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Pages 1-14

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From page 1...
... While the vast majority of U.S. women experience childbirth in hospital settings, there is wide variation in the geographic availability of maternity hospitals and in hospital capabilities, types of maternity care providers available, and access to minimal-intervention birth options.
From page 2...
... The pregnant person and infant are at the center of this triad, surrounded by the maternity care team; the systems and settings in which care takes place; and collaboration and integration among providers and systems. The physical setting in which a birth takes place is one part of this overall picture, but it is nested among other elements that are relevant regardless of setting and that can be optimized for positive outcomes across and within different birth settings.
From page 3...
... by a number of different providers during their pregnancy and when giving birth, and these providers differ in how they are educated, trained, ­ icensed, l and credentialed. Moreover, women pay for maternity care through a variety of mechanisms, including private insurance (both individually purchased and employer-sponsored)
From page 4...
... Moreover, these risk factors affect both the pregnant individual's and the health care provider's decision making, shaping which birth settings have the capacity to offer safe, risk-appropriate care. Women, however, may conceive of, tolerate, or understand risk differently from their health care providers, or may simply have competing priorities and values (e.g., control, respect, faith)
From page 5...
... In addition, the overall small number of women giving birth in home and birth center settings in the United States leads to unstable estimates with wide confidence intervals for outcomes of such rare events as maternal and fetal death. Furthermore, the literature on health outcomes by birth setting largely does not address difference by race/ethnicity or other subpopulations.
From page 6...
... Findings of studies of the comparative risk of neonatal morbidity between low-risk birth center and hospital births are mixed, with variation across studies by outcome and provider type. • In the United States, low-risk women choosing home or birth center birth compared with women choosing hospital birth have lower rates of intervention, including cesarean birth, operative vaginal delivery, induction of labor, augmentation of labor, and episiotomy, and lower rates of intervention-related maternal morbidity, such as infection, postpartum hemorrhage, and genital tract tearing.
From page 7...
... This reality undergirds our framework for maternal and newborn care in the United States -- recognizing the need to build a culture of health equity; ensuring that pregnant people and infants receive the right amount of care at the right time; and delivering care in a respectful way, regardless of circumstance -- but there is a critical need for more research on how these factors affect birth outcomes. Because the committee recognizes that no birth setting is risk free and supports a woman's right to choose where and with whom she gives birth, we focus on opportunities for addressing the question of how each setting can improve outcomes and make birth safer.
From page 8...
... CONCLUSION 7-2: Providing currently underutilized nonsurgical maternity care services that some women have difficulty obtaining, in cluding vaginal birth after cesarean, external cephalic version, planned
From page 9...
... This evidence indicates that key components of integration and collaboration include shared care and access to safe and timely consultation, seamless transfer across settings, appropriate risk assessment and risk selection across settings and throughout the episode of care, well-qualified maternity care providers with the knowledge and training to manage first-line complications, collaborative QI initiatives, and the use of multidisciplinary model guidelines for transfer between settings. CONCLUSION 7-4: Integrating home and birth center settings into a regulated maternity and newborn care system that provides shared care and access to safe and timely consultation; written plans for dis cussion, consultation, and referral that ensure seamless transfer across
From page 10...
... When assessing medical risk and monitoring for medical and obstetric complications among women of color, it is critically important that membership in a racial/ethnic group not overdetermine the assessment and constrain the birth setting or maternity care provider options made available to a given woman. Currently, as noted above, certain types of midwives cannot be licensed in some states or obtain admitting privileges to some medical facilities, and this wide variation in regulation, certification, and licensing of maternity care professionals is an impediment not only to integration but also to access to high-quality care across all birth settings.
From page 11...
... Effective aids and tools incorporate clinical risk assessment, as well as a culturally appropri ate assessment of risk preferences and tolerance, and enable pregnant people, in concert with their providers, to make decisions related to risk, settings, providers, and specific care practices. Access to Care and Birth Settings The committee's review of the current financing mechanisms and costs associated with maternity care in the United States revealed that access to care is often limited by a woman's ability to pay, as only a limited number of insurance payers offer coverage for care in home or birth center settings or for certain provider types, and some women are unable to access insurance coverage at all.
From page 12...
... Models for increasing access to birth settings for low-risk women that have been implemented at the state level include expanding Medicaid, Medicare, and commercial payer coverage to cover care provided at home and birth centers within their accreditation and licensure guidelines; cover care provided by certified nurse midwives, certified midwives, and certified professional mid wives whose education meets International Confederation of Midwives Global Standards, who have completed an accredited midwifery educa tion program, and who are nationally certified; and cover care provided by community-based doulas. Additional research, demonstration, and evaluation to determine the potential impact of these state-level models is needed to inform consideration of nationwide expansion, particularly with regard to effects on reduction of racial/ethnic disparities in access, quality, and outcomes of care.
From page 13...
... While the system at present relies primarily on a surgical specialty to provide front-line care, most childbearing women are largely healthy and do not need that type of care in first-line providers. The composition of the maternity care workforce in the United States stands in great contrast to that in a number of other countries where the ratio of midwives to obstetricians is much higher.
From page 14...
... To improve maternal and infant outcomes in the United States, it is necessary to provide economic and geographic access to maternity care in all settings, from conception through the first year postpartum; to provide high-quality and respectful treatment; to ensure informed choices about medical interventions when appropriate for risk status in all birth settings; and to facilitate integrated and coordinated care across all maternity care providers and all birth settings. Achieving these objectives will require coordination and collaboration among multiple actors -- professional organizations, third-party payers, governments at all levels, educators, and accreditation bodies, among others -- to ensure systemwide improvements for the betterment of all women, newborns, and families.


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