Using the Blueprint for Advancing High‐Value Maternity Care for transformative change

In June 2018, the National Partnership for Women & Families released a road map for the path ahead to high-value maternity care in the United States. We are among the 17 authors of the Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing who worked together as a multistakeholder and multidisciplinary advisory council.1 Council members have expertise in obstetrics, family medicine, midwifery, nursing, quality improvement, payment reform, performance measurement, consumer advocacy, and clinical and health policy research. Recognizing that each individual birth story is shaped by social determinants of health as well as the systems of health care organization, financing, and access, the Blueprint focuses on systematic, transformational change for “achieving a maternity care system in the United States that restores respect for the biologic capacities and contributions of women and their fetuses/newborns and maximizes benefits of these capacities.”11 This commentary summarizes the key points of the Blueprint and aims to encourage maternity care stakeholders (clinicians, women, families, health care delivery systems, birth workers, community leaders, health plans, employers, policymakers, and more) to critically examine its recommendations and to implement action steps on local, state, and national levels. The ultimate goal of the Blueprint is to achieve optimal health outcomes and experiences for childbearing women and their infants and families through wise use of evidence and judicious use of resources. Although the Blueprint was developed with reference to the United States, the strategies and recommendations are relevant to other settings. Maternal and newborn health systems throughout the world are struggling to improve outcomes, to spend wisely, and to situate prevailing medicalized approaches to maternal-newborn care appropriately within broad systems of health care. Virtually all are using context-specific versions of the six focal Blueprint strategies in their own settings. Blueprints are used in architecture as a template for building a structure. In this case, our Blueprint can be applied to remodeling the United States maternity care system. This Blueprint can be viewed through the lens of architectural principles.2 “Firmness” (firmitas) is the most basic quality, reflecting the ability of a building to preserve its physical integrity and survive. “Commodity” (utilitas) refers to how practical and functional it is; does the structure work for its designed purpose? Without these two, the third principle cannot be achieved. “Delight” (venustas), or the esthetic effect of the building on those who access it, denotes enjoyment and beauty, which is also essential. These principles mirror the Triple Aim as it is applied to maternity care with the goal of better health outcomes (functionality), cost-effectiveness (survival), and satisfaction (delight). Over the past several decades, the United States has experienced disturbing trends in maternal morbidity, mortality, and overuse of medical procedures during childbirth. Deeply troubling are the inequities in maternal and infant health that render black, Native American, rural, and low-income families among the most vulnerable to poor outcomes.3-8 We believe these overall trends and persistent disparities reflect a lack of attention to these architectural principles in maternity care. Some have argued that the United States does not have a maternity health care system and rather has a health care industry.9 When goals are market-based rather than value-based, diminished physical or philosophical integrity can lead to chaos, disarticulation, and inequity. The foundation of the Blueprint, and of the broader constructs on which it is premised, is based on scientific evidence that the majority of pregnant women are healthy and do not commonly require medical intervention in their pregnancies or births. However, they do require systems and practitioners to reliably help them attain their innate capacity to birth. Foundational for the Blueprint is a recent synthesis of over 1100 scientific sources identifying the benefits for women, fetuses, and infants of healthy perinatal physiologic processes and systems of care that promote, support, and protect these processes, while limiting use of interventions to those that are likely to do more good than harm.10 There is clear evidence that this is best provided by respectful, continuous, person-centered care.11 Our current approach to maternity care does not support this and can cause harm by providing “too much too soon” through unnecessary interventions, as well as “too little too late” as a result of failure to provide beneficial care, lack of access to care, and inattention to the most vulnerable.12, 13 The Blueprint is research-based with respect to its encouragement to innovate in many ways that are possible and promising in the present environment, while consistently evaluating, sharing results, and refining models and programs to move toward a high-performing evidence-based maternity care system. The recommended system innovations and the accompanying extensive research agenda include identifying, creating, and implementing effective alternative payment models, care navigator and laborist models, and tools for engaging childbearing women and families. (A navigator is a member of the care team who may help the woman find and interpret relevant information and coordinate with community and social services and across the care continuum; a laborist is a hospital-based physician or midwife who cares for childbearing women.) Furthermore, the document provides citations that support positions taken and provide further information to support implementation. In addition, it outlines a plan to fill research gaps in order to continuously improve the available evidence base on which policy is created, care provided, and family decisions made. The Blueprint is organized around six improvement strategies for achieving high-value maternity care. These are closely related to the National Quality Strategy, which was established by the Affordable Care Act.14 Each of the six strategies has a small number of high-level priority recommendations with accompanying action steps. The strategies, described briefly below, reflect the three architectural principles of functionality, cost-effectiveness, and satisfaction with services.2 This focus on transformation to effective, sustainable structures for maternity-related policy, practice, education, and research; on optimal deployment of personnel and reliable provision of high-value forms of care; and on a system that works well for childbearing women and families, clinicians, and payers and purchasers will be evident to Blueprint readers. This strategy unites innovation of delivery and payment systems with quality improvement. Simply put, reconfigured payment systems pose new opportunities for delivery system reform and involve accountability for quality care and