The Cure for An Ailing Maternity Care System

Amie Newman

Maternity care is big business in the U.S...$86 billion big. With that kind of investment, you’d think women and their newborn babes in this country would be entering the postpartum recovery period universally healthy and happy. Not so.

Maternity care is big business in the United States. We’re
talking $86 billion big.  With that kind of investment, you’d think women and their newborn babes in this
country would be entering the postpartum recovery period universally healthy
and happy after being well cared for throughout pregnancy and birth. Unfortunately, the return on investment for maternity care
is poor. The U.S. spends more on health care than most – a staggering
per person in fact – yet lags far behind when it comes to maternal
and newborn health and mortality indicators. The United States ranks 41st
out of 171 countries when it comes to our maternal mortality rates.  So it makes sense that stakeholders
from health care advocates and providers to hospital and insurance company
executives, but most importantly women themselves, would want to ensure a much
better return-on-investment for maternity care in this country, right?


Unfortunately, what has constituted success in terms of a
greater ROI among these various stakeholders has not always been
uniform.  Where women are growing
weary of the increase in unnecessary medical interventions during childbirth
that only increase costs and the chance of poorer health outcomes, doctors have
taken to routinely encouraging and performing unnecessary c-sections at an
exponential rate to keep malpractice claims lower but also because our health
care system’s “global
method of payment for in-hospital birth promotes a one-size-fits-all
type of care which does not lend itself well to vaginal birth but does increase
a hospital’s profit; where insurance companies and Medicaid do not provide
homebirth coverage across the country, which would bring overall maternity care
costs down (for insurance companies, states, those insured and tax-payers
across the board), Medicaid funds almost half of all hospital births.

It is precisely because of these issues and more that a team of over 100 national leaders in maternity care, led by maternity care advocacy
organization Childbirth Connection, convened two and a half years ago to come
up with a shared vision and an action plan for change.

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“It was time to act and we called upon key leaders across
the health care system to develop a long-term vision for the future of
maternity care in the United States,” said Maureen Corry, Childbirth
Connection’s Executive Director. The results of this multi-year
meeting-of-the-minds, the Transforming
Maternity Care Project
, are two key reports released today, “2020 Vision For A
High-Quality High-Value Maternity Care System”
and “Blueprint For Action.”

As we move forward, towards reform of our overall health
care system, the problems and solutions identified in these two reports are key
to fixing our broken maternity care system and may help birth an entirely new

The “2020 Vision” report underscores 11 key focus areas or
problems that include: payment reform, disparities in access and outcomes of
maternity care, coordination of maternity care, clinical controversies (such as
home birth, VBAC (vaginal birth after cesarean) and elective induction), and
decision-making and consumer choice. The “Blueprint for Action” report
identifies concrete actions to address all of these problems in order to move
closer to this shared vision of a high-quality, high-value system.  How do we get the most value – in every
possible way that word can be defined – for our money?

Rima Jolivet, Transforming Maternity Care Project Director
with Childbirth Connection is optimistic: “The good news is that every
challenge is an opportunity for improvement that can benefit millions of
mothers and babies annually.” In other words, maternity care is a problem with
a solution. And the solution lies in the answers to the questions posed to the
work groups involved with these reports:

“Who needs to do what, to, with, and for whom over the next
five years to improve the quality care?”

In truth, the answers to these questions are not earth
shattering. They seem to echo what women’s health advocate have said for years.
We need a system that is woman-centered, evidence-based, safe, timely,
efficient and equitable. But how exactly do these concepts translate into in practical approaches to care?

Woman-centered care, according to the “2020 Vision” report
is care that “that respects the values, culture, choices and preferences of the
woman, and her family, as relevant, within the context of promoting optimal
health outcomes. It means that all childbearing women are treated with…respect,
dignity and cultural sensitivity throughout their maternity care experiences.”

In effect, we’re talking about personalized care and the understanding that
each woman brings a unique vision, perspective, belief system, and cultural
identity to their pregnancy and birth experience. Let’s not only respect that but
also work with these ideals to promote positive experiences.

