Supporting Non-Hospital Birthing Options: Employer Strategies to Improve Quality

Maternal infant health outcomes in the U.S. remain the worst among high-income countries, and Black women in the U.S. are nearly three times more likely to die from pregnancy-related complications than white women are. Additionally, U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.

To underscore the high costs disproportionate to the poor maternal health outcomes, the cost of maternity care represents American employers’ second-highest annual health care expenditure – $1 in every $5. Faced with unacceptable results, employers are looking for pathways to improve maternal health care quality, affordability and the overall patient experience.

Improving Quality and Lowering Costs

Consumer surveys have shown that more patients are seeking non-hospital, community-based childbirth options, such as midwives, doulas and birth centers. This is particularly true for birth participants of color who are looking for alternatives to the hospital-physician childbirth experience.

Recent CDC 2020 vital statistics data mirror what we have seen from consumer surveys. Although overall births declined, in 2020 the number of births in birth centers nearly doubled.  This is a significant indication that more women want choice in their maternity care team and care location and that more families, when given a choice, are seeking a non-hospital childbirth option.

Non-hospital maternity care options can help to address the problem of high-cost, low-quality care. Evidence shows the use of midwives improves overall maternal and infant health and decreases the cost of maternity care. In fact, research shows that collaborative care led by certified nurse midwives can result in 22% fewer primary C-sections. It also helps address a growing shortage of perinatal health providers. Despite these benefits, however, certified nurse-midwives are vastly underutilized, delivering only 9% of babies nationally.

A birth center is a midwife-led childbirth facility that offers individuals and families a more natural, lower intervention and less medicalized childbirth experience. Birth centers are freestanding facilities and separate from acute obstetric or newborn care where care is provided in the midwifery and wellness model of care. Birth centers typically have relationships with other community health providers and arrangements with other facilities, such as hospitals, for transfers to other levels of care when needed.

The CMS Strong Start program demonstrated that women who received prenatal care in birth centers had better outcomes and lower costs. This included lower rates of:

• Preterm births
• Low birth weight
• C-sections

Additionally, costs were more than $2,000 lower per mother-infant pair during birth and the following year for women who received prenatal care in birth centers.

How Purchasers Can Support Non-Hospital Options

Employers know that improving maternal health outcomes in the U.S. and reducing disparities will require changes to the existing system of care to make it more patient centered. Here are three ways employers can influence the health system and health plan leaders’ perspectives to address the barriers preventing birth center expansion, collaboration between hospitals and birth centers and access to midwives:

• Benefit design: Benefits programs can be designed to expand access to midwives and birth centers. For example, eBay has started covering out-of-network midwives at in-network rates to improve access to community providers.
• Payment and contracting: By paying for care differently and moving towards value-based payment rather than fee-for-service models, employers can greatly improve access to high-value facilities such as birth centers. A simple birth center bundled payment model would allow all prenatal, labor and delivery and postpartum care provided by the birth center to be captured under one claim/invoice. A bundled payment project with Qualcomm produced valuable lessons learned that could benefit other employers pursuing a bundled payment option.
• Quality improvement: In the event of a transfer from a birth center to a hospital, the transfer process is smooth and respectful for the patient and their family. PBGH is leading a project in California to establish a model to inform procedures regarding transfers.

In response to the lack of comprehensive, coordinated care and the overmedicalization of childbirth PBGH has developed several strategies to help employers impact their maternity marketplace.