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Birth Settings in America: Outcomes, Quality, Access, and Choice (2020)

Chapter: 2 Maternal and Newborn Care in the United States

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Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Page 40
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 42
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 43
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 44
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 45
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 46
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 47
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 48
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 49
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 50
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 51
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 52
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 53
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 54
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 55
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 56
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 57
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 58
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 59
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 60
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 61
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 62
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 63
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 64
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 65
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 66
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
×
Page 67
Suggested Citation:"2 Maternal and Newborn Care in the United States." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Page 68

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

PREPUBLICATION COPY, UNCORRECTED PROOFS 2 Maternal and Newborn Care in the United States As discussed in Chapter 1, women in the United States give birth at home, in birth centers, and in hospitals. Across and even within these categories, the resources and services available can vary significantly. Women are cared for by a number of different health care professionals during pregnancy and birth, and these professionals differ in how they are educated, trained, licensed, and credentialed. Women also pay for care through different mechanisms, and the payment mechanism can affect what services, providers, and settings are available to them. State policies and regulations can affect a woman’s birth experience as well, through laws as to which providers can practice, their scope of practice, and the legal status of birth settings. This chapter provides a detailed look at the practices, resources, and services available in different birth settings; statistics and trends in birth settings; the education, training, credentialing, and practice of maternity care providers, as well as other clinicians and other members of the care team; and how policy and financing impact choices about birth experience. It is important to note that the perinatal care system in the United States is unique as compared with the systems of other countries in a number of ways. For example, the United States utilizes a regionalized system of maternity care that involves the potential for transfers from one level to another (American College of Obstetricians and Gynecologists, 2019a). This type of system requires strong relationships and communication between facilities so that individuals receive the appropriate level of care (American College of Obstetricians and Gynecologists, 2019a). The way that medical care is paid for in the United States is also unique, with women relying on a variety of mechanisms, including private insurance (both purchased individually and employer-sponsored), Medicaid, Medicare, and self-pay. Each of these payers has different eligibility requirements, covers services and providers differently, and entails variable out-of-pocket costs. Finally, the United States has three distinct nationally credentialed types of midwives, each of which completes different education and training requirements and whose authority to practice varies by state. These traits make maternity care in the United States complex, can make it difficult for women and families to negotiate the care system, and can have consequences for access to care and health outcomes. BIRTH SETTINGS In the United States, the vast majority (98.4%) of women give birth in hospitals, with 0.99 percent giving birth at home and 0.52 percent giving birth in freestanding birth centers (MacDorman and Declercq, 2019; see Chapter 1). Both across and within these three settings, 2-1

PREPUBLICATION COPY, UNCORRECTED PROOFS there are wide variations regarding approach to childbirth, available resources and services, birth attendants, and costs. Table 2-1 summarizes information on all three birth settings—home, birth center, and hospital—including the birth attendants that may be present and the services, supports, resources, and tools available to woman and newborns. This section provides further detail on these variations. See Chapter 6 for information about outcomes in each setting, and Chapter 7 for a discussion of initiatives to improve care and outcomes, such as the California Maternal Quality Care Collaborative. TABLE 2-1 Description of Attendants and Care across Birth Settings Home (Planned) Birth Center Hospital Prevalence 0.99% of U.S. births 0.52% of U.S. births 98.4% of U.S. births (85% of these were planned) Attendant Physician: 0.7% Physician: 2.7% Physician: 90.6% CNM/CM: 29.4% CNM/CM: 56.6% CNM/CM: 8.7% Other midwife: 50.7% Other midwife: 36.7% Other midwife: 0.1% Other: 19.1% Other: 3.9% Other: 0.5% Prenatal care Attendant provides 9–12 Pregnant woman attends Pregnant woman attends 9–12 prenatal visits in the 9–12 prenatal visits at prenatal visits at an outpatient office or at home; the birth center or an clinic or provider office; variable based on practice affiliated outpatient generally, that provider has clinic privileges to attend birth at the hospital or an arrangement for another provider to do so Birth Attendant provides 1-to-1 Attendant provides 1-to- Majority of hands-on care is continuous management 1 continuous usually provided by a labor and of labor in the woman’s management of labor in delivery nurse; birth attendant home; a second attendant the birth center; a second may be midwife (CM or CNM), or birth assistant attends attendant or birth family medicine physician, the birth along with the assistant attends the obstetrician, or maternal-fetal primary attendant birth along with the medicine specialist primary attendant Fetal Fetal assessment usually Fetal assessment usually Fetal assessment usually occurs assessment occurs via intermittent occurs via intermittent via continuous electronic fetal auscultation auscultation; however, monitoring; however, some some birth centers may hospitals offer periodic use periodic electronic electronic fetal monitoring or fetal monitoring intermittent auscultation Availability Licensed midwives carry Birth centers supply In addition to medications and of oxygen, neonatal and oxygen, neonatal and operative interventions to interventions adult resuscitation adult resuscitation prevent and manage postpartum equipment, suturing equipment, suturing hemorrhage, interventions and equipment, and equipment, and procedures that may be offered medications for medications for in the hospital setting that are preventing or managing preventing or managing generally not offered at home postpartum hemorrhage; postpartum hemorrhage; or in birth centers include attendant may offer deep birth centers generally medications to ripen the cervix tubs for pain relief in have deep tubs for pain (Cervidil or misoprostol) or labor relief in labor, and some induce or augment labor also offer nitrous oxide (Pitocin), epidural anesthesia, 2-2

