Reducing Maternal Mortality: Will the ‘Birthing-Friendly’ Hospital Designation Help?

­The Centers for Medicare and Medicaid Services (CMS) issued a final rule in August 2022 to improve maternal health outcomes and advance health equity — two of the Biden-Harris Administration’s key priorities. Maternal mortality remains a critical problem in the U.S., which has more than triple the rate of most other high-income countries. Sadly, U.S. rates are continuing to rise.

The CMS rule included new equity measures, updated policies, and increased payments to help reverse the trend. The new measures included the Birthing-Friendly hospital designation to help reduce maternal mortality and morbidity. What kind of impact can we expect from this designation and other initiatives in the CMS rule?

Maternal mortality is closely linked to social and behavioral factors

As documented extensively, higher U.S. maternal mortality rates persist, especially in underserved communities. Non-Hispanic Black, non-Hispanic white, and Hispanic mothers experience significantly higher rates of maternal mortality and morbidity than white mothers in the U.S.

Variation in care and access to care at the patient, provider, and system levels is linked to inequities that often lead to poor maternal health outcomes. While well-served areas have access to providers, facilities, and resources to help ensure that every patient receives quality care, underserved areas often do not have the same levels of access and resources.

Social determinants of health

Individuals and communities that are negatively impacted by social factors experience more negative health impacts. Known as the social determinants of health, these social factors include socioeconomic status, education, food security, exposure to violence, housing, social support, and others.

Not surprisingly, traditionally marginalized communities are the ones who are most often impacted by social determinants that prevent them from receiving the care they need. Efforts to change the narrative on U.S. maternal mortality must address these social inequities.

Maternal mental health

Another critical factor that does not get enough attention is maternal mental health, which is an underlying cause of more than 10% of pregnancy-related deaths in the U.S. Peripartum depression, which a mother can experience before, during, and/or after having a baby, often goes undetected or undiagnosed. It can occur with or without previous mental health factors, such as depression, anxiety, substance abuse, or domestic risks.

We must improve care in this area of maternal health by strengthening screening, diagnosis, treatment, follow-up, and ongoing care using recommended screening tools and evidence-based best practices, as well as developing innovative culturally appropriate community-based programs.

It is important to focus on clinical protocols and reduction in practice variation. But it’s also important to adopt a holistic view of the maternal healthcare experience. In our previous research, we examined correlations between mental health, social determinants, and maternal mortality and morbidity. Both clinical and behavioral factors contribute to maternal health outcomes.

Practices that can help address both areas include integrating behavioral health clinicians into the treatment team and connecting patients with critical resources. Managing gaps in mental health services by expanding the scope of services offered, increasing training on mental health for all staff, and reviewing documentation practices can also help. Ensuring that behavioral health and medical documentation are in the same system can help integrate and improve care.

During discharge planning when documenting in the electronic medical record, the care team should perform a thorough assessment of behavioral and social risks and act on any identified risks to ensure appropriate evaluation and care. This would involve putting resources into place prior to discharging the patient — not just checking a box. Collaborative care models can save lives.

What is the Birthing-Friendly designation?

The Birthing-Friendly hospital designation is one of five initiatives relating to care quality within CMS’ Maternity Care Action Plan. Hospitals can attain this designation by attesting that they participated in a state or national perinatal quality improvement program and implemented recommended interventions.

In addition to improving care, the designation will provide information to the public about a hospital’s commitment to “implementing best practices to advance healthcare quality and safety for pregnant and postpartum patients.” CMS will post data from participating hospitals on its Care Compare website annually each fall beginning in 2023.

The Birthing-Friendly designation provides an outward-facing component for the CMS’ previously issued Maternal Morbidity Structural Measure, which called for an attestation by hospitals stating that they participated in a structured perinatal quality improvement program and implemented patient safety practices or bundles as part of their quality initiatives. We still need clarity on what these attestations mean and what initiatives will qualify as meeting these requirements. Let’s take a look at other components that have been communicated by CMS.

What is in the Maternity Care Action Plan?

The Maternity Care Action Plan has a range of initiatives — including the Birthing-Friendly designation — that span the following five areas:

1. Coverage and access to care
2. Data
3. Quality of care
4. Workforce
5. Social supports

Coverage and access to care

The first section of the Maternity Care Action Plan addressed access to care. Ensuring access through Medicaid, Medicare, the Health Insurance Marketplace, or another payer is the first consideration for improving national maternal health outcomes. Quality peripartum care for every mother is fundamental to ensuring a successful birth experience and healthy baby. No mother or baby should experience a lack of care.