good outcomes. Payment systems undergird nearly all patterns in the United States health care, and aligning payment incentives with high-value maternity is a key starting point for improvement. To support physiologic childbearing, the Blueprint recommends investment in episode payment programs, maternity care homes, expanded use of high-performing elements of care, and quality improvement initiatives. This strategy encourages care that fosters healthy perinatal processes in women and their babies by leveraging priority standardized performance measures, using performance measurement for quality improvement and for accountability, and filling priority measure gaps. The aim of this strategy is to measure what matters, not just for those with complex pregnancies and childbirth, but for healthy women before, during, and after childbirth. Too often, efforts to reform maternity care fail to include the voices of childbearing women and to consider their views and experiences. It is crucial for childbearing women and those supporting and caring for them to understand the value of physiologic birth and to have tools to support informed, engaged decision making. The systems in which women experience pregnancy care and give birth must reliably support this engagement. Educational and communication resources, as well as shared care planning (inclusive of shared decision making), are needed to support their knowledge and activation. Shared multidisciplinary learning and teaching at the onset of and throughout clinical careers contributes to high-functioning care teams. Essential to this learning is shared foundational knowledge of the roles and responsibilities of different members of the care team and of the effects of physiologic childbearing and unneeded interventions on care experiences and health outcomes. At all levels of education, health professionals should stay abreast of best evidence about ways to support physiologic childbearing and implement quality improvement. The composition and distribution of maternity care clinicians across the United States inhibits efforts to ensure access to high-quality care. Nearly half of childbearing women are women of color, yet the clinicians who care for them are disproportionately white.15, 16 One half of the United States counties do not have an obstetrician, and many small hospitals and rural hospitals are rapidly eliminating maternity services.16, 17 There are indications that when midwifery care is less integrated at the state level or when scope of practice laws is more restrictive, maternal and infant outcomes suffer.18, 19 Critical steps must be taken to achieve optimal maternity care workforce composition, including enhancing diversity, retaining and optimally deploying obstetricians as active maternity care practitioners, increasing family physician provision of maternity care, expanding the midwifery workforce, achieving the potential of laborists, and developing effective models to ensure access to care in rural and underserved areas. There are many gaps in knowledge for supporting healthy perinatal physiologic processes, including little understanding of the longer-term effects of both healthy perinatal physiologic processes and many widely used intrapartum interventions. Too few of the most rigorous and impactful randomized controlled trials make any measure of infant (and most certainly, maternal) health after childbirth.20 Blueprint recommendations support filling in critical gaps in research at the levels of physiology, clinical epidemiology, and implementation science, as well as development of a supportive research infrastructure. The Blueprint comes at a time of increasing awareness of the United States crisis in maternal health of subpar and in key instances worsening outcomes with high levels of spending. Collectively across the realms of research, public health, policy, clinical care, and community, there is broad recognition that we cannot continue to rely on approaches that have proven insufficient.21 The Blueprint identifies many recent clinical practice guidance statements from the nation's leading maternity-related professional societies and organizations that similarly recognize the benefits of physiologic childbearing and oppose use of unneeded perinatal interventions.13, 22-25 Particularly important is apparent alignment of the Blueprint with the views of women who have given birth. Women's views appear to have shifted substantially over a 15-year time span. Three national Listening to Mothers surveys and the most recent state-level adaptation in California have asked women whether they agreed or disagreed with the statement that “Birth is a process that should not be interfered with unless medically necessary.”26 When first polled in 2002, similar proportions of women both agreed and disagreed with this statement. Subsequent national surveys in 2006 and 2012 found that fewer and fewer women disagreed with the statement. The 2017 Listening to Mothers in California survey found that just 8% of women disagreed with the statement, whereas 74% agreed (47% strongly and 27% somewhat) and 18% neither agreed nor disagreed. That is, childbearing women increasingly view pregnancy and childbirth as a natural, healthy, physiologic process that ought not to be disrupted, short of medical necessity—in line with compelling evidence. Finally, growing bodies of knowledge under the broader rubric of developmental origins of health and disease—including microbiome, epigenetics, life course health development, and hormonal physiology—urgently clarify that continued disregard for the integrity of bodily processes and systems that have been finely tuned before and throughout mammalian evolution is likely to be perilous for our species.10, 27-30 We must restore respect for our human organism and organize maternity care around that core value. Collectively, the recommendations and action steps constitute a very large agenda with voluntary uptake. However, they are well aligned with the present health care environment and can shape ongoing efforts to address quality, safety, and costs. They present an array of opportunities for agencies, organizations, and individuals from diverse vantage points to engage in improvement efforts. Interprofessional collaboration among the various disciplines is growing, along with professional and consumer consensus about the value of healthy perinatal physiologic processes. Recent sustained in-depth coverage of the maternal health crisis in numerous national media outlets is generating unprecedented awareness of the need for improvement, as suggested by a series of maternal health bills filed and under development in Congress. Many provisions of the bills themselves advance key Blueprint recommendations. This plan for transition to a more balanced, complete, and effective maternity care system aims to address current untenable challenges of overuse of unneeded practices and underuse of beneficial care; persistent racial and geographic inequities and other unacceptable outcomes; and excessive costs.