PREPUBLICATION COPY, UNCORRECTED PROOFS and cesarean birth; some hospitals also have deep tubs for pain relief in labor, and some offer nitrous oxide Transfers In some situations, the In some situations, the In some situations, the mother mother is transferred to mother is transferred to is transferred to a higher-level the hospital; the midwife the hospital; the midwife hospital; the provider usually may or may not be able to may or may not be able does not continue to provide continue to provide care, to continue to provide care after the patient has been depending on whether care, depending on transported agreements are in place whether agreements are between the midwife and in place between the the hospital midwife and the hospital Trainees A midwife trainee may be A midwife trainee may Trainees such as medical in attendance under be in attendance under students, student midwives, and supervision supervision resident physicians may be in attendance under supervision Post-birth Attendant generally stays Women generally stay Length of stay in hospital varies care 4–6 hours after the birth 4–6 hours after the birth based on individual clinical based on individual based on individual situation; federal law mandates clinical situation clinical situation that insurers may not restrict benefits for stays of 48 hours (vaginal) or 96 hours (cesarean) NOTE: CM = certified midwife; CNM = certified nurse midwife. SOURCE: These data are from the 50 states and Washington, DC in 2017 (MacDorman and Declercq, 2019). Hospitals Hospitals are the most common place of birth in the United States, with 98.4 percent of births taking place in a hospital in 2017 (MacDorman and Declercq, 2019). In this report, the committee considers hospital births to be those occurring in a hospital, whether a Level 1 community hospital or a Level 4 maternity unit. Among birth settings, hospitals provide the widest array of medical interventions for pregnant women and newborns. However, there is wide variation in provider types and practices among hospitals. Thus, the woman’s experience may vary widely from hospital to hospital, depending on such factors as the hospital’s level of care, staffing, maternal–fetal status, local values and culture, resources, and more. For example, a study of 88 hospitals in Michigan found that 43.2 percent of hospitals had no vaginal births after cesarean (VBACs) between 2009 and 2015, and among the hospitals that had at least one VBAC, rates ranged from 0.5 percent to 48.1 percent (Triebwasser et al., 2018). The study’s authors concluded that the choice of hospital can significantly impact the individual’s chances of VBAC. Another study in California found that low-performing and high-performing hospitals (as rated by the California Hospital Assessment and Reporting Taskforce) varied widely on measures including low-risk cesarean birth (56% vs. 19%), episiotomy (46% vs. 2%), and VBAC (1% vs. 27%) (California Health Care Foundation, 2014). Care providers at hospital maternity care units may include nurses, obstetricians, family physicians, pediatricians, and midwives (although family physicians and midwives do not practice in all maternity care units). Some hospitals may also have specialists, such as 2-3

PREPUBLICATION COPY, UNCORRECTED PROOFS anesthesiologists, maternal-fetal medicine specialists, and neonatologists, immediately available or on call. Despite their variation, the vast majority of hospital births are attended by physicians (90.6% of hospital births in 2017), while 8.7 percent were attended by certified nurse midwives (CNMs) or certified midwives (CMs) (MacDorman and Declercq, 2019). All hospitals in the United States are accredited or certified, either through the state or through such organizations as The Joint Commission, which accredits about 81 percent of the hospitals accredited in the United States (The Joint Commission, 2018). The Joint Commission also offers a voluntary Perinatal Care Certification, which requires adherence to specific standards and clinical practice guidelines, as well as continuous data collection on such performance measures as rates of cesarean birth and exclusive breastfeeding (Isbey and Martin, 2017). Maternal Levels of Care In 2019, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) published an Obstetric Care Consensus statement (American College of Obstetricians and Gynecologists, 2019a).1 This statement, an update of a 2015 document, reaffirmed the need for clear, standardized levels of maternal care. The four levels identified are accredited birth centers, basic care (Level I), specialty care (Level II), subspecialty care (Level III), and regional perinatal health care centers (Level IV). Criteria for designation of each level are based on the availability of resources, including specialists for women with high-risk pregnancies. The statement is intended to improve maternal care, in part by facilitating admission or transfer of women with high-risk pregnancies to the perinatal centers, which have the appropriate resources and providers to care for them in a safe and timely manner. The standardization of levels of maternal care also allows states to map the geographic distribution of the various levels and to identify and address gaps in care (American College of Obstetricians and Gynecologists, 2019b). However, the exact resources that are available within hospitals of a specific level could vary by state, depending on whether state legislation mandates that a hospital of a certain level must have specific resources or personnel. Currently, maternal care levels are unevenly distributed across the United States, leaving some women without access to appropriate resources and providers (see Chapter 4 for further detail). Just as women birthing at home or in birth centers may need to be transferred to a hospital for more intensive care, women birthing at lower-level hospitals may need to be transferred to a higher-level hospital with the appropriate resources. For example, if birth was expected to be low-risk but complications develop, the individual may need to be transferred from a Level II to a Level III hospital for access to providers with experience in the management of the specific issue. See Table 2-2 for the full description of the ACOG/SMFM levels of care. It should be noted that these are maternal levels of care only and do not include requirements about neonatal care. Neonatal levels of care have been developed by the American Academy of Pediatrics.2 1 The statement was endorsed by the American Association of Birth Centers; the American College of Nurse-Midwives; the Association of Women’s Health, Obstetric and Neonatal Nurses; the Commission for the Accreditation of Birth Centers; and the Society for Obstetric Anesthesia and Perinatology. The statement was supported by the American Academy of Family Physicians. The American Society of Anesthesiologists reviewed the statement (American College of Obstetricians and Gynecologists, 2019a). 2 See https://pediatrics.aappublications.org/content/130/3/587. 2-4