The idea that maternity care should be evidence-based,
safe, and efficient seems like a no-brainer but one key goal to note is how
these imperatives lay the groundwork to minimize “overuse, underuse, and misuse
of care practices and services.” We need to make sure we’re providing optimal
care to all women by guaranteeing
women are able to access the services they need if they need them. However
(this is a big one), let’s also start from a place of understanding that
pregnancy is a healthy state of being
– not an inherently sick state – and so let’s also minimize the amount of
unnecessary interventions that now drive up costs and place women and newborns
at risk for poorer health outcomes.

As the “2020 Vision” puts it:

“The majority of childbearing women are healthy and have
good reason to expect an uncomplicated pregnancy and birth and a healthy
newborn. Thus, practice variation for low-risk women is minimized under the
principle that any intervention in the physiologic processes of pregnancy and
childbirth must be shown to do more good than harm…”

The goal of ensuring greater equitability in
access to care is critical in this report. Racial and ethnic disparities run
rampant in maternity care. Shockingly, African-American women in the U.S. are
four times as likely to die during childbirth as white women. We know, too,
that the idea that women can “choose” where to birth and with whom is
non-existent for low-income women who cannot afford to pay out of pocket for a
homebirth or midwife at a birthing center. The “Blueprint for Action” notes

“Non-Hispanic black, Hispanic, and American Indian-Alaskan Natives were
more than twice as likely as non-Hispanic white women to receive late or no
prenatal care in 2006; as of 2008, nearly 40 percent of low-income women ages 18-44
were uninsured.”

The solutions lie in a host of actions including (what else?)
national health care reform legislation, encouraging states to exercise
Medicaid’s eligibility option for pregnant women under CHIP and other programs,
and expanding public support for maternity care programs, providers and
institutions as well.

Another key problem notes the “2020” report is improving the
functionality of payment systems. It sounds dry but the truth is that payment
reform is key to aligning financial goals with optimal health outcomes. As the
“Blueprint for Action” report puts it:

“Volume-driven reimbursement increases
cost without improving health outcomes. Providing more services than are needed
does not improve health and increases the risk of harm, while driving up

Not the best use of anyone’s time or money, really.

Of special interest, also, is the section in the “Blueprint
for Action” on what are termed “clinical controversies” such as Home birth and
VBAC (vaginal birth after cesarean section). The Blueprint acknowledges and
reinforces key solutions that grassroots advocates have been working towards
for years:

“…developing national clinical guidelines for VBAC, labor induction,
vaginal breech and out-of-hospital birth using transparent processes; improving
the capacity of hospitals and health systems to meet the needs of women who
face these controversial scenarios; improving the capacity of community health
systems to meet the needs of women who make an informed choice of planned home
birth and, finally, improving cooperation between hospital systems and home
birth providers.”

If these reports can be used as actual blue prints for
action within health care reform, I can see our maternity care system getting
healthier already.

For more on these reports, please check out Amy Romano’s post at Lamaze, International’s blog Science & Sensibility and Melissa Garvey’s post at Midwife Connection, ACNM’s blog!

Commentary Contraception

For Students at Religious Universities, Contraception Coverage Isn’t an Academic Debate

Alison Tanner

When the U.S. Supreme Court sent a case about faith-based objections to the Affordable Care Act's contraceptive mandate back to lower courts, it left students at religious colleges and universities with continuing uncertainty about getting essential health care. And that's not what religious freedom is about.

Read more of our articles on challenges to the Affordable Care Act’s birth control benefit here.

Students choose which university to attend for a variety of reasons: the programs offered, the proximity of campus to home, the institution’s reputation, the financial assistance available, and so on. But young people may need to ask whether their school is likely to discriminate in the provision of health insurance, including contraceptive coverage.

In Zubik v. Burwell, a group of cases sent back to the lower courts by the U.S. Supreme Court in May, a handful of religiously affiliated universities sought the right to deny their students, faculty, and staff access to health insurance coverage for contraception.

This isn’t just a legal debate for me. It’s personal. The private university where I attend law school, Georgetown University in Washington, D.C., currently complies with provisions in the Affordable Care Act that make it possible for a third-party insurer to provide contraceptive access to those who want it. But some hope that these legal challenges to the ACA’s birth control rule will reverse that.

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Georgetown University Law Center refused to provide insurance coverage for contraception before the accommodation was created in 2012. Without a real decision by the Supreme Court, my access to contraception insurance will continue to be at risk while I’m in school.

