The Centers for Medicare and Medicaid Services (CMS) added a new designation to identify which hospitals are “Birthing-Friendly”—a label it will begin adding to qualifying hospitals in fall 2023.
The designation aims to reduce maternal mortality and complications in the US; maternal mortality rose by 25% in 2020, and Black women die at nearly three times the rates of white women, according to a CDC report from February. The US ranked last in maternal mortality that year compared to 10 other high-income countries, according to the Commonwealth Fund.
To earn the designation, CMS said, hospitals must participate in a statewide or national collaborative program where medical teams and public health leaders work together to improve care quality for birthing parents and babies. Hospitals that opt in qualify for an operating payment rate increase of 4.3%, a much-needed boost for hospitals struggling with profitability in the wake of the Covid-19 pandemic and inflation.
“It’s a starting point,” said Missy Danforth, vice president of healthcare ratings at The Leapfrog Group, a nonprofit that collects and publishes hospital and outpatient surgery center safety and quality data. “Maternal mortality is one of the biggest problems in patient safety in this country right now. It’s encouraging that CMS is moving in the direction of establishing the infrastructure for a ‘birthing-friendly’ hospital designation.”
But there’s no single set of metrics that hospitals will be required to follow to earn CMS’s new designation, and any changes they make may depend on what areas need improvement. For example, hospitals could focus on reducing pregnancy complications and early births, which happen before 39 weeks, according to the CDC.
CMS’s designation—at least in its initial form—isn’t tied to outcomes, Danforth emphasized. However, medical professionals said there are a variety of measures and outcomes that have been shown to make a hospital truly birthing-friendly.
Why C-sections matter
When it comes to measuring maternal-care quality, one metric comes up over and over again: a hospital’s C-section rate, said Holly Loudon, chair of obstetrics, gynecology, and reproductive science at Mount Sinai West and Mount Sinai Morningside in New York City.
Certain medical conditions, like high blood pressure during pregnancy or other circumstances, like a baby not getting enough oxygen or with an irregular heartbeat during birth, may precipitate the need for a C-section. But often it’s performed when medically unnecessary, raising the risk for everything from bleeding to infection compared with vaginal birth.
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“C-section rate definitely is driven more by the hospital than the individual patient or physician,” Loudon said. “So there are hospitals that have a culture of a high C-section rate.”
A patient may elect to schedule a C-section for planning purposes or for other reasons, like if a previous vaginal delivery was difficult. A C-section generally isn’t recommended for a low-risk pregnancy.
The federal government set a goal to decrease the national C-section rate from 25.9% in 2020—the most recent data available—to 23.6% of low-risk births among women who hadn’t given birth previously.
Eyeing other metrics
Cynthia Gyamfi-Bannerman, chair of the department of obstetrics, gynecology, and reproductive sciences at UC San Diego Health, said physicians should not induce a pregnancy before 39 weeks without a medical reason.
Ob-gyns are increasingly emphasizing a less-is-more approach to labor and delivery. That involves taking a cautious, judicious approach to interventions, while still monitoring closely and providing supportive care during and after birth.
Birthing parents would ideally also be supported in a way that fits their preferences, such as having the assistance of a doula or midwife, Loudon said. This may confer a safety benefit as well, where research has found C-section rates go down when women with low-risk pregnancies give birth in a hospital and receive care from a midwife. (Some state Medicaid programs and cities are working to improve access to doulas for lower-income people, but other birthing parents might be hamstrung by insurance, cost or the number of providers in their area).
CMS will not have full-year data on the uptake until spring 2023.
“While we were really pleased to see that CMS is taking a step in this direction, basically to have a maternity-care designation, we also hope that it’s something that they build on and expand over the coming years,” Danforth said.