PREPUBLICATION COPY, UNCORRECTED PROOFS TABLE 2-2 Levels of Maternal Care: Definitions, Capabilities, and Health Care Providers Accredited Birth Center Definition Care for low-risk women with uncomplicated singleton term vertex pregnancies who are expected to have an uncomplicated birth. Capabilities and health Refer to birthcenters.org for American Association of Birth Centers’ care providers Standards for Birth Centers. Level I (Basic Care) Definition Care of low- to moderate-risk pregnancies with the ability to detect, stabilize, and initiate management of unanticipated maternal-fetal or neonatal problems that occur during the antepartum, intrapartum, or postpartum period until the patient can be transferred to a facility at which specialty maternal care is available. Capabilities  Capability and equipment to provide low-risk and appropriate moderate-risk maternal care and a readiness at all times to initiate emergency procedures to meet unexpected needs of women and newborns within the center. This includes o Ability to begin emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits. o Limited obstetric ultrasonography with interpretation readily available at all times.a o Support services readily available at all times,a including laboratory testing and blood bank. o Capability to implement patient safety bundlesb for common causes of preventable maternal morbidity, such as management of maternal venous thromboembolism, obstetric hemorrhage, and maternal severe hypertension in pregnancy.c o Ability at all timesa to initiate massive transfusion protocol, with process to obtain more blood and component therapy as needed.  Stabilization and the ability to facilitate transport to a higher-level hospital when necessary. This includes o Risk identification and determination of conditions necessitating consultation, referral, and transfer. o A mechanism and procedure for transfer/transport to a higher-level hospital available at all times.a o A reliable, accurate, and comprehensive communication system among participating hospitals, hospital personnel, and transport teams.  Ability, in collaboration with higher-level facility partners, to initiate and sustain education and quality improvement programs to maximize patient safety. Health care providers  Every birth attended by at least one qualified birthing professional (midwife,d family physician, or OB/GYN) and an appropriately trained and qualified registered nurse (RN) with level-appropriate competencies as demonstrated by nursing competency documentation.  Physician with privileges to perform emergency cesarean readily available at all times.a 2-5

PREPUBLICATION COPY, UNCORRECTED PROOFS  Primary maternal care providers, including midwives,d family physicians, or OB/GYNs readily available at all times.a  Appropriately trained and qualified RNs with level-appropriate competencies as demonstrated by nursing competency documentation readily available at all times.a  Nursing leadership has level-appropriate formal training and experience in maternal care.  Anesthesia providers, such as anesthesiologists, nurse anesthetists, or anesthesiologist assistants working with an anesthesiologist,e for labor analgesia and surgical anesthesia readily available at all times.a Level II (Specialty Care) Definition Level I facility plus care of appropriate moderate- to high-risk antepartum, intrapartum, or postpartum conditions. Capabilities Level I facility capabilities plus  Computed tomography scan, magnetic resonance imaging, nonobstetric ultrasound imaging, and maternal echocardiography with interpretation readily available daily (at all times not required).  Standard obstetric ultrasound imaging with interpretation readily available at all times.a Health care providers Level I facility health care providers plus  OB/GYN readily available at all times.a o Based upon available resources and facility determination of most appropriate staffing, it may be acceptable for a family physician with obstetric fellowship training or equivalent training and skills in obstetrics and with surgical skill and privileges to perform cesarean delivery to meet the criteria for being readily available at all times.  Physician obstetric leadership is board-certifiedf OB/GYN with experience in obstetric care. o Based upon available resources and facility determination of the most appropriate staffing, it may be acceptable for such leader to be board-certified in another specialty with privileges and expertise in obstetric care, including with surgical skill and privileges to perform cesarean delivery.  Maternal-fetal medicine (MFM) subspecialist readily available at all timesa for consultation onsite, by phone, or by telemedicine, as needed.  Anesthesiologist readily available at all times.a  Internal or family medicine physicians and general surgeons readily available at all timesa for obstetric patients. Level III (Subspecialty Care) Definition Level II facility plus care of more complex maternal medical conditions, obstetric complications, and fetal conditions. Capabilities Level II facility capabilities plus  In-house availability of all blood components.  Computed tomography scan, magnetic resonance imaging, maternal echocardiography, and nonobstetric ultrasound imaging services and interpretation readily available at all times.a 2-6

PREPUBLICATION COPY, UNCORRECTED PROOFS  Specialized obstetric ultrasound and fetal assessment, including Doppler studies, with interpretation readily available at all times.a  Basic interventional radiology (capable of performing uterine artery embolization) readily available at all times.a  Appropriate equipment and personnel physically present at all timesg onsite to ventilate and monitor women in labor and delivery until they can be safely transferred to intensive care unit (ICU).  Onsite medical and surgical ICUs that accept pregnant women and women in postpartum period. The ICUs have adult critical care providers physically present at all times.g An MFM subspecialist is readily available at all timesa to actively communicate or consult for all obstetric patients in the ICU.  Documented mechanism to facilitate and accept maternal transfers/transports.  Provide outreach education and patient transfer feedback to Level I and Level II designated facilities to address maternal care quality issues.  Provide perinatal system leadership if acting as a regional center (for example, in areas where Level IV facilities are not available) (see Level IV). Health care providers Level II health care providers plus  Nursing leaders and adequate number of RNs who have special training and experience in the management of women with complex and critical maternal illnesses and obstetric complications.  Board-certifiedf OB/GYN physically presentg at all times.  An MFM subspecialist with inpatient privileges readily available at all times,a either onsite, by phone, or by telemedicine. Timing of need to be onsite is directed by urgency of clinical situation. However, MFM subspecialist must be able to be onsite to provide direct care within 24 hours.  Director of maternal-fetal medicine service is a board-certified MFM subspecialist.  Director of obstetric service is a board-certified OB/GYN or MFM subspecialist.  Board-certified anesthesiologistf physically presentg at all times.  Director of obstetric anesthesia services is board-certified anesthesiologist with obstetric anesthesia fellowship training or experience in obstetric anesthesia.  Full complement of subspecialists, such as subspecialists in critical care, general surgery, infectious disease, hematology, cardiology, nephrology, neurology, gastroenterology, internal medicine, behavioral health, neonatology, readily available for inpatient consultation at all times.a Level IV (Regional Perinatal Health Care Centers) Definition Level III facility plus onsite medical and surgical care of the most complex maternal conditions and critically ill pregnant women and fetuses throughout antepartum, intrapartum, and postpartum care. Capabilities Level III facility capabilities plus  Onsite medical and surgical care of complex maternal conditions with the availability of critical care unit or ICU beds.  Onsite ICU care for obstetric patients with primary or comanagement by maternal-fetal medicine team. Comanagement includes at least daily rounds 2-7

