Drivers of maternity care in high-income countries: can health systems support woman-centred care?

Paper 4 in the Lancet Maternal Series explores the main models used to deliver maternity care in high-income countries. It examines the drivers of these models, looks at case studies from the USA and Sweden, and discusses how the models influence the health of mothers and babies.Maternity care has been largely successful in high-income countries (HICs) evidenced by the low mortality rates for mothers and newborns. In these contexts almost all births occur with a skilled provider and most occur in a facility. However, there are a wide variety of models of delivering care and practices, cadres of staff, types of facilities and places of birth varies greatly across these settings. Some care practices are not evidence based and some of those may be harmful. Quality still needs to be improved in HICs.In some places the cost of medical liability is a major issue. In some countries fear (amongst some women and providers) is contributing to overuse of interventions e.g. caesarean section. Staff shortages and the high costs of providing quality care create problems in some contexts. Equity remains an issue for high-income countries. Women who are disadvantaged face substantially higher risks.Key messages:

• All women should have access to woman-centred care that supports safe birth with the lowest level possible interventions
• Midwifery-led care, in various models, has been integrated in the countries which have the lowest intervention rates, lowest costs and best outcomes.
• Protocols, drill and simulation in team training are important for maternal safety.

Care delivery models in high income settingsBirth-setting

• Few women give birth at home, except in the Netherlands where 20% do so.
• Most women in HICs give birth in hospitals. They are well designed for high risk women but might not be optimal for low risk women:  over monitoring and unnecessary interventions are common and can cause avoidable harm.
• ‘Hospital cited midwifery-led birthing units’ (birthing units located at hospitals that are midwifery led) have been implemented as a solution to this as rates of intervention are lower and mothers’ satisfaction is higher at no additional risk.

Costs

• Costs are much higher in the USA than other HICs.
• In general, costs in HICs are increasing, largely due to a trend towards more interventions.
• More spending improves some outcomes, e.g. for premature babies. Increasing caesarean sections and induced labour are major cost drivers.
• Birth centres and home births have been shown to have lower costs than hospitals.

Size and location

• The trend is toward closure of units and fewer, larger units meaning greater travel for some rural women. Research findings are mixed on the impact for health outcomes.

Best practice in surveillance and reviewThe authors emphasise the need for better data to inform practice, especially data that is feasible to collect given resources available, timely, reliable and useful for action. Audit data particularly is needed as it gives details of both the clinical and social circumstances that lead to the death. However, many HICs lack strong surveillance systems. UK Confidential Enquiry into Maternal Deaths is given as the best example of a maternal death surveillance system. The UK Enquiry example is used to show that maternal death audits and surveillance of severe maternal morbidity are complimentary and can inform policy and improve quality, and ultimately reduce preventable deaths.The shift in the epidemiology and demography of births in these countries also creates new challenges, for example births occurring at older ages and higher rates of obesity. In the UK, for example, 74% of maternal deaths were to women who had an existing medical condition.To read the article click here. Free registration is required.Shaw, D., Guise, J.M., Shah, N., Gemzell-Danielsson, K., Joseph, K., Levy, B, Wong, F., Woodd, S. & Main, E. (2016). Drivers of maternity care in high-income countries: can health systems support woman-centred care? The Lancet, Maternal Health Series Paper 4, (Early online publication).