Why Maternity Care Quality Matters

Is health care quality a problem in the United States?

Is maternity care quality a problem in the United States?

Why is maternity care quality important to me?

How can we define maternity care quality?

Why do we need a single national set of high-quality maternity care performance measures?

What is transparency in maternity care, and why is it important?

What maternity care procedures are being overused in the United States?

What safe and effective maternity care practices are underused in the United States?

Why do mothers and babies benefit from physiologic childbirth?

Is health care quality a problem in the United States?

Try asking your friends and family about the U.S. health care system. Each will likely come up with a long list of problems, including
  • many people lack health insurance
  • race, ethnicity, and economic status influence whether people have access to quality health care 
  • many Americans suffer serious financial problems due to medical bills
  • medical errors in hospitals and other settings result in too many unnecessary injuries and deaths
  • there is a shortage of caregivers to meet the health care needs of our population
  • getting the right care at the right time is a major challenge for many.

Experts as well agree that our health care system needs work. Common concerns are that the system does not reliably delivery high-quality care and that care is costly and often wasteful.

Is maternity care quality a problem in the United States?

While everyone agrees that the U.S. health care system needs improvement, many assume that maternity care quality in the United States is very good. Is this correct? 

One way to judge maternity care quality is to compare U.S. performance with other countries. A recent World Health Organization report identified 33 countries with lower maternal death rates than the United States, while 37 countries had lower newborn death rates, 40 had lower infant death rates, and 65 had lower rates of low birthweight. Thirty-two nations had higher rates of exclusive breastfeeding to at least six months (2010). The Organisation for Economic Co-operation and Development identified 24 high- and middle-income countries with lower cesarean rates in 2007 and just 4 with higher rates (2010). Despite this poor international ranking, the International Federation of Health Plans recently reported that average payments for vaginal birth in the U.S. were far higher than all other countries reported, including Canada, France, and Australia (2010).

Others have carefully examined the best available research on safe and effective care for mothers and babies. More and more rigorous systematic reviews clarifying the effects of maternity practices are available.  Unfortunately, these reviews are rarely used to guide practice or policy. Many low-tech beneficial practices are underused, while invasive procedures are overused. The tendency in the United States to provide expensive, procedure-intensive maternity care without improving the health of women and babies has been called the "perinatal paradox: doing more and accomplishing less" (Rosenblatt 1989). 

Why is maternity care quality important to me?

Maternal and newborn care is the nation's most common reason for hospitalization, with more than four million women giving birth every year. Yet, as a pregnant woman, your needs are vastly different than those of others who are hospitalized: pregnant women are neither ill nor injured. Most childbearing women in the United States are healthy and have no reason to expect complications from childbirth. Then why, each year, do millions of healthy mothers and babies experience care similar to that of patients in intensive care units?

Optimal maternity care should follow the principle of "effective care with least harm." Instead, nearly all women who give birth in U.S. hospitals experience high rates of interventions, with risks of adverse effects. Procedures appropriate for a much smaller proportion of mothers, such as episiotomy and continuous electronic fetal monitoring, are common. Meanwhile, numerous beneficial practices that support women's own innate capacities or the "physiologic" process of childbirth, such as labor support and supportive care for breastfeeding, are underused.    

As an expectant mother, and later as a new mother, you want the best quality of care for you and your baby.  High-quality care will
  • provide you with good information and support during pregnancy, labor and birth, and the postpartum period
  • give you information based on the best available evidence about benefits and harms of different options and help you to make informed decisions that are right for you and your baby
  • give you access to practices that support and promote physiological birth
  • foster attachment and breastfeeding with your baby through such simple but proven practices as skin-to-skin contact with your newborn.

How can we define maternity care quality?

In its landmark 2001 Crossing the Quality Chasm report, the Institute of Medicine called for large-scale changes to the U.S. health care system and laid out six national aims for improvement: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