PREPUBLICATION COPY, UNCORRECTED PROOFS by an MFM subspecialist, with interaction with the ICU team and other subspecialists with daily documentation. In some settings, the ICU is an adjoining or connected building, which is acceptable as long as maternal- fetal medicine care is as noted above. If the woman must be transported by ambulance to the ICU, this is not considered onsite.  Perinatal system leadership, including facilitation of collaboration with facilities in the region, analysis and review of system perinatal outcome and quality data, provision of outreach education, and assistance with quality improvement as needed. Health care providers Level III health care providers plus  Maternal-fetal medicine care team with expertise to manage highly complex, critically ill, or unstable maternal patients. A board-certified MFM subspecialist attending with full inpatient privileges is readily available at all timesa for consultation and management. This includes comanagement of ICU-admitted obstetric patients.  Nursing Service Line leadership with advanced degree and national certification.  Continuous availability of adequate numbers of RNs who have experience in the care of women with complex medical illnesses and obstetric complications, with close collaboration between critical care nurses and obstetric nurses with expertise in caring for critically ill women.  Board-certified anesthesiologist with obstetric anesthesia fellowship training or experience in obstetric anesthesia physically present at all times.g  At least one of the following adult subspecialties readily available at all times for consultation and treatment as needed onsite: neurosurgery, cardiac surgery, or transplant. If the facility does not have all three subspecialties available, there should be a process in place to transfer women to a facility that can provide the needed service. NOTES: These guidelines are limited to maternal needs. Consideration of fetal or neonatal needs and the appropriate level of care should occur following existing guidelines. In fact, levels of maternal care and levels of neonatal care may not match within facilities. Additionally, these are guidelines, and local issues will affect systems of implementation for regionalized maternal care, perinatal care, or both. a Readily available at all times: the specific person should be available 24 hours a day, 7 days a week for consultation and assistance, and able to be physically present onsite within a timeframe that incorporates maternal and fetal or neonatal risks and benefits with the provision of care. This timeframe should be further defined and individualized by facilities and regions, with input from their obstetric care providers. If referring to the availability of a service, the service should be available 24 hours a day, 7 days a week unless otherwise specified. b Available at https://safehealthcareforeverywoman.org/patient-safety-bundles. c See also “Emergent therapy for acute-onset, severe hypertension during pregnancy and the post- partum period” (American College of Obstetricians and Gynecologists, 2019c). d Midwives who meet International Confederation of Midwives standards, such as certified nurse midwives (CNMs) and certified midwives (CMs), and who are legally recognized to practice within the jurisdiction of the state. e Scope of practice for nurse anesthetists and anesthesiologist assistants may vary by state. f Also includes physicians who have completed residency training and are eligible for board certification according to applicable board policies. 2-8

PREPUBLICATION COPY, UNCORRECTED PROOFS g Physically present at all times: the specific person should be onsite in the location where the perinatal care is provided, 24 hours a day, 7 days a week. SOURCE: Adapted from American College of Obstetricians and Gynecologists, 2019a. Reprinted with permission from Levels of maternal care. Obstetric Care Consensus No. 9. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134:e41-55. Care Routine Generally, when a pregnant woman presents for care in a hospital, she undergoes an obstetric (OB) triage process to determine whether she should be admitted and if so, to which unit. This process includes a federally mandated medical screening examination by a qualified provider, consisting of initial assessment and prioritization for evaluation (American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2017; Centers for Medicare & Medicaid Services, 2012). A hospital may also conduct triage by telephone in order to prevent unnecessary in-person visits and the potential for unnecessary admissions. Acuity and disposition are based in part on maternal condition, fetal heart rate tracing, uterine contractions, reason for presentation, labor status (presence of uterine contractions, vaginal bleeding, membrane status), estimated due date, woman’s perception of fetal movement, and any high-risk medical or OB conditions identified by a review of history or the woman’s report (American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2017). Some hospitals use a standard process, such as the Maternal-Fetal Triage Index, for evaluating women and prioritizing the order of and type of care (Association of Women’s Health, Obstetric and Neonatal Nurses, 2015). OB triage may occur in a specialty unit or in the labor room. Specialty OB triage units are more common in high-volume perinatal facilities. If the triage process reveals that the woman is not in labor or that she is in very early stages of labor, she will likely be sent home, provided that there are no maternal or fetal conditions warranting admission (Angelini and Howard, 2014). Once a decision has been made to admit a woman to the labor and delivery unit, a number of options are available based on whether the admission is due to spontaneous labor or planned, and if planned, whether the admission is elective or medically indicated. The woman’s preferences, the labor nurse assigned to her, her choice of birth attendant, and the hospital are key influences on how labor and birth care proceed. Interventions and procedures that can occur in the hospital during labor and birth include insertion of an intravenous (IV) line, continuous electronic fetal monitoring, bed rest, limited oral intake during labor, cervical ripening, induction or augmentation of labor, artificial rupture of membranes, epidural analgesia, blood draws for laboratory studies, episiotomy, vacuum- or forceps-assisted birth, and cesarean birth. Rates of these procedures are highly variable across hospitals (Lundsberg et al., 2017). For example, Lundsberg and colleagues (2017) found significant differences among hospitals in use of routine IV lines, blood draws, and oral intake. Nurse staffing during labor and birth differs among hospitals as well: in some hospitals, women will have one-to-one nursing care during labor and birth, while in others, nurses must devote their attention to more than one woman (Simpson et al., 2019). Also variable is the availability of labor support, birth and peanut balls for comfort and positioning, hydrotherapy in the shower or tub, telemetric electronic fetal monitoring (to allow continuous fetal assessment while ambulating or out of bed), intermittent auscultation, and doulas. Varying as well are hospital policies and routines for enabling other individuals to be in attendance to support the woman, from strict rules allowing one or two “visitors” to policies encouraging the woman to choose how many people and whom she would like to be with her during birth. 2-9

