This page is excerpted from the 2020 Vision Report and summarizes the goals and features of a high-quality, high-value maternity care system. You can also read Two Birth Stories: An Allegory to Compare Experiences in Current and Envisioned Maternity Care Systems to better understand what high-quality, high-value maternity care is – and what it isn’t.
In 2002, Donald Berwick published A User’s Manual for the IOM’s ‘Quality Chasm’ Report. In it, he described the framework that its authors used to plan, discuss, and propose health system change and redesign. The Vision Team used Berwick’s paradigm of four levels of care (labeled A through D) to achieve granularity and specificity in looking at maternity care system change. When applied to maternity care, the four levels are:
- A) the experience of women, their families and support networks
- B) the clinical microsystems that provide direct maternity care
- C) the hospitals and health care organizations that house and support clinical microsystems
- D) the environment of policy, payment, regulation, accreditation, litigation, and other macro-level factors that influence the delivery of maternity care
The group generated goals for each level of care. Features of care that apply across the continuum of maternity care were incorporated into the Values and Principles, and features specific to a particular phase of care were incorporated into the summary of goals for that phase (during pregnancy, around the time of birth, and after birth).
Care Levels A and B: Women and Their Support Networks, and the Microsystems That Provide Direct Care
Applying Berwick’s framework (2002) of four levels of care to the maternity care system, this section addresses key goals and principles for Care Levels A and B: women and their support networks, and the microsystems that provide direct care to them. It proposes a vision for the care experience of women and their support networks within a high-quality, high-value maternity care system, and describes the essential attributes and characteristics of the microsystem that reliably delivers such an experience.
Maternity care at Care Levels A and B is divided into three phases. The vision begins with a set of goal statements for each phase of maternity care—care during pregnancy, care around the time of birth, and care after birth—that describe the optimal experience of care from the perspective of the woman and her family and support network. This is followed by a description of the criteria for key participants and the principles that inform decisions about who takes part in providing high-quality, high-value care during each phase.
Principal considerations concerning decisions about settings, locations, or the environment of care that are conducive to the realization of the vision goals in each phase are also described.
- Each woman is engaged as a partner in her own care and education during pregnancy; she receives affirmation and practical support for her role as the natural leader of her care team to the extent that she so desires, and is encouraged to provide input to shape her own care.
- Each woman’s preferences are known, respected, and matched with individually tailored care that meets her needs and reflects her choices during pregnancy, delivered by a care team whose composition is also customized based on her needs and preferences.
- Each woman has access to complete, accurate, up-to-date, high-quality information, decision support, and education to help ensure that she feels emotionally and psychologically prepared to make decisions during her pregnancy, and confident about her birth care options and choices well in advance of the onset of labor.
- Education and care during pregnancy are designed and delivered to be empowering to women, emphasizing a climate of confidence.
- Education and care during pregnancy include support for breastfeeding; most women make decisions about infant feeding well before they give birth.
- Each pregnant woman receives personalized coaching and has access to high-quality resources for comprehensive health promotion, disease prevention, and improved nutrition and exercise for optimal wellness during her pregnancy.
- Care during pregnancy is available when needed and can be accessed in a time and place that is convenient and accessible for each woman, as balanced with concerns for value and efficiency.
- Care during pregnancy acknowledges the social context in which pregnancy occurs for each woman and includes opportunities for social networking and access to adequate professional and peer support during pregnancy.
- Each woman has a comfortable, confident relationship of trust with her birth care provider(s).
- Each woman is engaged as a partner in her own care around the time of birth; she receives affirmation and practical support for her role as the natural leader of her care team and approaches birth prepared and confident to express her preferences and make informed choices about key decisions for labor and birth.
- Each woman can decide where to labor and give birth as appropriate based on her health status and that of her fetus/baby; she is free to make this choice without judgment and can change her mind without sanction, as an array of risk-appropriate birth setting choices is available and supported system wide.
- Low-risk women planning hospital birth remain at home during early labor with adequate support and appropriate contact with their care team.
- All maternity caregivers have knowledge and skills necessary to enhance the innate childbearing capacities of women. Each woman is attended in labor and birth in the manner that is most appropriate for her level of need and that of her baby and experiences only interventions that are medically indicated, supported by sound evidence of benefit, with least risk of harm compared with effective alternatives. Women and babies at high risk for complications for whom a higher level of specialized care is appropriate have specialty care available to them that adheres to the same basic values and principles.
