders.5,6 One of the first steps was the development of the 2020 Vision for a High-Quality, High-Value Maternity Care System.7 This vision was formulated by a 12-member interdisciplinary team to describe the desired maternity care system, which was used as the starting point for developing a plan to fix the current system. The vision paper7 describes the process by which the 2020 Vision was created; discusses values and principles for a high-quality, high-value maternity care system; and presents key goals for four levels of care: women and their support networks, microsystems that provide direct care, health care organizations, and the macro environment. The 2020 Vision comes to life in an accompanying allegory that provides a vivid and compelling illustration, through narratives of two women's birth stories, of how the current and envisioned maternity care systems affect individual women.8

The 2020 Vision was given to five workgroups of stakeholders who represented: 1) quality and measurement experts; 2) consumers and their advocates; 3) maternity care clinicians and health professions educators); 4) hospitals, health systems, and other care delivery models; and 5) health plans, public and private purchasers, and liability insurers. The diverse individuals in these workgroups were charged with developing priority strategies to move toward the 2020 Vision for the maternity care system. Each workgroup developed a report and recommendations, which are available in their entirety on the Childbirth Connection website.9

The workgroup reports and recommendations were presented at the Transforming Maternity Care: A High Value Proposition policy symposium in April 2009 in Washington, DC. Nearly 250 individuals with a wide range of interests and involvement in maternity care attended this symposium, and I was privileged to be among them. When Symposium Program Director Rima Jolivet, CNM, MSN, MPH introduced the presentation of the 2020 Vision, she commented this is “a time of tremendous momentum… [at a] tipping point in maternity care quality improvement.”10 Her words are a great description of what it was like to be in that room with the incredible level of energy and enthusiasm. There was a real sense of urgency that something could and would be done. The Women's Health Issues supplement includes the symposium proceedings with a summary of the workgroup reports, remarks of panelists invited to respond to the reports, and comments from the audience.10

After the Symposium, the workgroup reports and recommendations were synthesized into the Blueprint for Action: Steps toward a High-Quality, High-Value Maternity Care System, which answers the question “who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years.”11 The Blueprint for Action identifies 11 critical focus areas for moving toward the 2020 Vision (see Table 1). Current problems, system goals, major recommendations and action steps, and lead responsibilities are identified for each of these critical focus areas. While the Blueprint for Action is large in scope, it is also specific. It breaks down the overwhelming, and sometimes seemingly impossible, goal of fixing the maternity care system into specific, workable steps. Midwifery is present throughout the Blueprint for Action, and recommendations include expanding access to mid-wives, providing midwives equal access to liability insurance, and reducing barriers to midwifery practice.

Table 1.  Critical Focus Areas to Improve Maternity Care Quality and Value
  1. Source: Angood et al.11

• Performance measurement and leveraging of results
• Payment reform to align incentives with quality
• Disparities in access and outcomes of maternity care
• Improved functioning of the liability system
• Scope of covered services for maternity care
• Coordination of maternity care across time, settings, and disciplines
• Clinical controversies (home birth, vaginal birth after cesarean [VBAC], vaginal breech and twin birth, elective induction, cesarean without in dication)
• Decision making and consumer choice
• Scope, content and availability of health professions education
• Workforce composition and distribution
• Development and use of health information technology (IT)

The 2020 Vision introduces the values and principles of the envisioned maternity care system with the following description:

The mission of a maternity care system that delivers the highest quality and value is to achieve optimal health outcomes and experiences for mothers and babies through the consistent provision of woman-centered care grounded in the best available evidence of effectiveness with least risk of harm, and the best use of resources. Such care is provided in ways that are safe, effective, timely, efficient, and equitable for all women and their families. The ideal maternity care system protects, promotes, and supports physiologic childbirth, and optimal experiences for childbearing women based on shared decision making and respect for informed choice; provides care that is coordinated, evidence-based, and subject to ongoing performance measurement and quality disclosure; and promotes a work environment that is satisfying and fulfilling for its caregivers.7

The time has come to make this vision a reality by implementing the Blueprint for Action. Visit the Transforming Maternity Care Partnership section of the Childbirth Connection website12 to learn more and join the action community. The 2020 Vision is the destination, and the Blueprint for Action is the map. Now the journey begins to transforming maternity care.