PREPUBLICATION COPY, UNCORRECTED PROOFS Hospital births vary in a number of other ways as well. Birthing positions vary, for example, with some women giving birth in the lithotomy position and others in an upright or side-lying position. Births can also occur in the labor room or in the operating room (OR). Examples of births in the OR include cesarean birth, vaginal birth of twins, or a woman at risk for complications. Recovery after birth lasts at least 2 hours, typically with one-to-one nursing care, and can occur in the labor room (vaginal birth and some cesarean births) or the postanesthesia recovery room (cesarean births) (American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2017; Association of Women’s Health, Obstetric and Neonatal Nurses, 2010). After this immediate postpartum recovery period, the woman may be transferred to another unit in the hospital (mother–baby unit) within the perinatal service or remain in the room where she gave birth (labor–delivery–recovery–postpartum room). This placement is based on the configuration of the maternity unit. Generally, large-volume perinatal facilities have separate units for labor and birth care and woman–baby care postpartum. Also varying is the practice of rooming-in, whereby the newborn remains with the mother in her postpartum room, which may or may not be standard practice and is based on the mother’s and newborn’s condition and hospital routines. Likewise, support for breastfeeding, including access to lactation professionals, varies across hospitals. Finally, length of stay postpartum differs significantly across birthing hospitals, and depends on length of labor, whether the birth was vaginal or cesarean, maternal–fetal complications, regional and hospital routines, and type of reimbursement the hospital receives. In the United States, women stay an average of 48 hours for a vaginal birth. Federal law requires that most insurance companies cover a postdelivery hospital stay of 48 hours for vaginal birth and 96 hours for cesarean birth (Centers for Medicare & Medicaid Services, n.d.), although women may opt to leave earlier if they and their babies are healthy. Before leaving the hospital, the woman and newborn are seen by a midwife or physician, pediatric provider, lactation consultant, and/or other providers. Some providers offer a checkup within the first week after discharge from the hospital; ACOG recommends contact between provider and woman within the first 3 weeks postpartum, followed by a comprehensive postpartum visit within 12 weeks after birth (American College of Obstetricians and Gynecologists, 2018a). In-hospital “Birth Centers” Some hospitals in the United States have separate units within or associated with the labor and delivery unit that offer women a more home-like atmosphere. These units are often called “birth centers” by the hospital; however, the services they offer and the extent to which they resemble freestanding birth centers vary widely. Some, like freestanding birth centers, use the midwifery model of care, are available only to low-risk mothers, and offer only physiologic birth without medical interventions. For example, the Midwifery Center at Tucson Medical Center in Arizona is located within the hospital but offers a low-intervention, midwife-led birth experience. If complications arise, or if the woman desires or needs an epidural, she can quickly be transferred to the hospital’s standard labor and delivery unit (The Midwifery Center Healthcare, 2019). These types of units are called “alongside maternity centers” by the Commission for the Accreditation of Birth Centers (CABC). To receive CABC accreditation, an alongside maternity center must meet a number of requirements; for example, the center may not offer augmentation of labor, continuous electronic monitoring, epidurals, or assisted vaginal birth. As of November 2019, there were four such 2-10