- Each woman is well-supported physically and emotionally throughout labor and birth; continuous labor support is built in to maternity care.
- Each woman has access to a full-range of evidence-based, nonpharmacologic and pharmacologic strategies for pain management and relief as appropriate to each birth setting and to staff that is trained to implement them effectively.
- Providers are trained to maintain skills and have system support to offer the fullest range of management options supported by evidence for women with special clinical circumstances.
- Mothers and babies routinely stay together, skin to skin, receiving evidence-based care, support, and minimal disruption in the minutes and hours after birth to promote early attachment and the initiation of breastfeeding, whenever neither requires specialized care at this time.
- Each woman, baby, and family receives care that effectively addresses their needs starting in the immediate postpartum period, and extending seamlessly forward across time, settings and disciplines to anticipate and respond to both continuing and new-onset mental, physical, and social needs that may develop throughout the first year of life and beyond.
- Each woman receives strong support for breast- feeding through an array of community-based resources and the implementation of workplace supports for breastfeeding.
- Each woman receives strong support for mother– baby attachment that includes educational offerings, experiential learning opportunities, and peer group support available through a web of services and support systems.
- Each woman has adequate help to cope with the challenges of the period after birth, including physical changes, shifting priorities, changes in primary relationships, family planning, and is- sues related to sexuality, isolation, mother–baby codependence, and postpartum depression and other mood disorders. Care at this time includes opportunities to connect with people and ser- vices through innovative mechanisms and delivery models that emphasize community and social networking, and facilitate the development of longitudinal supportive relationships.
- Each woman receives practical support at home as needed to cope with increased demands and fatigue in the period after birth and to develop confidence in her competence as a new mother. Each woman has access to social support, health care services and information, and practical advice and assistance in the period after birth. To this end, given consideration for value and efficiency, maternity care extends beyond the direct provision of health care services to routinely include postpartum services that facilitate optimal family development. This helps to ensure that each woman is valued and supported by society in her role as a new mother.
The goals for maternity care are best met by implementing a holistic, relationship-based model of care that is woman-centered, inclusive, and collaborative. Caregivers are included as dictated by the health needs, values, and preferences of each woman, taking into account her social and cultural context as she de- fines it, and given consideration for evidence of effectiveness, value, and efficiency.
In each phase, starting with Care During Pregnancy, maternity care is a team endeavor coordinated by a primary maternity care provider. Qualified primary providers of maternity care have completed an accredited education program, passed a board certification examination with a mechanism for certification maintenance, and are legally licensed to practice within their jurisdiction. Professional cooperation is a system priority. There is innovation to formalize the inclusion and effective functioning of more multidisciplinary team roles. The rules and systems of care are rewritten to make room for the advent of a variety of complementary coaches, advisors, and experts, who may be involved according to their scope of practice and as desired by each woman and indicated by her individual health needs and those of her fetus.
For Care Around the Time of Birth, each woman is able to assemble the team of caregivers that best meets her needs for ample support and safe, effective care with least risk for harm during labor, birth, and the immediate postpartum period. The goal of the birth care team is to optimize her health outcomes and care experience during this critical time and to protect, promote and support her innate ability to give birth while providing for her individual health needs and those of her fetus.
Care After Giving Birth is envisioned as a team endeavor orchestrated around, and directed by, the needs of each woman to provide optimal care for her, for her baby, and for her family. During this vulnerable developmental period, each woman’s care is coordinated by a primary caregiver with postpartum care competencies.
For all maternity care phases, safe, effective care is available to women in the locations that are most convenient and accessible to them, given consideration for value and efficiency. The environment of care in all set- tings is designed to be woman-centered and to facilitate the realization of goals for care during this phase. Specific elements of design that may contribute to achieving these goals are considered.
An array of community, ambulatory and hospital-based choices for Care During Pregnancy optimizes the possibilities for each woman to take advantage of this time of great opportunity to make improvements in her life and overall health, and to prepare for giving birth and parenting.
For Care Around the Time of Birth, a full range of safe birth settings is available and receives system-wide support, so that each woman is free to choose the setting that is most appropriate for her level of need and that of her fetus/baby and that best reflects her values, culture, and preferences. This choice can be made with confidence because each setting assures her a consistent standard of safe, effective, risk-appropriate care, within an integrated system that provides for coordinated consultation, collaboration, or transfer in either direction should her level of need or that of her baby change.