The plan aims to help close care gaps in regions and populations that lack access. Initiatives include guaranteed access to Medicaid for a year after pregnancy, protection for patients’ access to emergency care after Dobbs v. Jackson under the Emergency Medical Treatment and Active Labor Act (EMTALA), access to the full range of contraceptive coverage, and assistance for those who lose Medicaid eligibility after pregnancy. The plan referenced two additional existing efforts — Connecting Kids to Coverage and the No Surprises Act — which provide resources and protection for families.

Data collection

Data collection and measurement initiatives comprised the second section of the Maternity Care Action Plan. Three data-centered efforts build on CMS’ Hospital Inpatient Quality Reporting Program (which already requires hospitals to submit data) and the Maternal Morbidity Structural Measure (mentioned earlier).

The new data components include two electronic clinical maternal health quality measures relating to the number of inpatient hospitalizations for severe obstetric complications during delivery and the number of patients with low-risk pregnancies who have cesarean births. Cesarean deliveries raise the risk of maternal morbidity and mortality, especially when not medically necessary.

CMS also encouraged state Medicaid agencies to begin reporting on quality measures related to maternal health in a data set known as the Maternity Core Set beginning in 2024. CMS will conduct an equity assessment of postpartum care in Medicaid and the Children’s Health Insurance Program (CHIP) to identify disparities and opportunities to work with federal, state, and private entities to improve care.

Quality of care

The Maternity Care Action Plan section dedicated to the quality of care listed five initiatives, including the Birthing-Friendly hospital designation. The four other initiatives in this section involved soliciting public comments on hospital quality standards, promoting the reduction of low-risk cesarean births through the Maternal and Infant Health Initiative launched in 2020, encouraging hospital quality improvement, and seeking opportunities to expand access to intensive care for people with chronic health conditions.

While the Birthing-Friendly designation suggested a course of action for hospitals to follow, the other four initiatives were more exploratory in nature. It remains to be seen whether CMS will add accountability measures to ensure that actionable results come from these initiatives.

Workforce and social supports

The final two sections of the Maternity Care Action Plan outlined additional equity-related initiatives. The Workforce section addressed community-based pregnancy and childbirth care, specifically the work of doulas, community health workers, midwives, and freestanding birth centers. Acknowledging that few states have a robust network of these types of caregivers, CMS pledged to work with states to expand access to doula care and build connections among federal, state, and local partners.

CMS also pledged to work with state Medicaid agencies to link beneficiaries to social supports such as tenancy-related services, housing vouchers, and nutrition services. For example, people enrolled in nutrition assistance programs might not know they may be eligible to enroll in Medicaid to receive peripartum care.

Lastly, CMS created a screening tool for health-related social needs that will enable tracking of patients screened for food insecurity, housing instability, transportation needs, difficulty with utilities, and interpersonal safety concerns. Data reporting from this tool will become mandatory in 2024.

Anticipated impacts of the Maternity Care Action Plan

Maternal mortality in the U.S. is a complex and longstanding problem often rooted in societal inequities. The CMS rule acknowledged the important step of addressing disparities in care to improve outcomes.

However, it is not yet clear how the largely optional and self-selecting Birthing-Friendly designation will lead to sufficient widespread improvement. We still need answers to questions about which actions qualify a hospital for the designation and how additional data reporting and other initiatives contained in the Maternity Care Action Plan will work together to create real change.

Many of the initiatives in the plan will serve to raise awareness of different aspects of the maternal mortality problem. But to significantly reverse the trend, further work needs to happen. In many cases, this plan represents only the first stage of discussion.

Why education must be part of the solution

To make real progress, these initiatives must lead to action. Too many mothers are still experiencing completely preventable negative outcomes. Education can help ensure that everyone — from clinicians to healthcare leaders to policymakers — can work together to solve this multifaceted problem.

Healthcare providers must understand the needs of vulnerable populations and be able to incorporate knowledge from these dimensions into their practice. In some instances, this may require legislative changes so that CMS and/or the states can innovate to bring in resources — like known education solutions that improve outcomes — to their state hospitals.

Research has shown that assessment-driven obstetrical education improves outcomes. It is imperative to ensure that clinicians and providers have access to the most effective, high-quality education so they are better prepared to provide highly reliable care to everyone who needs it.