PREPUBLICATION COPY, UNCORRECTED PROOFS centers accredited by CABC (Commission for the Accreditation of Birth Centers, 2019); there are many similar centers across the nation that are either unaccredited at this time or in the process of accreditation.3 Other “birth centers” that are located within hospitals in the United States vary widely in the resources and care model that they offer. Some may essentially be standard labor and delivery units but with additional options such as tubs for hydrotherapy, birthing balls, and nitrous oxide for pain relief. Others may emphasize and encourage low-intervention birth, but also offer interventions as needed or desired (e.g., augmentation of labor, continuous fetal heart rate monitoring, and medication for pain management). Depending on the hospital, some interventions may be offered directly in the “birth center,” while others require transfer to the hospital’s standard labor and delivery unit. In the event that the mother requires more intensive care (e.g., a caesarean birth), the hospital usually has the capacity to provide that service immediately or to call in a specialist. The fact that the term “birth center” is used to describe a wide variety of birth options can cause confusion. In the remainder of this report, the term “birth center” refers only to freestanding birth centers, not in-hospital units. Freestanding Birth Centers As noted above, for the purposes of this report, a birth center is defined as a freestanding health facility not attached to or inside a hospital. Birth centers are intended for low-risk women who desire less medical intervention during birth, a home-like atmosphere, and an emphasis on individually tailored care. Birth center numbers are increasing in the United States, with 375 such centers in operation as of November 2019.4 In a review of birth centers in 33 states, Stapleton and colleagues (2013) found 23.8 percent of birth center participants were Medicaid enrollees, and 28.3 percent had equal to or less than a high school education. Birth center care is typically led by midwives (CNMs, CMs, and certified professional midwives [CPMs]), sometimes with additional care from other maternity care support staff, such as registered nurses (RNs), doulas, and birth assistants. In 2017, 56.6 percent of births at birth centers were attended by CNMs/CMs, 36.7 percent by CPMs, and 2.7 percent by physicians (MacDorman and Declercq, 2019; see Table 2-3). Midwives in birth centers provide the full scope of maternity care, from the prenatal through the intrapartum and postpartum periods out to the first 6–8 weeks following birth, as well as newborn care. Most birth centers provide preconception care and well-woman services to nonpregnant clients (American Association of Birth Centers, 2016a). Typically, birth centers are designed to resemble a home environment and routinely offer some nonmedical interventions during labor and delivery that are not always available in hospital settings. For example, birth centers encourage walking and position changes during active labor, encourage oral fluid and food intake as tolerated, offer round and peanut-shaped birth balls to facilitate comfort and effective positioning, often offer a tub for laboring and birth, and provide options such as nitrous oxide and acupressure for managing pain. After birth, care is provided 3 These types of centers have also been expanding in the United Kingdom and Canada, where they are called “alongside maternity units” (AMUs). In the United Kingdom, the number of AMUs nearly doubled between 2010 and 2016, and about 12 percent of women gave birth in an AMU in 2016, compared with 3 percent in 2010 (Walsh et al., 2018). 4 Personal communication, Kate Bauer, Executive Director AABC. 2-11

PREPUBLICATION COPY, UNCORRECTED PROOFS with the infant skin to skin, and breastfeeding is encouraged. After discharge from the birth center, the birth center nurse or midwife typically makes a home visit at approximately 24 hours and again at 3 days postpartum (varies based on midwifery practice). The initial postpartum home visits are commonly followed by office visits at 10 days to 2 weeks, and 4 to 6 weeks postpartum; follow-up is provided by phone and additional visits as needed (American Association of Birth Centers, 2016b). In the birth center, care is woman- and family-centered, and families are invited to participate in the experience as desired by the woman. Within the birth center framework, care is provided for healthy, uncomplicated pregnancies and births and for first-line complications. First-line complications such as maternal hemorrhage or initial resuscitation of a compromised infant are managed by midwives and birth center staff, and transfer to a higher level of care is available when needed. Compared with hospitals, birth centers have fewer resources available for emergency situations, such as those requiring cesarean birth or blood transfusion. When a transfer for higher-level care is indicated during labor or postpartum, the woman must be physically transported by ambulance or private car from the birth center to a hospital. The birth center prepares for emergencies by having plans and emergency medications in place for stabilization and transfer to an acute care facility if needed (American Association of Birth Centers, 2016c). The American Association of Birth Centers (AABC) describes the birth center as a “maximized home rather than a mini-hospital” (American Association of Birth Centers, 2016c). Birth centers can be accredited by the CABC, but accreditation is not mandatory. CABC- accredited birth centers must follow the standards of the AABC, which require, among other things, that the birth center practice the midwifery model of care; honor the mother’s needs and desires throughout labor; and avoid the use of certain interventions, including vacuum extraction and continuous electronic monitoring (American Association of Birth Centers, 2019). All accredited birth centers must also have emergency supplies on hand for woman and newborn, and must have a specific plan for transfer to a hospital if required. Home Births Home births occur at a person’s residence and can be either planned or unplanned. Most home births are planned, although about 15 percent are unplanned (MacDorman and Declercq, 2019). A home birth may be attended by a midwife, physician, or other attendant, or by no medical attendant at all, as is preferred by a small number of “freebirthers”5 or when unplanned. For planned home births only, about 80 percent are attended by midwives, 0.7 percent by physicians, and 19.1 percent by “other.”6 (See Table 2-3.) Women who plan home births may do so out of a wish to experience physiologic childbirth, a desire for a personalized experience, a desire to avoid unneeded medical interventions, a dislike of the hospital atmosphere, a desire for a sense of control, the lack of a hospital in their community, cultural beliefs and practices, financial constraints, or geographic 5 A “freebirther” is a woman who gives birth without a physician or midwife in attendance (Hickman, 2009). 6 Of all home births (planned and unplanned), 70 percent are attended by a midwife (including CNMs, CMs, CPMs, and other midwives); 3.7 percent by a physician; and 26.4 percent by “other,” which includes family members, emergency medical technicians, and no attendant (MacDorman and Declercq, 2019). 2-12