An expanded choice of settings for Care After Giving Birth continues the possibilities for each woman to make effective use of this time of opportunity for improving her life and overall health, and that of her family. To that end, care after birth is community-based, situated within the social context of the woman, and founded on a holistic model that prioritizes wellness and preventive services.
Applying Berwick’s framework of four levels of care to the maternity care system, this section addresses key goals and principles for Levels C and D: the hospitals and health care organizations that house and support clinical microsystems, and the greater environment of health care policy, payment, regulation, accreditation, litigation, and other macro-level factors that influence the delivery of maternity care. This section describes a vision for the key attributes and characteristics at the macro levels of a high-quality, high-value maternity care system that can best support the goals put for- ward for the care experiences of women and babies receiving maternity care and the microsystems that directly provide such care.
Level C: Health Care Organizations
This section outlines the goals for the system features and roles of health care organizations providing maternity services within a high-quality, high-value maternity care system.
To strengthen the structure of the maternity care delivery system.
- Health care organizations align the capacity for community-level, multidisciplinary, multiservice maternity and family wellness care and the capacity for acute maternity care to be commensurate with the needs of childbearing women and families.
- Health care organizations providing maternity care shift their focus to be primarily community- based and wellness-centered, with regionalized tertiary care settings focusing specifically on the specialized needs of high-risk women and babies. Health care organizations fulfill the role of regional maternity care coordinators, integrating maternity care across settings, providers, and levels of care.
- The role of hospitals with maternity services is not only to provide inpatient maternity care with a focus on the highest level of risk, but also to provide support, training, back-up, and resources to com- munity-based maternity care centers and service providers, including well woman and well baby services.
To strengthen the maternity workforce.
- Health care organizations providing maternity services restructure care to deploy the most appropriate providers for wellness care during the childbearing cycle, making best use of primary care providers and paraprofessionals, with mechanisms to ensure that the most appropriate, most cost-effective level of care is provided to each woman and baby according to their needs.
- Health care organizations, through their policies and programs, ensure that all maternity care providers are skilled in best practices for protecting, promoting, and supporting physiologic labor and birth.
- Health care organizations provide leadership in promoting and supporting professional cooperation through high functioning multidisciplinary team models for maternity care rather than individual provider models and silos that separate maternity caregivers from one another and from other relevant health care fields.
- Health care organizations give attention to staffing of maternity care personnel to foster professional work/life balance in a manner that enables provision of high-quality maternity care.
To foster high-quality maternity care.
- At the leadership level, all health care organizations embrace and incentivize quality measurement and reporting, and quality improvement programs aimed at fostering the provision of effective care with least harm and improving the processes, structures, and outcomes of maternity care, as well as the experiences of childbearing women and families.
- All health care organizations collect, evaluate, and make publicly available data about performance in maternity care.
- All health care organizations provide maternity care staff with access to electronic databases, resources, clinical tools and programs to promote safety, care coordination, quality improvement, and continuous learning.
- Health care organizations participate in and provide a locus for clinical and comparative effectiveness research to contribute to better understanding of the full range of effects of maternity care treatments and practices in the uncontrolled settings and diverse patient populations in which they are used.
- Health care organizations participate in integrated systems of care provided on a regional basis, including maternity care quality collaboratives designed to address disparities of care based on geography, socioeconomic status, race and ethnicity, and language.
To provide woman- and family-centered care.
- Maternity care is organized, structured, formatted, and delivered to meet the needs of the individual and the community rather than the institution. The timing, duration, interval, setting, format, and content of maternity care prioritize the consumer/patient perspective.
- Health care organizations collect feedback from all women and their families regarding their ex- periences of maternity care and use the informa- tion for continuous quality improvement.
- Health care organizations convene quality boards with representation from users of the maternity care system and their advocates to participate in shared governance.
- Health care organizations test innovations to in- crease maternity care access and community- based services.
Level D: Macro Environment of Care
This section outlines the goals for the system features and roles of the environment of policy, payment, regulation, accreditation, litigation, and other macro-level factors that influence the delivery of care within a high-quality, high-value maternity care system.
To strengthen performance measurement.
- A comprehensive set of national standardized evidence-based maternity care performance measures, including measures of process, structure, outcome, access, and patient experience of care, is developed and maintained to foster a high standard of effective care with least harm; these measures are widely applied and transparently reported and all accrediting bodies reinforce them.
