The Lancet Maternal Health Series published in September 2016 contains six papers highlighting the importance of improving access to high quality maternal health care for all women across the globe. In paper 4, “Drivers of maternity care in high-income countries: Can health systems support women-centred care?” Shaw and colleagues review different models of maternity care, address key influential factors and offer insights into strategies for improving the quality of maternity care in high-income countries (HICs).
Maternity care models
The majority of women in HICs deliver in some sort of health facility with a skilled birth attendant—either an obstetrician or a midwife. Other than in the Netherlands, home birth is uncommon, perhaps due to mixed results on the relative safety of home birth for mothers and infants. The prevalence of over-intervention during childbirth varies among HICs. The percentage of women who labor with an epidural ranges from less than 10% in Germany to 82% in France, and the cesarean section rate ranges from about 17% in the Netherlands, Sweden, Finland and Norway to about 32% in the United States and Australia. Overall, there has been a trend in HICs toward centralizing care by closing smaller facilities, especially in rural areas, forcing women to travel farther distances to access care. The authors include two case studies to exemplify key differences in models of maternity care in the United States and Sweden.
Most women in the United States deliver with an obstetrician, despite evidence that for women with low-risk pregnancies, midwifery-led units have comparable rates of adverse perinatal outcomes, lower rates of medical interventions during labor and higher patient satisfaction. The fee for service model and fear of malpractice litigation in the United States create incentives for providers to intervene with inductions and cesarean deliveries, sometimes without medical indication. Childbirth costs much more in the United States than in other HICs: As of 2015, the average vaginal delivery costs $10,232 and the average cesarean delivery costs $15,591. However, hospital-level cesarean rates vary from 6% to 70% even after taking these financial factors into account.
In many other HICs with lower rates of obstetric intervention, women with low-risk pregnancies are cared for by midwives, and obstetricians only tend to those at higher risk of developing pregnancy or childbirth-related complications. This approach is taken in Sweden, whose maternal mortality ratio (MMR) is among the lowest in the world at 4 deaths per 100,000 live births. Additionally, health facilities in Sweden are required to publish data on quality indicators such as cesarean section rates and complications, and maternity care—including contraceptive counseling—is publicly funded. With the exception of the United States, all HICs offer paid maternity or family leave, further reducing the financial burden of having a baby.
Improving quality of care
There are a number of opportunities within the maternity care system to improve quality. Some studies have found that involving midwives and laborists (obstetricians who provide only labor and delivery services) is associated with substantial reductions in cesarean rates. Midwifery-led care can take place in numerous settings, including at home, in freestanding birth centers, in low-risk units alongside maternity hospitals and as a part of team-based care within maternity hospitals. These models tend to yield lower intervention rates, better outcomes and reduced costs. Team-based quality improvement tools such as simulated training for obstetric emergencies and patient safety reviews have been effective. Innovative models that incorporate telehealth and group-based care have also had some success, although further evaluation is needed. Maternal mortality surveillance is essential: Collecting, analyzing and distributing comprehensive disaggregated data, conducting audits at national and local levels and holding maternal death reviews provide opportunities to learn from past mistakes and prevent them from happening in the future. Considering system-level factors is necessary in order to optimize birth outcomes and women’s experiences in HICs and across the globe.
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Graph: Shaw et al. Drivers of maternity care in high-income countries: Can health systems support women-centred care? The Lancet Maternal Health Series, 2016.