Have you heard? 94% of U.S. births involve some kind of complication. That was the headline-inducing take-away from a statistical brief prepared by researchers at AHRQ’s Healthcare Cost and Utilization Project (HCUP) in May. Childbirth Connection prepared an analysis of the brief and shared our response with HCUP staff, who expressed appreciation and invited our input and feedback on forthcoming reports. We continue to see the statistical brief referenced without the necessary context, so we are sharing our response more widely. Please share your thoughts in the comments, and let us know how you think HCUP data can best be used to improve maternity care quality and value. If you could write the next statistical brief on maternity care, what data would you be interested in presenting?
Putting Complications Data in Perspective: A Response to AHRQ/HCUP Statistical Brief #113: Complicating Conditions of Pregnancy and Childbirth, 2008 (May 2011)
A new statistical brief recently released by the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality (AHRQ) reports that 94% of U.S. births in 2008 involved one or more complicating conditions (Elixhauser 2011). Childbirth Connection sees the collection and reporting of maternity care data as a priority for achieving a high-quality, high-value maternity care system. However, we are concerned that, without putting reports such as this in perspective, these data – and media interpretations of them – may provide misleading inflated views of risks of childbearing and reinforce the perception that a majority of women need high-technology, resource-intensive approaches to manage these risks and complications.
In fact, a skewed understanding of population risks may be making efforts to improve maternity care more difficult. The 2008 report, Evidence-Based Maternity Care: What It Is and What It Can Achieve (Sakala 2008), jointly issued by Childbirth Connection, the Milbank Memorial Fund and Reforming States Group, documented the overuse of many risky and costly obstetric interventions and concluded that, among other drivers of poor quality care:
as standards of maternity care and the culture of maternity care shift…fewer and fewer professionals, administrators, policymakers, journalists, and women themselves have a frame of reference for what is appropriate care, and it is becoming difficult for all stakeholder groups to know what care is possible and optimal and to provide and seek such care (p. 67).
In light of these considerations, Childbirth Connection has prepared this response to the Statistical Brief to provide context for individuals trying to interpret the data. Our response addresses concerns and questions raised by the Statistical Brief about:
- the state of maternal and newborn health in the U.S.
- how we measure and report pregnancy and birth complications
- how payment systems may contribute to overreporting of some complications, and how payment reform can align incentives with quality
- how current practice patterns may contribute to maternal complications, and opportunities for quality improvement
Maternal and newborn health
The Statistical Brief reports high rates of preterm labor and blood pressure problems such as preeclampsia. Despite their frequency and serious consequences – including life-long physical, developmental and behavioral effects – the United States has made little progress in the prevention of these conditions. Although preterm birth rates have decreased slightly in recent years, the 2008 rate remains higher than it was throughout the 1990s (Hamilton 2010). Despite decades of research, there are no known effective strategies for prevention of preeclampsia (Steegers 2010), a leading cause of maternal death. The persistence of these two conditions contributes to the poor overall performance of the U.S. maternity care system. Many countries achieve better maternal and newborn outcomes than the United States, and spend far less on maternity care (Childbirth Connection 2011).
Due to lack of standards for diagnosing these conditions and the limitations of administrative, billing, and vital records data, serious maternal complications are difficult to measure and track using national data sets such as HCUP. Better tracking and more granular understanding of these conditions are priorities for data collection and reporting efforts.
Measuring pregnancy and birth complications
The Statistical Brief reports that 94% of births in 2008 involved at least one “complicating condition”. Reported conditions include those that are categorized as complications of pregnancy, delivery, or the postpartum period based on billing diagnosis codes. The list of complicating conditions included serious conditions such as those discussed above, as well as:
- common complications that are minor and lead to minimal if any short-term or long-term harm. Examples include the umbilical cord looped around the neck (18% of births) and superficial (first degree) lacerations of the perineum (16%).
- common conditions that are risk factors for poor outcomes but are not in fact complications. Examples include advanced maternal age (12% of births), prolonged pregnancy (12%), and history of prior cesarean (17%).