- Performance data are collected and shared in a manner that permits calculation of performance benchmarks and subpopulation analysis to ad- dress disparities in maternity care access, quality, and outcomes according to geography, socioeconomic status, race, ethnicity, and language.
- There is a mechanism for ensuring meaningful consumer engagement in the development, assessment, and reporting of maternity care performance measures.
- In all professions providing maternity services, certification and recertification are linked with performance and improvement on measures of quality and safety.
- Benchmarking for maternity care quality is organized through national organizations, regional and state organizations, and multi-stakeholder quality collaboratives.
To improve the functionality of payment systems.
- There is a comprehensive health care system in the United States that includes maternity care coverage for all women and newborns.
- Medicaid and other payors analyze positive, negative, and perverse incentives and align financial incentives with optimal care. Payors monitor and foster quality improvement through contracting and payment systems with individual, group, and facility care providers that reward the provision of effective care with least harm and desired outcomes, and do not provide financial incentives for inappropriate care.
- Health and employee benefits plans offer women and families financial incentives for choosing maternity care, including practices, providers, and settings, associated with the best outcomes for the most efficient use of resources, while preserving women’s choice among comparably effective options.
- There is reimbursement for health education and expanded preventive services across the child- bearing continuum through a redesigned package of priority maternity care services, as supported by current evidence of enhanced health outcomes and good value.
- Payors explore and pilot value-based payment system alternatives to the present reimbursement system for maternity care services and track their impact on rates of intervention and harm, re- source utilization, and maternity care outcomes.
- There is equitable reimbursement through the Centers for Medicare and Medicaid Services, and other public and private payors for equivalent care provided by all types of qualified maternity care providers.
To strengthen professional education and guidance.
- The content of health professions education and continuing education for all maternity caregivers emphasizes critical appraisal skills for ongoing evaluation of the quality and relevance of evidence on maternity care practices and their effects, and confers adequate knowledge, skills and judgment for the protection, promotion, and support of physiologic childbearing.
- An independent multi-stakeholder body develops, collects, updates, and disseminates evidence-based practice guidelines and decision tools for maternity care through processes that are transparent and governed by multiple stake-holders.
To close priority gaps in research.
- Comparative effectiveness and outcomes research, supported through federal funding, helps to refine the evidence base for maternity care and identify variation in processes and structures that have the greatest impact on outcomes. These data inform the development of maternity care guidelines and performance measures, the provision of maternity care, the reimbursement of maternity services, and professional and consumer education.
- There is a multi-stakeholder process that includes meaningful consumer engagement for identifying research priorities for comparative clinical effectiveness to avoid financial and industry conflicts of interest and to ensure funding for studies of clinical importance and high value to the public.
- There is targeted federal funding to support re- search on quality measurement and quality improvement in maternity care.
- It is a national priority to learn more about the physiology of labor and to evaluate the outcomes of physiologic management of labor in comparison with usual care practices, through randomized, controlled trials and using other comparative effectiveness methodologies.
- It is a national research priority to evaluate long- term effects of health care treatments and interventions, nutrition and lifestyle, and environmental exposures during the childbearing cycle.
- A national entity supports practice-based research networks that collect, measure, analyze, and feedback data to maternity care providers in outpatient microsystems.
To improve the functioning of the liability system.
- As a complement to safety and quality initiatives, a system that is fair and equitable for patients and providers handles compensable adverse events and maternity claims to reduce the likelihood that fear of litigation will compromise the provision of effective maternity care with least harm.
- As a complement to safety and quality initiatives, the functionality of the liability insurance system is improved through regulatory intervention and by better integrating it with health insurance, the source of payment for liability costs.
To pursue other strategies for fostering high-quality maternity care.
- Interoperable health information technology systems are in place for providing high-quality clinical care and coordination, and for capturing and sharing maternity care performance data at state, regional, and national levels, with appropriate safeguards for patient privacy and security.
- Coordination of financial, licensure, accreditation, and other relevant systems ensures that each mother can designate her maternity care ‘‘medical home’’ led by the qualified provider of her choice for the coordination of all aspects of care for herself and that of her baby.
- National health care quality organizations are committed to continuous learning from effective systems to identify lessons that could be adapted in maternity care settings.
- Motherhood and fatherhood are valued as reflected in family-friendly programs and policies.