I’m not alone. Approximately 1.9 million students attend religiously affiliated universities in the United States, according to the Council for Christian Colleges and Universities. We students chose to attend these institutions for lots of reasons, many of which having nothing to do with religion. I decided to attend Georgetown University Law Center because I felt it was the right school for me to pursue my academic and professional goals, it’s in a great city, it has an excellent faculty, and it has a vibrant public-interest law community.

Like many of my fellow students, I am not Catholic and do not share my university’s views on contraception and abortion. Although I was aware of Georgetown’s history of denying students’ essential health-care benefits, I did not think I should have to sacrifice the opportunity to attend an elite law school because I am a woman of reproductive age.

That’s why, as a former law clerk for Americans United for Separation of Church and State, I helped to organize a brief before the high court on behalf of 240 students, faculty, and staff at religiously affiliated universities including Fordham, Georgetown, Loyola Marymount, and the University of Notre Dame.

Our brief defended the sensible accommodation crafted by the Obama administration. That compromise relieves religiously affiliated nonprofit organizations of any obligation to pay for or otherwise provide contraception coverage; in fact, they don’t have to pay a dime for it. Once the university informs the government that it does not want to pay for birth control, a third-party insurer steps in and provides coverage to the students, faculty, and staff who want it.

Remarkably, officials at the religious colleges still challenging the Affordable Care Act say this deal is not good enough. They’re arguing that the mere act of informing the government that they do not want to do something makes them “complicit” in the private decisions of others.

Such an argument stands religious freedom on its head in an attempt to impose one group’s theological beliefs on others by vetoing the third-party insurance providers’ distribution of essential health coverage to students, faculty, and staff.

This should not be viewed as some academic debate confined to legal textbooks and court chambers. It affects real people—most of them women. Studies by the Guttmacher Institute and other groups that study human sexuality have shown that use of artificial forms of birth control is nearly universal among sexually active women of childbearing years. That includes Catholic women, who use birth control at the same rate as non-Catholics.

Indeed, contraception is essential health care, especially for students. An overwhelming number of young people’s pregnancies are unplanned, and having children while in college or a graduate program typically delays graduation, increases the likelihood that the parent will drop out, and may affect their future professional paths.

Additionally, many menstrual disorders make it difficult to focus in class; contraception alleviates the symptoms of a variety of illnesses, and it can help women actually preserve their long-term fertility. For example, one of the students who signed our brief told the Court that, “Without birth control, I experience menstrual cycles that make it hard to function in everyday life and do things like attend class.” Another woman who signed the brief told the Court, “I have a history of ovarian cysts and twice have required surgery, at ages 8 and 14. After my second surgery, the doctor informed me that I should take contraceptives, because if it happened again, I might be infertile.”

For these and many other reasons, women want and need convenient access to safe, affordable contraceptives. It is time for religiously affiliated institutions—and the Supreme Court—to acknowledge this reality.

Because we still don’t have an ultimate decision from the Supreme Court, incoming students cannot consider ease of access to contraception in deciding where to attend college, and they may risk committing to attend an university that will be legally allowed to discriminate against them. A religiously affiliated university may be in all other regards a perfect fit for a young woman. It’s unfair that she should face have to risk access to essential health care to pursue academic opportunity.

Religious liberty is an important right—and that’s why it should not be misinterpreted. Historically, religious freedom has been defined as the right to make decisions for yourself, not others. Religious freedom gives you have the right to determine where, how, and if you will engage in religious activities.

It does not, nor should it ever, give one person or institution the power to meddle in the personal medical decisions of others.

Commentary Abortion

It’s Time for an Abortion Renaissance

Charlotte Taft

We’ve been under attack and hanging by a thread for so long, it’s been almost impossible to create and carry out our highest vision of abortion care.

My life’s work has been to transform the conversation about abortion, so I am overcome with joy at the Supreme Court ruling in Whole Woman’s Health v. Hellerstedt. Abortion providers have been living under a very dark cloud since the 2010 elections, and this ruling represents a new day.

Abortion providers can finally begin to turn our attention from the idiocy and frustration of dealing with legislation whose only intention is to prevent all legal abortion. We can apply our energy and creativity fully to the work we love and the people we serve.