- conditions for which reported prevalence is highly dependent on screening tests that are unreliable or the clinical judgment of individual caregivers. Examples include gestational diabetes (7% of births), abnormal fetal heart rhythm (15%), obstructed labor (baby doesn’t fit through the pelvis, 5%), and uterine inertia (prolonged labor, 8%).
- preventable complications that result from the overuse of obstetrical procedures such as induction of labor, cesarean section, and episiotomy. Examples include placental complications (2% of births), postpartum hemorrhage (3%), and severe (third and fourth degree) perineal lacerations (2%).
- concerns that can be often be corrected with appropriate guidance and care. Examples include genitourinary infections (13% of births), anemia (12%) and breech presentation (3%).
The contribution of many minor, subjective, preventable, and iatrogenic (caused by medical intervention) conditions and risk factors appears to account for a significant proportion – or even the majority – of complications noted in the Statistical Brief.
Paying for Maternity Care
The current system ties payment to complications, risk factors, and procedures. Although some increased payment for more complicated pregnancies is appropriate, the current payment system creates incentives to designate more women as high risk and lacks incentives for providing care that keeps women and babies healthy and low-risk (Angood 2010). In addition to the factors mentioned above, high rates of complicating conditions reported in the Statistical Brief may reflect financial rewards for discretionary “upcoding” to more complicated conditions, along with underuse of effective preventive care processes such as smoking cessation therapies and continuous professional labor support that may not be adequately reimbursed.
Practice patterns and opportunities for quality improvement
The Statistical Brief reports high rates of modifiable risk factors and preventable complications. Research has demonstrated that the prevalence of these conditions is impacted by practice patterns and may be reduced with quality improvement efforts. For example, rates of severe (third and fourth degree) perineal lacerations are highly dependent on episiotomy rates, which vary 10-fold or more across providers and settings (Howden 2004, Goode 2006), despite evidence that frequent or routine use of episiotomy is ineffective and harmful (Carroli 2009). Fetal heart rate abnormalities and fetal distress can result from overuse or misuse of artificial oxytocin, and hospitals that have instituted standard, evidence-based protocols for use of this high-alert medication have shown reductions in such fetal complications (Clark 2008).
Careful interpretation of the data presented in the new HCUP Statistical Brief provides needed context for individuals considering what constitutes optimal care in pregnancy and birth. It also suggests many opportunities to improve data collection and presentation, payment for and delivery of maternity care, and maternal and newborn health. Childbirth Connection convened more than 100 health care leaders and maternity care stakeholders to define the steps and actions needed to improve the quality and value of maternity care (Angood 2010). The consensus Blueprint for Action, which addresses data collection and reporting, payment reform, clinical quality improvement, appropriate preventive care, and many other areas, can be accessed at http://transform.childbirthconnection.org/blueprint.
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2. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2009;(1)(1):CD000081.
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4. Childbirth Connection. United States maternity care facts and figures. New York: Childbirth Connection; 2011. Available for download at http://transform.childbirthconnection.org/resources/datacenter/factsandfigures/
5. Elixhauser A, Wier LM. Statistical brief #113: Complicating conditions of pregnancy and childbirth, 2008. Rockville, MD: Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality; 2011. Available for download at http:// www.hcupus.ahrq.gov/reports/statbriefs/sb113.pdf
6. Goode KT, Weiss PM, Koller C, Kimmel S, Hess LW. Episiotomy rates in private vs. resident service deliveries: A comparison. J Reprod Med. 2006;51(3):190-192.
7. Hamilton BE, Martin JA, Ventura SJ, M.A., Division of Vital Statistics. Births: Preliminary data for 2009. National Vital Statistics Report. 2010;59(3):1-14.
8. Howden NL, Weber AM, Meyn LA. Episiotomy use among residents and faculty compared with private practitioners. Obstet Gynecol. 2004;103(1):114-118.
9. Sakala C, Corry MP. Evidence-based maternity care: What it is and what it can achieve. New York: Milbank Memorial Fund; 2008. Available for download at http://www.childbirthconnection.org/ebmc
10. Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010;376(9741):631-644.