PREPUBLICATION COPY, UNCORRECTED PROOFS barriers (Declercq and Stotland, 2017). Like birth center births, planned home births may result in transfer to a hospital for nonemergency or emergency care. Midwives7 provide care throughout the prenatal period for families planning a home birth. Home birth clients must remain low-risk throughout the pregnancy and must typically reach 37 weeks’ gestation to be eligible for a home birth. During labor, midwives monitor the woman and fetus, providing one-to-one care and continuously assessing for complications. As a best practice, a birth assistant (who may be another midwife or someone who is trained as a birth assistant) is used as a second attendant when birth is drawing near.8 Once the baby is born, the newborn is assessed and stimulation is performed in place as needed. Resuscitation equipment is assembled during labor and located proximal to where the birth is likely to occur, although it can be moved as needed. As one attendant is attending to the newborn, the other is attending to the delivery of the placenta and administering medications as needed (if licensed to do so) to treat a postpartum hemorrhage. In states where midwives are not able to access licensure for carrying these medications, they may utilize herbal medicine and manual skills to stop a postpartum hemorrhage. Box 2-1 provides further detail on typical home birth supplies and medications. BOX 2-1 Typical Home Birth Supplies and Medications Whereas hospitals and birth centers are already equipped with supplies and medications that are commonly used during birth, midwives must bring these items with them to a home birth. At the onset of labor, the midwife travels to the client’s home with supplies that include the following: Birth supplies: blood pressure cuff and stethoscope, pediatric stethoscope, thermometer, fetal Doppler, paper or electronic chart forms, infant scale, cord clamps, sterile instruments for cutting the cord and suturing, suctioning equipment (bulb syringe, DeLee suction trap), urinary catheter equipment, amnihook, heating pad, sterile gloves, absorbable underpads, gauze sponges. Supplies for labor support and pain relief: deep tub; hot/cold compresses; a transcutaneous electrical nerve stimulation (TENS) machine; items such as a sling, yoga ball, and peanut balls for comfort and positioning. Resuscitation equipment: firm surface for neonatal resuscitation; bag and mask in adult and newborn sizes; a laryngeal mask airway; epinephrine for adult anaphylaxis and/or newborn resuscitation. Medications: oxygen tank(s); medications for preventing or treating postpartum hemorrhage (Pitocin, methergine, misoprostol); IV equipment and fluids; antibiotics for Group B strep prophylaxis; local injectable anesthetic for suturing; vitamin K and erythromycin eye ointment for the newborn; hepatitis B vaccine and immune globulin for infants born to mothers with hepatitis B. Some states have laws that restrict midwives’ ability to carry or administer certain medications. For example, in Virginia, licensed certified professional midwives are prohibited 7 The majority of home births are attended by a midwife, although a small percentage are attended by physicians. For brevity’s sake, home birth providers are most often referred to as midwives in this report. 8 State licensure statutes typically require that two attendants be present at every birth because two people are required for neonatal resuscitation. See, e.g., statutes in Oregon, Washington, and California. 2-13

PREPUBLICATION COPY, UNCORRECTED PROOFS from carrying any controlled substance, including antihemorrhagic medicines, oxygen, or antibiotics (Virginia Law, 2013). [END BOX] After birth, attendants assist with breastfeeding; monitor the mother’s and newborn’s vital signs; inspect and repair the perineum as needed; assess uterine involution and bleeding; ensure that the mother is able to empty her bladder; and conduct a full newborn exam, administering vitamin K and erythromycin eye ointment (if licensed to do so) with the consent of the parents. If at any point the woman or the newborn develops complications, hospital transport is initiated. When assured that the woman and newborn are stable and without complications, the attendants give instructions to the parents, including warning signs that call for paging the midwife, and they depart the client’s home within 4–6 hours after the birth. A midwife typically returns to the client’s home between 24 and 48 hours postpartum for a full checkup on both mother and newborn, with another home visit on day 3. Often another postpartum visit is conducted at 1–2 weeks, another at 3–4 weeks, and a final visit at 6 weeks postpartum. Prenatal and postpartum visits may occur in the woman’s home or in an office setting. Well-newborn care is also usually managed by the midwife for the first 2–6 weeks of life, with consultation or referral to the newborn’s pediatric provider as needed or desired. As with most practices surrounding birth, birth and postpartum care are influenced by the licensure of the provider and insurance coverage or source of payment, which are discussed later in this chapter. TABLE 2-3 Percentage of Births Attended by Physicians, Certified Nurse Midwives, (CNMs)/Certified Midwives (CMs), and Other Midwives by Place of Birth, United States, 2017 Attendant at All Births Hospital Out of Birth Homeb Planned (n = 3,855,500) (n = 3,793,272) Hospital a (n = 38,343) Homeb,c birth (%) Center (n = 62,228) (n = 19,878) (n = 28,994) Physician 89.2 90.6 4.3 2.7 3.7 0.7 CNM/ CM 9.1 8.7 34.1 56.6 24.4 29.4 Other midwifed 0.8 0.1 41.2 36.7 45.6 50.7 Other 0.8 0.5 20.3 3.9 26.4 19.1 NOTES: Column percentage computed per 100 women in specified group. Notstated responses (<4% for all variables) were dropped before percentages were computed. a Category includes 3,273 “other," 553 “clinic or doctor’s office,” and 181 “unknown” location. b Does not include planned home births that were transferred to hospitals. c Excludes data from California, which did not report the planning status of home births. d Includes all non-CNM/CM midwives, including certified professional midwives (CPMs) and licensed and direct entry midwives. SOURCE: MacDorman and Declercq, 2019. Transfer to Hospital Settings Because health professionals attending birth center and home births do not offer some services during labor (e.g., epidural pain relief, induction or augmentation with medications) and do not have the capacity to provide certain emergency services (e.g., cesarean capability, 2-14

