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

Summary

In high-income countries, medical interventions to address the known risks associated with pregnancy and birth have been largely successful and have resulted in very low levels of maternal and neonatal mortality. In this Series paper, we present the main care delivery models, with case studies of the USA and Sweden, and examine the main drivers of these models. Although nearly all births are attended by a skilled birth attendant and are in an institution, practice, cadre, facility size, and place of birth vary widely; for example, births occur in homes, birth centres, midwifery-led birthing units in hospitals, and in high intervention hospital birthing facilities. Not all care is evidenced-based, and some care provision may be harmful. Fear prevails among subsets of women and providers. In some settings, medical liability costs are enormous, human resource shortages are common, and costs of providing care can be very high. New challenges linked to alteration of epidemiology, such as obesity and older age during pregnancy, are also present. Data are often not readily available to inform policy and practice in a timely way and surveillance requires greater attention and investment. Outcomes are not equitable, and disadvantaged segments of the population face access issues and substantially elevated risks. At the same time, examples of excellence and progress exist, from clinical interventions to models of care and practice. Labourists (who provide care for all the facility’s women for labour and delivery) are discussed as a potential solution. Quality and safety factors are informed by women’s experiences, as well as medical evidence. Progress requires the ability to normalise birth for most women, with integrated services available if complications develop. We also discuss mechanisms to improve quality of care and highlight areas where research can address knowledge gaps with potential for impact. Evaluation of models that provide woman-centred care and the best outcomes without high costs is required to provide an impetus for change.

Introduction

Global efforts to end preventable maternal and newborn mortality have appropriately focused on addressing of known risks associated with pregnancy and birth. This approach has been the great success of medical intervention in high-income countries (HICs), resulting in very low maternal mortality (12 deaths per 100 000 livebirths) and neonatal mortality (four deaths per 1000 livebirths).1, 2 HICs virtually guarantee antenatal care and a skilled birth attendant, and generally have institutional births, which can provide appropriate emergency care for complications.

The new era of Sustainable Development Goals (SDGs)³ brings HICs under the accountability lens, providing an opportunity for timely reflection on the status of maternal health and its drivers in these countries. Although mortality is generally low, the picture is far from perfect. Care varies greatly, not all care is evidenced based, and some care might actually be harmful. In some settings, fear prevails among subsets of women and providers, driving increased and inappropriate intervention. Medical liability costs are enormous, human resource shortages are common, and costs of provision can be very high. Outcomes are not equitable, and disadvantaged subpopulations can face substantially elevated risks. New challenges linked to changing epidemiology, such as older age at birth and increased obesity are also present. At the same time, examples of excellence and progress are evident, from clinical interventions to models of care. This Series paper presents the main drivers of the models of maternity and childbirth care in 14 HICs, and their influences on outcomes. Drivers are factors that cause a particular phenomenon to happen or develop. This Series paper also includes mechanisms and research direction to promote evidence-based change and woman-centred care.

To explore potential drivers, including cost, we compared available national data from 14 representative HICs. We also draw on the scientific literature, particularly reviews, to identify additional potential drivers (methods are shown in the appendix).