A foundation for envisioning high-quality, high-value maternity care

The Institute of Medicine’s landmark report, Crossing the Quality Chasm, called for a fundamental redesign of the U.S. health care system. The report provided a rational framework for improvement through six dimensions of care. Beginning with this framework, the Transforming Maternity Care Vision Team described how each dimension applies to maternity care, and agreed on additional foundational values and principles for a high-quality, high-value maternity care.

IOM’s Six Aims Applied to Maternity Care

Woman-centered means that care respects the values, culture, choices, and preferences of the woman, and her family, as relevant, within the context of promoting optimal health outcomes. It means that all childbearing women are treated with kindness, respect, dignity, and cultural sensitivity, throughout their maternity care experiences.

  • Pregnancy and birth are unique for each woman. Women and families hold different views about childbearing based on their knowledge, experiences, belief systems, culture, and social and family backgrounds. These differences are understood and respected, and care is adapted and organized to meet the individualized needs of women and families.
  • To promote positive maternity care experiences, care teams engage in high-quality relationships with women and their families, based on mutual respect and trust.
  • Caregivers and settings have a powerful effect on childbearing women. Attention is given to the power of language, communication, and care practices to create a climate of confidence and enhance outcomes of care, as well as women’s childbearing experiences.

Safe means that care is reliable, appropriate, and provided in systems that foster coordination, a culture of safety, and teamwork to produce the best outcomes for women and babies and minimize the risk of harm. Maternity care processes impact outcomes for both mothers and babies; safe care considers and balances the risks and benefits to both recipients, taking into account the health status of each.

Effective means that the care is based on sound evidence applied properly to the circumstances of the individual pregnant woman and her baby to achieve desired outcomes. Effective care minimizes overuse, underuse, and misuse of care practices and services and emphasizes care coordination to prevent duplication, omission, fragmentation, and error.

Timely means that care delivery is structured so that all care is delivered at the time that it is needed. In maternity care, this means that the timing of the onset and course of all stages of labor and the birth of the baby are determined by maternal–fetal physiology whenever possible, and not by time pressures exerted externally without clear medical indication. In the context of informed consent/refusal in maternity care, timely means that whenever possible discussions and information to facilitate women’s decision making around the time of birth are available well in advance of the onset of labor and again as relevant during labor. Finally, unnecessary wait times do not compromise safety, system efficiency, cost effectiveness, and satisfaction with maternity care.

Efficient means that the maternity care system delivers the best possible health outcomes and benefits with the most appropriate, conservative use of resources and technology. Overuse and misuse of treatments and medical interventions are avoided because they waste resources and can result in preventable iatrogenic complications. Similarly, efficient maternity care captures the unrealized benefits from effective underutilized measures.

Equitable means that all women and families have access to and receive the same high-quality, high-value care. Any variation in maternity care practice is based solely on the health needs and values of each woman and her fetus/newborn, and not on other extrinsic, non-medical factors. Furthermore, an equitable maternity care system addresses disparities in the baseline health status of women related to class, race, ethnicity, and language to ensure optimal maternity care outcomes and experiences for every woman and her children.

Further Foundational Values and Principles for Maternity Care

In addition, the following values and principles are foundational to our vision for a maternity care system of highest quality and value.

Life-changing experience. Pregnancy, labor and birth, and the early postpartum and newborn period are important life-changing and memorable times in the lives of women and their families. Taken together, they represent a time of great opportunity to promote and improve health, because women and families often are greatly motivated to improve their lives at this time. The outcomes and experiences of childbearing have wide-ranging impact.

Care processes protect, promote, and support physiologic childbirth. Women and their fetuses/newborns share complex innate, mutually regulating, hormonally driven processes that constitute the biological foundation for childbearing. These physiologic neuroendocrine feedback mechanisms facilitate the period from the onset of labor through birth of the baby and placenta, as well as the establishment and continuation of breastfeeding and the development of mother–baby attachment. These processes confer physical, psychological, and social benefits. The complex hormonal orchestration of the process of parturition taken in its entirety constitutes physiologic childbirth.

Effective care with least harm is optimal for childbearing women and newborns. This entails conservative, preventive practices and support for physiologic childbearing for all women and babies without significant complications, for whom unnecessary intervention is likely to incur more harm than benefit. The majority of childbearing women are healthy and have good reason to expect an uncomplicated pregnancy and birth and a healthy newborn. Thus, practice variation for low-risk women is minimized under the principle that any intervention in the physiologic processes of pregnancy and childbirth must be shown to do more good than harm. Higher levels of care are only appropriate for those with a demonstrated need. Women and fetuses/newborns who experience complications, adverse situations, and unexpected outcomes require additional treatment and support tailored to their individual needs.

