What Employers Can Do to Make Childbirth Safer in the U.S.

When it comes to maternal and infant outcomes from childbirths, the United States has a worse record than other developed countries. Employers can help address this major problem by taking these steps: improve the design of benefits, mandate that health plans provide information on the quality of care to their members, require plans to routinely report to them on the quality of care, ask plans to pay providers for value, and push plans to highlight quality providers for employees and their families.

Childbirth in the United States is dramatically more dangerous than in other developed countries, but it doesn’t have to be this way. Employers, who pay for just over half of deliveries in the United States, can drive improvement in maternal and infant outcomes through thoughtful benefit design and by demanding accountability from health plans and improved performance from providers.

Here are some disturbing facts:

• According to recently released data, over 1,200 women died within 42 days of childbirth in the United States in 2021, the latest year for which data is available. That’s an increase of over 80% compared to 2018.
• Between 50,000 and 60,000 women each year have life-threatening complications of pregnancy. These complications are distressingly common whether mothers are insured by commercial insurance or Medicaid.
• Disparities in maternal safety remain the norm. Maternal mortality is nine times higher for Black women, and not because of income disparities. Infant mortality for Black babies of families in the top 5% of family income is higher than infant mortality of white babies of families in the bottom 5%.

Bad pregnancy outcomes in the United States are not because the country spends too little on maternal care. The average delivery costs $19,000, and out-of-pocket costs average $3,000. This high cost is in part because the United States has more surgical deliveries than other countries. Almost a third of live births (32%) are delivered by Cesarean section (C-section) in the United States. Costs for employer-sponsored health insurance could be $1 billion lower if this rate were 23.6%, the target in the U.S. Department of Health and Human Service’s Healthy People 2030.

Employers can take five specific actions to drive meaningful changes.

1. Improve the design of benefits.

Employers can design benefit plans to support healthy births. Health insurance plans with affordable out-of-pocket costs can encourage early prenatal care and reduce the financial worries of new parents. Employers can include women of childbearing age in programs that address metabolic diseases, including obesity, hypertension, and diabetes prior to and during pregnancy. Adequate parental leave can decrease stress and promote parental bonding.

Offering access to doulas, nonmedical professionals that provide women with emotional, physical, and educational support during pregnancy, labor, and after the birth, can help address racial disparities in maternity care. Nurse midwives and birth centers also have fewer C-sections and can offer more culturally inclusive care.

Given that depression and other mental health issues are common during pregnancies and after births, plans should also provide access to culturally appropriate mental health care. Separately, contraception benefits in plans should allow new parents to space their pregnancies, reducing risk of complications from subsequent pregnancies.

Finally, employers can support virtual care and coaching to support health before, during, and after pregnancy. Such programs can help members better navigate physical, mental, and financial needs through pregnancy, explain care options, and avoid gaps in care.

2. Make health plans provide information about quality of care to members.

Employers can insist that health plans provide information to members who are pregnant or contemplating pregnancy to help them make the best decisions for their health. This includes directories that list nurse midwives, birth centers, doulas, and birth coaches, even if some services (e.g., doulas) are not covered by the plan. Some plans already do this for Medicaid beneficiaries.

Directories can also provide information about hospital quality of care, including rates of C-sections (especially for women at low risk) and for trials of labor (attempting to determine if a vaginal birth is possible) for those who have had previous C-sections. Perinatal collaboratives promote best practices and data sharing among maternity providers. Health plan directories can inform members which hospitals participate in these activities.

3. Require plans to routinely report on the quality of maternal care.

Employers can insist that health plans provide accurate and timely reporting (at least quarterly for large employers but perhaps annually for small employers) on the quality of care provided to employees and their dependents. Reporting should include total and low-risk C-section rates, trials of labor and vaginal birth after C-section (VBAC), deliveries before 39 weeks without medical indication, and serious maternal morbidity. This data should be segmented by race to identify racial disparities that need to be addressed. For smaller employers, this information should be the health plan’s overall experience, since an individual employer’s claims might have too few data points to identify patterns.

Employers should advocate for health plan quality metrics to be aligned with national standards to have the largest impact on provider practice. Increased employer attention will drive health plans to dedicate more resources to measuring and improving maternal health.

4. Ask plans to pay providers for value.

Medical plans have long paid obstetricians a “bundled payment” for medical care provided before, during, and after the delivery, so that there is no financial incentive for obstetricians to perform C-sections. But carriers almost always pay hospitals substantially more for C-sections, even though hospital resource costs are similar for vaginal deliveries due to longer time in labor and delivery. Therefore, many hospitals have a far higher margin for routine C-sections than for vaginal deliveries. It’s no wonder that many hospitals have C-section rates of 40% or more. A “blended” facility payment that pays the same for vaginal and C-section deliveries will encourage hospitals to reduce unnecessary C-sections.

Carriers can also offer hospitals financial incentives to participate in perinatal collaboratives. These collaboratives help hospitals implement evidence-based bundles of care for serious complications of pregnancy and measure their effectiveness. The California Maternal Quality Care Collaborative was associated with a substantial decrease in maternal mortality in that state.

5. Push plans to highlight providers of high-quality care for employees and their families.

So-called “centers of excellence” in health care all too often end up being centers of mediocrity. To address this problem, employers can insist that carriers design networks that limit designations such as “centers of excellence” or “preferred providers” to providers that have genuinely better processes and outcomes.

This can include a requirement that such hospitals prohibit early deliveries that are not medically indicated, offer vaginal birth after C-section (VBAC), have maternity review boards, report to external entities such as the Leapfrog Group, and participate in perinatal collaboratives. Hospitals with high rates of serious maternal morbidity or excessive operative interventions should never be designated as preferred facilities for childbirth.

Employers can tailor their benefits and influence health plans and providers of maternity care to make childbirth in America far safer. By doing so, they can both reduce the costs of maternity care and improve outcomes.