My work has been with independent providers who have always proudly delivered most of the abortion care in our country. It is thrilling that the Court recognized their unique contribution. In his opinion, after taking note of the $26 million facility that Planned Parenthood built in Houston, Justice Stephen Breyer wrote:

More fundamentally, in the face of no threat to women’s health, Texas seeks to force women to travel long distances to get abortions in crammed-to-capacity superfacilities. Patients seeking these services are less likely to get the kind of individualized attention, serious conversation, and emotional support that doctors at less taxed facilities may have offered.

This is a critical time to build on the burgeoning recognition that independent clinics are essential and, at their best, create a sanctuary for women. And it’s also a critical time for independent providers as a field to share, learn from, and adopt each other’s best practices while inventing bold new strategies to meet these new times. New generations expect and demand a more open and just society. Access to all kinds of health care for all people, including excellent, affordable, and state-of-the-art abortion care is an essential part of this.

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We’ve been under attack and hanging by a thread for so long—with our financial, emotional, and psychic energies drained by relentless, unconstitutional anti-abortion legislation—it’s been almost impossible to create and carry out our highest vision of abortion care.

Now that the Supreme Court has made it clear that abortion regulations must be supported by medical proof that they improve health, and that even with proof, the burdens can’t outweigh the benefits, it is time to say goodbye to the many politically motivated regulations that have been passed. These include waiting periods, medically inaccurate state-mandated counseling, bans on telemedicine, and mandated ultrasounds, along with the admitting privileges and ambulatory surgical center requirements declared unconstitutional by the Court.

Clearly 20-week bans don’t pass the undue burden test, imposed by the Court under Planned Parenthood v. Casey, because they take place before viability and abortion at 20 weeks is safer than childbirth. The federal Hyde Amendment, a restriction on Medicaid coverage of abortion, obviously represents an undue burden because it places additional risk on poor women who can’t access care as early as women with resources. Whatever the benefit was to late Rep. Henry Hyde (R-IL) it can’t possibly outweigh that burden.

Some of these have already been rejected by the Court and, in Alabama’s case, an attorney general, in the wake of the Whole Woman’s Health ruling. Others will require the kind of bold action already planned by the Center for Reproductive Rights and other organizations. The Renaissance involves raising an even more powerful voice against these regulations, and being firm in our unwillingness to spend taxpayer dollars harming women.

I’d like to entertain the idea that we simply ignore regulations like these that impose burdens and do not improve health and safety. Of course I know that this wouldn’t be possible in many places because abortion providers don’t have much political leverage. This may just be the part of me that wants reproductive rights to warrant the many risks of civil disobedience. In my mind is the man who stood in front of moving tanks in Tiananmen Square. I am yearning for all the ways to stand in front of those tanks, both legal and extralegal.

Early abortion is a community public health service, and a Renaissance goal could be to have early abortion care accessible within one hour of every woman in the country. There are more than 3,000 fake clinics in this country, many of them supported by tax dollars. Surely we can find a way to make actual services as widely available to people who need them. Of course many areas couldn’t support a clinic, but we can find ways to create satellite or even mobile clinics using telemedicine to serve women in rural areas. We can use technology to check in with patients during medication abortions, and we can provide ways to simplify after-care and empower women to be partners with us in their care. Later abortion would be available in larger cities, just as more complex medical procedures are.

In this brave new world, we can invent new ways to involve the families and partners of our patients in abortion care when it is appropriate. This is likely to improve health outcomes and also general satisfaction. And it can increase the number of people who are grateful for and support independent abortion care providers and who are able to talk openly about abortion.

We can tailor our services to learn which women may benefit from additional time or counseling and give them what they need. And we can provide abortion services for women who own their choices. When a woman tells us that she doesn’t believe in abortion, or that it is “murder” but she has to have one, we can see that as a need for deeper counseling. If the conflict is not resolved, we may decide that it doesn’t benefit the patient, the clinic, or our society to perform an abortion on a woman who is asking the clinic to do something she doesn’t believe in.

I am aware that this last idea may be controversial. But I have spent 40 years counseling with representatives of the very small, but real, percentage of women who are in emotional turmoil after their abortions. My experience with these women and reading online “testimonies” from women who say they regret their abortions and see themselves as victimized, including the ones cited by Justice Kennedy in the Casey decision, have reinforced my belief that when a woman doesn’t own her abortion decision she will suffer and find someone to blame for it.