To this end, all providers of maternity care recognize, protect, promote, and support physiologic childbirth; respond appropriately to complications; and receive adequate training to do both. Protection of physiologic childbearing involves avoiding disruption and interference (e.g., unnecessary interventions, noise, personnel), promotion involves the health system (e.g., research, education, measurement, policies, values), and support involves skillful facilitation (e.g., comfort measures, encouragement, supportive care).

Care is evidence-based. Maternity care policy and practice evolve with the emergence of new research evidence and new ability to refine research methods. There is a focus on continuous critical appraisal of the existing research literature and investment in the ongoing study of the comparative effectiveness of a wide array of practices and approaches in maternity care, using a variety of validated methodologies in keeping with the mandate of the ‘‘Sicily Statement on Evidence-Based Practice,’’ to continue to advance toward optimal care, defined as effective care with least harm, for all childbearing women and their fetuses/newborns.

Quality is measured and performance is disclosed. Quality measurement and disclosure through public reporting are essential features of a high-performing maternity care system. They are critically important to those who seek, provide, purchase, and pay for maternity care. System capacity is enhanced to evaluate and report the quality and outcomes of care at clinician, facility, health plan, and other levels. Both performance measurement and public reporting are inherent in the obligation to advance knowledge of the effects of care. A comprehensive set of nationally endorsed, evidence-based consensus standards to assess the quality of prenatal, intrapartum, and postpartum services is in place to foster system-wide capacity for quality improvement, and these standards are regularly incorporated into care at all levels. Consumers have excellent support for understanding and using performance measures and other quality measures to make informed health care decisions. Health professionals and systems have ready access to reliable measures to support continuous quality improvement. Purchasers and payors have access to results of performance measurement to inform value-based purchasing decisions.

Care includes support for decision making and choice.

  • Decision making. Support for shared decision making is built into care at every level. Shared decision making is an ongoing, interactive process that takes place between childbearing women and their caregivers. To make fully informed decisions, women receive complete, objective information based on the best available research. This includes information about known benefits, harms, and areas of uncertainty associated with care offered to them, and with other available options, including the decision to avoid intervention. Such information is available to all women in a variety of consumer-friendly formats through trustworthy sources. Consistent with highest standards for informed consent and informed refusal processes, such information is discussed in a shared decision making process that allows for the desired level of family involvement, conducted in language that is understandable and at a time that is conducive to optimal information processing, whenever possible. It includes support in the form of decision aids, values clarification, and discussions of risk expressed in terms of probability.
  • Choice. Women have the opportunity and the responsibility to make informed choices about their care from early pregnancy through the postpartum period. The ultimate control over choices surrounding the events of pregnancy and birth resides primarily with the woman, who has access to the full range of safe and effective care options, including choice of care providers, care settings, family participation, labor companions, help with labor pain, mode of birth, and infant feeding method. Following a supportive, shared decision making process, caregivers respect and honor a woman’s informed choices and her right to change her mind.

Care is coordinated. Highest quality and value in maternity care are increased through seamless, effective coordination of care across settings and disciplines to maximize safety and efficiency and reduce waste. Care is coordinated to best meet the needs of mothers and their fetuses/newborns through effective teamwork, communication, coordinated management of care plans and provider responsibilities, medication reconciliation, and other shared information using electronic health records and interoperable data systems. There is particular attention to transitions of care, including from pregnancy to childbirth to postpartum care, and between settings or providers of care, to ensure consistent consideration of the woman’s health history, values and wishes, plan of care, medications, and evolving needs.

Caregiver satisfaction and fulfillment is a core value. Caring for women, babies, and families during the critical time from pregnancy through the early postpartum period is both a great honor and a joy. To experience it as such, all caregivers in the maternity care system have a safe and respectful environment in which to practice, grow, and learn. This system welcomes and values caregiver contributions. It has and supports high standards of performance and respects the human needs and limits of providers. A just culture, grounded in a systems perspective and founded on appropriate assignment of accountability rather than individual blame, also protects caregivers from harm, and encourages continuous learning and professional development to maximize professional fulfillment and the ability to provide high-quality care.