Birth Settings in America Outcomes, Quality, Access, and Choice (2020) / Chapter Skim
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1 Introduction
1 Introduction
Pages 15-44
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From page 15... ...
However, we recognize that people of various gender identities, including transgender, nonbinary, and cisgender individuals, give birth and receive maternity care. See Box 1-1 for a more detailed discussion.
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The committee recognizes that intersex people and people of various gender identities, including transgender, nonbinary, and cisgender individuals, give birth and receive maternity care. Because we understand the term women may be isolating and not reflective of how some individuals choose to identify, we periodically use the terms "pregnant people" or "pregnant individuals" in place of "pregnant woman" (see, e.g., Likis et al., 2018)
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Internalized rac ism occurs when negative feelings and stereotypes are turned inward, both in the form of low self-esteem and in racist attitudes toward oneself and others in one's ethnic group. Structural inequities are historically rooted and deeply embedded in policies, laws, governance, and culture, such that power and resources are distributed differentially across characteristics of identity (perceived race, ethnicity, gender, class, sexual orientation, and others)
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Birth centers can be adjacent to or even within hospitals or can be freestanding, with varied transfer and backup arrangements. And home births vary by type of birth attendant and transfer and backup options.
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Financing models for childbirth across settings 5. Licensing, training, and accreditation issues pertaining to professionals providing maternity care across all settings 6.
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The 1982 committee noted that while the data were unreliable for determining the number of planned home births, the number of freestanding birth centers had increased from 3 in 1975 to 130 in 1982, suggesting a significant upswing in women choosing to give birth outside the hospital setting. The report also highlighted differences in birth practices across settings.
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Prenatal care settings and provider types also can influence maternal choice of birth setting, as, for example, when a woman chooses to give birth in the hospital where her prenatal care provider has admitting privileges or chooses in-home care with a midwife because she lives in a rural community and lacks reliable transportation. The committee understands that broader societal forces and the life circumstances of preceding generations affect birth outcomes, which in turn are modified far beyond the first year of life.2 The committee also recognizes that the model of prenatal and post partum care varies by birth setting and within types of settings, that pre 2 For further information on how critical neurobiological systems develop in the prenatal through early childhood periods and how social, economic, cultural, and environmental factors significantly affect a woman's and child's health ecosystem and ability to thrive, see National Academies of Sciences, Engineering, and Medicine (2019)
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levels of maternal mortality and morbidity exceed those of many other countries, even as more is spent on maternity care.3 To make matters worse, the morbidity and mortality outcomes are worse for Black and Native American women, and the trend is not encouraging. For children, the appropriate care of newborns is crucial during a window of rapid growth and development at the beginning of life.
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women lack access to essential maternity care services. Prenatal care provides risk assessment and treatment of some conditions, monitoring of the health of mother and baby, and vital health 4As of 2019, 33 states and the District of Columbia had adopted and implemented Medicaid expansion, and 14 states had not.
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pregnancy-related mortality rate was recorded at about 7.2 maternal deaths per 100,000 live births in 1987. The rate then began to increase, and at its height in 2014, there were 18 pregnancy-related deaths per 100,000 live births (Centers for Disease Control and Prevention, 5 According to WHO, "the international healthcare community has considered the ideal rate for cesarean birth to be between 10 percent and 15 percent" (World Health Organization, 2015, p.
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Like the rates of maternal mortality, U.S. rates of severe maternal morbidity are high relative to those in other high-resource countries (Geller et al., 2018)
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In 2017, infant mortality rates per 1,000 live births by race and ethnicity were as follows: nonHispanic Black, 10.97 per 1,000; American Indian/Alaska Native, 9.21 per 1,000; Native Hawaiian or Other Pacific Islander, 7.64 per 1,000; Hispanic, 5.1 per 1,000; non-Hispanic White, 4.67 per 1,000; and Asian, 3.78 per 1,000 (Ely and Driscoll, 2019; see Figure 1-4)
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45 40 35 30 25 20 15 10 5 Pregnancy-Related Mortality Ratio 0 2007–2008 2009–2010 2011–2012 2013–2014 2015–2016 Hispanic Asian/Pacific Islander American Indian/ Black White Alaskan Native FIGURE 1-2 Trends in pregnancy-related mortality ratio: United States, 2005–2016. SOURCE: Centers for Disease Control and Prevention (2019g)
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. 12 10.97 10 9.21 3.82 Infant deaths per 1,000 live births 8 7.64 4.41 6 3.82 5.10 4.67 1.54 Postneonatal 4 3.78 mortality rate 1.63 7.16 1.08 4.77 2 3.82 3.56 Neonatal 3.04 mortality rate 2.71 0 White Black American Indian Asian Native Hawaiian Hispanic or Alaska Native or Other Pacific Islander Non-Hispanic FIGURE 1-4 Infant, neonatal, and postneonatal mortality rates, by race and Hispanic origin: United States, 2017.
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, maternity care costs also are generally higher than those of other countries (International Federation of Health Plans, 2015)
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Examples of these devel opments in the areas of integration across care teams and birth settings and maternity care quality improvement are detailed below. Additionally, research expanded knowledge of physiologic childbearing (see, e.g., Buckley, 2015)
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An online maternity episode payment resource bank was created to support implementation of maternity care episode alternative payment models (Health Care Payment Learning and Action Network, n.d.)
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(MacDorman and Declercq, 2019) ; the rate of home births increased by 77 percent, rising to 0.99 percent of all births; and the rate of birth center births more than d oubled, rising to 0.52 percent of all births (MacDorman and Declercq, 2019)
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entiate between planned hospital births and births that were planned for home but transferred to the hospital. Therefore, the number of planned home births reported in the study is an underestimate of the actual number of births that began as planned home births.
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compared with planned home births (<1%)
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aCategory includes 3,273 "other," 553 "clinic or doctor's office," and 181 "unknown" location. bDoes not include planned home births that were transferred to hospitals.
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coverage. In 2017, 43.4 percent of hospital births were paid for by Medicaid, compared with 17.9 percent of birth center births and only 8.6 percent of planned home births.
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aCategory includes 3,273 "other," 553 "clinic or doctor's office," and 181 "unknown" location. bDoes not include planned home births that were transferred to hospitals.
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aStructural inequities and biases include systemic and institutional racism. Interpersonal racism and implicit and explicit bias underlie the social determinants of health for women of color.
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. Thus, one advantage of adopting a social determinants of health lens in the analysis of maternal and newborn health is that it offers the possibility of identifying factors asso iated with health inequities that may be c amenable to change through efforts aimed at prevention or intervention, as discussed further in Chapter 4.
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Birth outcomes are the results of pregnancy, childbirth, and the postpartum period, and they may also be influenced by the woman's health status prior to pregnancy. They can be positive or negative and encompass the condition of both mother and infant following childbirth.
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. Maternal mortality: "The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes" (World Health Organization, 2019)
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The most salient of these values and goals emerging from public testimony and the literature are outlined below: • The need of women and their children for access to affordable, respectful, responsive, clinically and culturally safe, high-quality care from the prenatal period through at least 1 year postpartum. • Women's right to informed choice in maternity care.
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Chapter 3 summarizes the epidemiology of clinical and social risks in pregnancy and childbirth at the individual level, such as medical and obstetric risk factors, and the relationship among choice, risk assessment, and informed decision making. Chapter 4 reviews system-level risks in pregnancy and childbirth, including structural inequities and biases, as well as the social determinants of health that influence psychosocial, medical, and obstetric risk.
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Key Terms
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