We can define maternity care quality in the context of these six aims.  Optimal maternity care will be:
  • Safe care minimizes the risk of error and harm. Care that supports the physiology of childbirth, and minimizes use of interventions with established risks, will often be the safest care.
  • Effective means sound evidence is available to demonstrate that care achieves expected benefits. Overuse (providing unneeded care) and underuse (not providing beneficial care) of interventions are minimized.
  • Woman-and family-centered means that care is based on the values, culture, and preferences of the woman and her family, while promoting optimal health outcomes.
  • Timely means that care is delivered when needed. Wait times compromising safety and efficiency are avoided. Timely also means that the timing of the start and course of labor and birth is determined by the physiology of birth when possible. Decisions are made to optimize maternal and newborn health rather than for convenience. Timely also means that information to support women's decision-making is available well before the onset of labor, and, as relevant, again during labor.  
  • Efficient means delivering the best possible health outcomes and benefits with the most appropriate use of resources and technology. Efficient maternity care avoids the waste of overuse, underuse and errors.
  • Equitable means that women and families of all racial, ethnic, and economic groups have access to the same high quality care, and that any variation in maternity care practice is based solely on the health needs and values of the woman and her baby. Currently, black non-Hispanic mothers experience much higher rates of preterm birth, low birthweight, and fetal, perinatal, and maternal death than white non-Hispanic and Hispanic women. Equitable also means that the maternity care system addresses linguistic, cultural, and geographic barriers.

Why do we need a comprehensive set of high-quality nationally recognized maternity care performance measures?

Poor quality maternity care can lead to medical errors or to unnecessary interventions and complications, longer hospital stays, and infants needing intensive care services. These problems, in turn, increase costs and short- and long-term health problems in mothers and babies. With so many expectant mothers admitted to hospitals each year, maternity care quality affects many women, newborns and families. 

Until recently, there has been little focus on quality measurement and reporting for maternity care. In 2008, the National Quality Forum (NQF) released important new tools for improving maternity care quality: a set of 17 national measures for assessing the quality of care from the end of pregnancy through facility care of women and newborns. (NQF is a national non-profit organization that helps set and achieve national priorities and goals for performance improvement, and endorses national consensus standards for measuring and publicly reporting on performance.) Most of the maternity care measures address care provided by hospitals and birth centers.  

Nationally recognized maternity care performance measures will help improve maternity care quality by:
  • providing information about the performance of caregivers, facilities, health plans, and other entities to increase transparency and accountability
  • helping women choose high-quality maternity services
  • providing incentives for caregivers and facilities to improve their services
  • helping policymakers see and address problems 
  • giving focus to local quality improvement efforts
  • encouraging national agreement about maternity care quality.

Measure developers, NQF, and others are working to refine and expand the original maternity care measure set. Measures are needed for the entire course of prenatal through postpartum care and for individual providers, provider groups, hospitals and birth centers, accountable care organizations, health plans, and states.

What is transparency in maternity care, and why is it important?

Transparency is the opposite of privacy. Transparency means making information about maternity care practices and outcomes of caregivers, facilities, health plans, and other entities fully available to the public. Transparency is needed to evaluate the quality of maternity care, help with decision making, and promote quality improvement. 

Rates of medical interventions during labor and birth, including labor induction, cesarean section, and episiotomy, vary widely from caregiver to caregiver, facility to facility, and place to place. The wide variation has little to do with differences in the needs or preferences of women. It primarily reflects differences in styles of practice, maternity markets and other factors that should not influence care. Your choice of caregiver and choice of where to give birth are major decisions that impact the kind of care that you experience during childbirth.

Many women wish to avoid routine, unneeded childbirth interventions. How can a woman find a caregiver and place of birth with, for example, relatively low episiotomy or cesarean rates?  This type of information is increasingly collected and reported, and this website includes links to state-level maternity care performance websites.

What maternity care procedures are being overused in the United States?

Optimal maternity care follows the principle of "effective care with least harm." Yet many interventions with harmful side effects are widely used in the United States, even when there is little or no expected benefit for mother or baby and safer, effective approaches are available. Numerous maternity practices developed for specific needs of a small portion of mothers are now used frequently — even routinely — in healthy women. Practices that are widely used despite lack of evidence of clear benefit include some routine prenatal tests and treatments, continuous electronic fetal monitoring, rupturing membranes during labor, and episiotomy.

Labor induction is another important example of an overused maternity practice. While induction is occasionally of value in certain circumstances, induction for convenience — the mother's convenience, the caregiver's convenience, or both — is increasingly common. Also, labor induction is being done for "reasons" that do not in fact improve health, such as "fetus seems large." Increased use of labor induction is leading to more babies born before they reach 40 weeks of gestation, even though the development of the fetus's brain, lungs, and other organs continues up to that time and babies born earlier are more likely to have problems. In addition, labor induction leads to an increased chance of c-section in first-time mothers and when a woman's cervix is not soft and ready to open.

