New National Maternity Care Performance Measure Set: A Much-Needed Tool to Improve the Health of US Women and Children

by Carol Sakala, PhD, MSPH

There are serious problems with the quality of maternity care in the U.S. On the one hand, there is widespread "overuse" of practices that expose women and babies to harm while offering little or no benefit. Examples include breaking open the "bag of waters," giving birth while lying on one's back, liberally cutting episiotomies, and record-level rates of labor induction and cesarean section. On the other hand, many effective care practices are "underused", such as interventions to help pregnant women quit smoking or to promote breastfeeding. Additionally, many healthy women who would like to have a vaginal birth after cesarean (VBAC) cannot find a willing caregiver or hospital and are forced to give birth by major abdominal surgery.

Despite spending far more on health care than all other nations, the U.S. has worse outcomes than many others on basic indicators of maternal and newborn health. For example, in 2003, of the Organisation for Economic Co-operation and Development’s 30 member nations, 23 countries had better low birthweight rates, 14 had lower perinatal mortality rates, and 19 had lower cesarean rates. Rates of preterm birth and low birthweight have steadily worsened in the U.S. in recent decades, and growing evidence suggests that the common practices of planned cesareans and labor induction contribute to this troubling trend. Following a steady decrease through most of the last century, maternal mortality stagnated in the 1980s and 90s, and may now be rising. With 4.3 million births annually in the U.S., these trends impact many women and newborns. This style of care also takes a financial toll on employers, taxpayers, and families who pay the maternity bills. Hospital charges for the primarily healthy population of birthing women and newborns — $86 billion in 2006 — far exceeded charges for any other condition. This situation has been called "the perinatal paradox: doing more and accomplishing less."

To date, awareness about the troubling deficiencies in maternity care has been limited, and policies and programs have not resolved the problems. Hopefully, this situation will soon improve. Advocates for childbearing families are enthusiastic about new resources from the National Quality Forum (NQF) to improve the quality of maternity care. This non-profit organization recently completed a project to identify, refine, and endorse national standardized performance measures for care around the time of birth. The new measures will be used to assess the performance of facilities, clinicians, group practices, integrated systems, and/or communities.

NQF is the consensus standards body that endorses national health care performance measures. Sound measures allow us to evaluate and compare the performance of specific components of the health care system such as hospitals or group practices of health care providers. In keeping with the philosophy that “what gets measured gets done,” the new performance measures will focus attention and effort on improving critical aspects of maternal and child care. While use of the new NQF measures is voluntary, measuring performance and leveraging results are critical tools to drive improvements in the quality of the nation’s health care system. Professionals and facilities can use the reported results to improve their practice, build confidence and morale, and attract pregnant women to their services. Childbearing women can use publicly reported results to make informed choices about their maternity caregivers and place of birth. Purchasers of health services can use performance measures to make contract decisions, such as whether to contract with a group practice or to reward high performers and "pay for performance." The measures can help drive quality improvement by focusing all of these groups on similar aims.

NQF conducts its work through a rigorous and systematic "consensus development process" involving diverse stakeholders. For this project, it convened a multi-disciplinary Steering Committee co-chaired by Maureen Corry, the Executive Director of Childbirth Connection and a leader within NQF's Consumer Council, and Laura Riley, who was nominated by the American College of Obstetricians and Gynecologists (ACOG). The Steering Committee considered whether existing performance measures met established criteria for sound measures, worked to improve some measures, and recommended the best ones for endorsement. NQF member organizations and the public had an opportunity to provide comments; in fact, this topic generated more feedback than any previous NQF project and some comments were used to improve the measures. Member organizations then had an opportunity to vote on individual measures. Ultimately, the NQF Board of Directors endorsed 17 measures to assess care provided to birthing women and newborns.

The following newly-endorsed performance measures have the potential to improve care for a large proportion of childbearing women and newborns in the U.S. by focusing attention on these outcomes and driving rates in a beneficial direction:

• Elective Delivery Prior to 39 Completed Weeks Gestation: intended to greatly reduce the number of babies who are born too early due to induced labor or a planned cesarean.
• Cesarean Rate for Low-Risk First-Birth Women: intended to reduce this overused and invasive procedure by focusing attention on a low-risk subgroup.
• Incidence of Episiotomy: intended to curb overuse of this procedure, which poses risks and rarely offers benefits.
• Exclusive Breastfeeding at Hospital Discharge: intended to increase the rate of exclusive breastfeeding, which is desired by many women and recommended by many professional groups.

Despite the new path-breaking perinatal care measure set, maternity care performance measurement has a long way to go. It will be important to use the measures to assess performance and to ensure that key groups have access to current data. Entities with a stake in the results include State and Federal governments, employers, hospitals, health systems, maternity providers and childbearing women themselves. While pregnant women have much to gain from results of performance measurement, many are likely to need help understanding the value and meaning of this useful, but somewhat technical, information. The Steering Committee also identified crucial areas where new measures are needed, including measures of women's experiences of care; measures to address issues related to VBAC; and a "normal birth" measure, which is well-established in the United Kingdom but has not been adapted here yet. Measures are also needed to foster high-quality care during pregnancy and in the postpartum period, and to coordinate care across settings and caregivers, which were largely outside the scope of the recent project.

In addition to this project, NQF has completed, or is working on, many other consensus standards projects of special relevance to women's health. These include projects on cultural competency, informed decision-making, mammography center quality, and nursing home care. NQF recently launched a bold initiative to identify and target national priorities for health care quality improvement. There are some ways for individuals to become involved (e.g., by commenting on NQF projects and attending semi-annual conferences), but most work occurs through the NQF’s 400+ member organizations. If you are interested in being part of the NQF’s work to improve health care quality, visit the organization’s website at http://www.qualityforum.org. NQF’s Consumer Council and seven other sector-specific councils (e.g., health professionals, health plans, public/community health agencies) provide excellent opportunities for collaborating to improve national health policy. NQF’s sliding membership fee scale encourages broad participation from health-related organizations.

The final new report, National Voluntary Consensus Standards for Perinatal Care, will be available in the Completed Projects area of NQF's website.

 Carol Sakala is Director of Programs at Childbirth Connection and is the organization's primary liaison to the National Quality Forum. She worked closely with Maureen Corry and other organizations to foster a woman- and family-friendly perinatal measure set and recommendations.