It’s remarkable to see the improvements in maternal health around the globe, which have produced a steady decline in the number of women dying from childbirth over the last 30 years. But in the United States, there is rain on the parade. Its maternal-mortality rate has been steadily rising — the only developed country whose is. Given that women with employer-sponsored health insurance account for over half of the annual pregnancies in the United States, employers are in a position to demand higher quality care. In this article, the authors recommend four actions that employers can take by wielding their purchasing power.
It’s remarkable to see the improvements in maternal health around the globe, which have produced a steady decline in the number of women dying from childbirth over the last 30 years. But in the United States, there is rain on the parade. Its maternal-mortality rate has been steadily rising — the only developed country whose is. Given that women with employer-sponsored health insurance account for over half of the annual pregnancies in the United States, employers are in a position to demand higher quality care. In this article, we recommend actions they can take by wielding their purchasing power.
The U.S. maternal mortality rate has more than doubled from 10.3 per 100,000 live births in 1991 to 23.8 in 2014. Over 700 women a year die of complications related to pregnancy each year in the United States, and two-thirds of those deaths are preventable. Fifty thousand women suffer from life-threatening complications of pregnancy. A report from the Commonwealth Fund released in December found American women have the greatest risk of dying from pregnancy complications among 11 high-income countries.
What’s worse, there are massive disparities. Black women are three to four times more likely to die in childbirth than white women — regardless of education, income, or any other socio-economic factors. This is the primary reason the United States lags so far behind other affluent countries. According to the World Health Organization, black mothers in the U.S. die at the same rate as pregnant women in Mexico or Uzbekistan.
Some of these statistics can be explained by Cesarean-section deliveries, a procedure that carries added risk and financial burden and is frequently performed unnecessarily in the United States. As of 2015, the proportion of C-sections at individual U.S. hospitals varied from 7% of births to a startling 70% of births. These differences play out by race. For example, 36% of births among non-Hispanic black women are C-sections versus 30.9% for non-Hispanic white women — a difference that medical experts consider significant. In addition, once a woman has a C-section, her future deliveries are much more likely to be the same. This is, in part, because it can be difficult to find providers who will support a vaginal birth after a woman has had a Cesarean, even though they can be done safely.
The business community has a unique opportunity to leverage its health care purchasing power to improve maternity care. In addition to the lives at stake, C-sections and their risk of complications create a significant and wasteful financial cost for employers and employees to bear.
In fact, data from IBM Marketscan Research Databases suggests, on average, that each C-section costs an employer $5,100 more than a vaginal delivery. With 1.9 million deliveries in employer sponsored health insurance plans each year, even a 1% decrease from the current rate of Cesarean deliveries of 32% would save about $97 million. If we further decreased the rate to 23%, around the Healthy People 2020 target, we’d reach over $1 billion in savings, and would have healthier mothers and babies.
What can employers do?
1. Push contracted health plans to create strong incentives for health care providers to charge a single “bundled” price for the entire episode of maternity care. Since C-sections cost more than vaginal deliveries, a bundled payment would give providers an incentive to avoid unnecessary Cesarean births.
Demand that health plans require participating hospitals to follow best evidence-based practices, such as those endorsed by the California Maternal Quality Care Collaborative and the Alliance for Innovation on Maternal Health Program. These include the prohibition of early elective deliveries, which the Joint Commission, the largest hospital accreditation body in the United States, defines as less than 39 weeks. Such efforts have helped California decrease its rate of maternal mortality by over half in less than a decade.
2. Implement benefit designs to connect pregnant mothers with high-value providers (i.e., those who offer the best outcomes at a relatively low cost). These designs should include a “centers of excellence” program that encourages mothers-to-be to select high-value providers for labor and delivery services by reducing or waiving her share of the costs. Furthermore, they should urge women with low-risk pregnancies to consider using freestanding birth centers. These providers have excellent outcomes, and the likelihood of unnecessary interventions occurring at such a center is lower than at a hospital.
3. Educate employees on the importance of full-term births and the potential adverse health consequences of elective inductions and unnecessary Cesarean deliveries.
4. Push health plans to contract with, provide full coverage for, and offer access to certified nurse midwives. The evidence suggests they deliver high-quality care at lower costs. Health plans can also offer access to doulas, or lay birth coaches.
The high maternal mortality rate is distressing. By wielding their purchasing power, employers can help do something about it. They can help bring about much better outcomes, and by doing so, they can lower their costs and those incurred by their employees and their families.