What’s Wrong with the Status Quo?

Described in 1989 as “the perinatal paradox: doing more and accomplishing less,”* the crisis in maternity care has fundamentally worsened in the intervening period.

Despite good intentions of many dedicated health professionals and very large expenditure of resources, the U.S. maternity care system shares many deficiencies of the overall U.S. health care systems.

Care is procedure-intensive and costly

The largely healthy and low-risk population of childbearing women and newborns experiences 6 of the 10 most common hospital procedures. One out of three babies is born via cesarean section, the most common operating room procedure in the United States. Best evidence supports more judicious, restrictive use of maternity care procedures, and suggests that overuse is contributing to significant excess  harm and costs.

Care of childbearing women and their newborns is by far the most common reason for hospitalization, and facility charges billed for “mother’s pregnancy and delivery” and “newborn infants” ($98 billion in 2008) far exceed charges for any other hospital condition in the United States. Medicaid covers about 41% of births while private insurance covers about 52%. The United States spends far more on maternity care than any other industrialized country.

Preventive care is underused and poorly integrated

Preventive care like smoking cessation help, nutritional counseling, and breastfeeding support are difficult to access because health professionals may lack the skills or time necessary to offer them and insurance does not reimburse adequately, creating a financial disincentive. Other underutilized practices that would improve outcomes include midwifery care, continuous labor support, and keeping mothers and babies skin-to-skin after birth.

Performance on key health indicators is poor overall and uneven across settings

Over the past few decades, key indicators of maternal and newborn health have been moving in the wrong direction or stagnating at unacceptable levels. The U.S. ranks behind at least 30 other countries in maternal mortality, neonatal mortality, low birthweight, and exclusive breastfeeding, according to data from the World Health Organization.

Rates of of obstetric procedure use and maternal and newborn outcomes vary widely across providers and facilities, with little of the variation explained by the health status or preferences of women.

Childbearing woman lack choice and autonomy

Women do not currently have access to a wide range of choices about where to give birth, how to give birth, and with whom to give birth. Factors that constrain their choices include institutional policies, provider preferences, loss of clinical skills, and reimbursement policies.

Shameful disparities in access and outcomes persist

Women from racial and ethnic minority communities and low-income women have limited and fragmented access to high-quality maternity care services and experience worse pregnancy outcomes. The maternity care system is ill-equipped to address many perinatal disparities that arise from social factors such as poverty, social isolation, low education, and racism.

For more information

To learn more about the state of the U.S. Maternity Care System, access these resources:

*Rosenblatt RA. The perinatal paradox: doing more and accomplishing less. Health Aff 1989;8(3):158-68.