We can transform the conversation about abortion. As an abortion counselor I know that love is at the base of women’s choices—love for the children they already have; love for their partners; love for the potential child; and even sometimes love for themselves. It is this that the anti-abortion movement will never understand because they believe women are essentially irresponsible whores. These are the accusations protesters scream at women day after day outside abortion clinics.

Of course there are obstacles to our brave new world.

The most obvious obstacles are political. As long as more than 20 states are run by Republican supermajorities, legislatures will continue to find new ways to undermine access to abortion. The Republican Party has become an arm of the militant anti-choice movement. As with any fundamentalist sect, they constantly attack women’s rights and dignity starting with the most intimate aspects of their lives. A society’s view of abortion is closely linked to and mirrors its regard for women, so it is time to boldly assert the full humanity of women.

Anti-choice contends that there have been approximately 58,586,256 abortions in this country since 1973. That means that 58,586,256 men have been personally involved in abortion, and the friends and family members of at least 58,586,256 people having abortions have been too. So more than 180 million Americans have had a personal experience with abortion. There is no way a small cadre of bitter men with gory signs could stand up to all of them. So they have, very successfully so far, imposed and reinforced shame and stigma to keep many of that 180 million silent. Yet in the time leading up to the Whole Woman’s Health case we have seen a new opening of conversation—with thousands of women telling their personal stories—and the recognition that safe abortion is an essential and normal part of health care. If we can build on that and continue to talk openly and honestly about the most uncomfortable aspects of pregnancy and abortion, we can heal the shame and stigma that have been the most successful weapons of anti-abortion zealots.

A second obstacle is money. There are many extraordinary organizations dedicated to raising funds to assist poor women who have been betrayed by the Hyde Amendment. They can never raise enough to make up for the abandonment of the government, and that has to be fixed. However most people don’t realize that many clinics are themselves in financial distress. Most abortion providers have kept their fees ridiculously and perilously low in order to be within reach of their patients.

Consider this: In 1975 when I had my first job as an abortion counselor, an abortion within the first 12 weeks cost $150. Today an average price for the same abortion is around $550. That is an increase of less than $10 a year! Even in the 15 states that provide funding for abortion, the reimbursement to clinics is so low that providers could go out of business serving those in most need of care.

Over the years a higher percent of the women seeking abortion care are poor women, women of color, and immigrant and undocumented women largely due to the gap in sexual health education and resources. That means that a clinic can’t subsidize care through larger fees for those with more resources. While Hyde must be repealed, perhaps it is also time to invent some new approaches to funding abortion so that the fees can be sustainable.

Women are often very much on their own to find the funds needed for an abortion, and as the time goes by both the costs and the risk to them increases. Since patients bear 100 percent of the medical risk and physical experience of pregnancy, and the lioness’ share of the emotional experience, it makes sense to me that the partner involved be responsible for 100 percent of the cost of an abortion. And why not codify this into law, just as paternal responsibilities have been? Perhaps such laws, coupled with new technology to make DNA testing as quick and inexpensive as pregnancy testing, would shift the balance of responsibility so that men would be responsible for paying abortion fees, and exercise care as to when and where they release their sperm!

In spite of the millions of women who have chosen abortion through the ages, many women still feel alone. I wonder if it could make a difference if women having abortions, including those who received assistance from abortion funds, were asked to “pay it forward”—to give something in the future if they can, to help another woman? What if they also wrote a letter—not a bread-and-butter “thank you” note—but a letter of love and support to a woman connected to them by the web of this individual, intimate, yet universal experience? This certainly wouldn’t solve the economic crisis, but it could help transform some women’s experience of isolation and shame.

One in three women will have an abortion, yet many are still afraid to talk about it. Now that there is safe medication for abortion, more and more women will be accessing abortion through the internet in some DIY fashion. What if we could teach everyone how to be excellent abortion counselors—give them accurate information; teach them to listen with nonjudgmental compassion, and to help women look deeper into their own feelings and beliefs so that they can come to a sense of confidence and resolution about their decision before they have an abortion?

There are so many brilliant, caring, and amazing people who provide abortion care—and room for many more to establish new clinics where they are needed. When we turn our sights to what can be, there is no limit to what we can create.

Being frustrated and helpless is exhausting and can burn us out. So here’s a glass of champagne to being able to dream again, and to dreaming big. From my own past clinic work:

At this clinic we do sacred work
That honors women
And the circle of life and death.