Epidural analgesia is also used more widely than necessary. Mothers are given epidurals routinely as the "first line of defense" for labor pain. Not only is this routine use of epidural analgesia expensive, an epidural poses extra challenges for women and fetuses and can lead to use of many additional interventions. For example, this procedure can impair a woman's ability to move during labor, and later to push, decreasing the chance of a "spontaneous" vaginal birth with no vacuum extraction, forceps or cesarean. Using labor support, tubs, and other pain relief measures first, then moving to an epidural if needed, makes more sense for the health of mothers and babies.

The rate of cesarean section in the U.S. has been increasing steadily for more than a decade, and now reaches a new record level each year. Both the rate of "primary" or first-time cesareans and the rate of repeat cesareans are rising. Recent research reaffirms earlier World Health Organization guidance that optimal national cesarean rates are in the range of 5% to 10% of all births, while rates above 15% are likely to do more harm than good (Althabe and Belizán 2006). However, one woman in three now gives birth this way. Many factors contribute to this trend, and most are not related to the needs of women and newborns. Many women lack good information about the numerous risks of c-section for both mother and baby and the benefits of vaginal birth.

In many cases of medical intervention — including labor induction, epidural analgesia, and cesarean section — one intervention requires many others to monitor, prevent, or treat side effects of the first intervention. This "cascade of intervention" increases the risk of maternal or newborn harm and greatly increases costs.

What safe and effective maternity care practices are underused in the United States?

Optimal maternity care is the safest care that is also effective care. Many beneficial practices for mothers and babies are underused in the United States.

For prenatal care, underused beneficial practices include prenatal vitamins, help with quitting smoking, breastfeeding support programs, and caregiver hands-to-belly movements to turn "breech presentation" fetuses to a head-first position before birth to avoid cesarean section.

Underused practices around the time of birth that can improve outcomes for mothers and babies include continuous labor support; use of tubs and other non-drug methods to help with labor pain; upright and side-lying positions for giving birth; delayed cord clamping; early mother-baby skin-to-skin contact; various measures to support breastfeeding; and counseling for women with postpartum depression. 

For women who have had a previous cesarean section, a vaginal birth after cesarean (VBAC) is often the best option for birth, with the least chance of short and long term harm to mother and baby. Yet VBAC is underused and often unavailable. Many pregnant women who have had a previous cesarean section cannot find caregivers or hospitals offering VBAC as an option.

Maternity care providers other than obstetricians are also underused in this country.  Best available research has shown that mothers who choose midwives as their lead maternity caregivers experience reduced likelihood of episiotomy, labor induction, electronic fetal monitoring, pain medications, forceps, artificially ruptured membranes, and low birthweight infants.  Studies also show that women who choose midwives are more likely to be satisfied with their care. Yet fewer than 10% of women use midwives as their lead maternity caregivers.

Why do mothers and babies benefit from physiologic childbirth?

With protection from interference and good support, childbearing women and their fetuses/newborns experience effective innate, hormonally-driven processes that have developed over the course of evolution. These processes begin at the onset of labor, continuing through the birth of the baby, delivery of the placenta, and then through the establishment of breastfeeding and mother-baby attachment. When caregivers give priority to facilitating these capacities, most mothers and babies can avoid medical procedures and drugs that push and pull labor along, often with side effects.

The great majority of expectant mothers in the U.S. are healthy and at low risk for complications during childbirth. While much attention is given to the important needs of pregnant women with medical problems, or to those women who are at high risk of experiencing problems (about 1 in 6 pregnant women), we also need to ensure that healthy childbearing women receive high-quality care that is safe, effective, woman and family-centered, timely, efficient and equitable.


Althabe F, Belizán JM. Caesarean section: The paradox. Lancet 2006;368(9546):1472-73.

Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press, 2001. Available at: http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

International Federation of Health Plans. 2010 comparative price report: Medical and hospital fees by country. Available at: http://ifhp.com/documents/IFHP_Price_Report2010ComparativePriceReport29112010.pdf.

Organisation of Economic Co-operation and Development. OECD health data 2010. Paris: OECD, October 2010.

Rosenblatt RA. The perinatal paradox: Doing more and accomplishing less. Health Aff 1989;8(3):158-68.

World Health Organization. World health statistics 2010. Geneva: WHO, 2010. Available at: http://www.who.int/whosis/whostat/2010/en/index.html

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Most recent page update: 6/22/2011

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Founded in 1918, Childbirth Connection has joined forces with and become a core program of the National Partnership for Women & Families. Together, these two women's health powerhouses are transforming maternity care in the United States.
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