PREPUBLICATION COPY, UNCORRECTED PROOFS neonatal intensive care unit), some women need to transfer to a hospital during or after birth. A meta-analysis of studies in the United States and other Western countries found that the rates of transfer for nulliparous women ranged from 23.4 percent to 45.4 percent, and for multiparous women ranged from 5.8 percent to 12.0 percent (Blix et al., 2014). Emergency transfers made up a small percentage of transfers. Although the definition of “emergency” varied across studies, the rates ranged from 0 percent to 5.4 percent (Blix et al., 2014). The authors note that transfers were more common in settings where home birth was regulated and integrated with the health care system, and less common in settings with unregulated midwives. Unfortunately, in the United States, integration and coordination among providers and settings is uncommon, and clear protocols for when and how to transfer patients to risk-appropriate facilities are lacking (Shah, 2015). Freestanding birth centers are only partially integrated into the U.S. maternity care system. Nine states currently do not license or regulate freestanding birth centers, and variation in regulations and hospital policies across the United States makes it difficult for birth centers in some regions to form collaborative relationships with transfer hospitals and physicians (American Association of Birth Centers, 2016d). Further research is needed to evaluate the impact of integration of maternity systems on outcomes for planned birth center births, although one large U.S. study has shown a positive correlation between midwifery integration across birth settings and improved maternal and neonatal outcomes (Vedam et al., 2018). (See Chapter 6 for further discussion of outcomes.) Model transfer guidelines for home births have been developed through a multidisciplinary, multistakeholder process (Home Birth Summit, n.d.). See Chapter 7 for further discussion of these guidelines. MATERNAL AND NEWBORN CARE TEAM Nurses, physicians, and midwives provide the majority of maternal and newborn care across birth settings. Other members of the care team who also provide care include social workers, psychologists and psychiatrists, dietitians, anesthesia professionals, lactation consultants, and physical therapists. The care team also encompasses pregnant individuals and their partners, family, and friends; doulas; community health workers; childbirth educators; breastfeeding peer counselors; and pregnancy fitness educators. Members of the maternal and newborn care team educate, support, and care for women and newborns before and throughout pregnancy, during labor and birth, and after birth. This section provides details about the practice, education, training, and licensing of members of the care team. Registered Nurses (RNs) The majority of nurses working in hospital labor and delivery units are RNs. RNs monitor the woman and baby during labor and birth; assess the woman’s progress through the stages of labor; identify potential complications; administer medications; monitor the newborn after birth; help new parents learn about baby care; and communicate with the woman, her family, physicians, midwives, and other members of the care team. The specific ways in which nurses work in different hospitals vary considerably (see Box 2-2). RNs also contribute to maternal care through public health nursing (see Box 2-3), and may work in birth centers as well. 2-15

PREPUBLICATION COPY, UNCORRECTED PROOFS RNs must have either a diploma in nursing, an associate’s degree in nursing, or a bachelor’s degree in nursing, and have passed the National Council Licensure Examination (NCLEX-RN) exam. After licensure, an RN may choose to obtain certification in a specialty area of nursing practice within maternity and newborn care, including low-risk neonatal nurse, maternal newborn nurse, neonatal intensive care nurse, or inpatient obstetric nurse. Certification in one of these specialties requires 2 years of experience as an RN in that specialty, comprising at least 2,000 hours of practice time, and passing the National Certification Corporation exam in the specialty. BOX 2-2 Variety of Nursing Work Structures in Hospitals Such factors as birth volume, philosophy of the leadership team, and physical design of the maternity unit directly influence how nurses are assigned to specific patients and what type of care each nurse provides. In small-volume perinatal services, nurses care for women across the course of their childbirth hospitalization, including the admission assessment, labor, birth, and postpartum/newborn periods. Some small-volume services use perioperative nurses to care for women who have cesarean birth during the intraoperative and postanesthesia recovery periods. Moderate- to high-volume perinatal services often have designated nurses with specific skill sets and have separate units for antepartum, obstetric triage, intrapartum, postpartum, well- baby, and high-risk baby care. Nurses in high-volume units are less likely to care for women over the course of their entire hospitalization. Hospitals with high birth volumes are more likely to have specialization of nurses, categorizing them as labor and delivery, mother–baby, and special care or neonatal intensive care nursery nurses. In some hospitals, the physical design is single-room maternity care, where the mother labors, gives birth, and spends the postpartum period in the same room. Single-room physical design does not guarantee continuity of nursing care. Birth volume, leadership team philosophy, and shift scheduling are factors in how maternal–newborn care is provided in the context of a single-room physical design and the priority placed on continuity of care (Association of Women’s Health, Obstetric and Neonatal Nurses, 2010, 2018). Labor nurses at times turn the patient care assignment over to a mother–baby nurse after the 2-hour immediate postpartum recovery period. In some hospitals, new mothers are cared for by postpartum nurses and well babies are cared for by nursery nurses, even in models where mother–baby rooming-in has been established. In some hospitals, there is an effort to assign the same nurse each day to the mother– baby couplet. Nurses in many hospitals choose their patient assignments. Therefore, the type of nursing care a woman receives is influenced by her choice of birthing hospital, as each hospital has a unique culture, operations, staffing model, and routine unit flow that determine how nursing care is provided and by which nurses. Education, skill level, personal philosophy, and experience of the nurses are further influences (Association of Women’s Health, Obstetric and Neonatal Nurses, 2010, 2018). [END BOX] 2-16

PREPUBLICATION COPY, UNCORRECTED PROOFS BOX 2-3 Public Health Nurses Public health nurses play an important role in maternity care through delivery of a range of services, including pregnancy screening; family planning services; assistance with Medicaid applications; enrollment in the Supplemental Nutrition Program for Women, Infants, and Children (WIC); patient education; lead screening; breastfeeding support; and social service referrals. These nurses—most of whom are registered nurses—often provide these services through pregnancy and postpartum home visits. One public health nursing program that has demonstrated particular success is the Nurse-Family Partnership (NFP), an evidence-based nurse home visiting program that has been shown through randomized controlled trials to improve maternal and child outcomes. The NFP is a program, funded by a variety of public and private sources, that sends nurses into the homes of mostly low-income and unmarried first-time mothers. Nurses visit the mothers about once a month during pregnancy and the first 2 years after they give birth, and teach positive health behaviors, care of children, and maternal personal development. The NFP has been shown to have positive impacts on maternal and child well- being, including lower rates of pregnancy-induced hypertension and preterm births (Laura and John Arnold Foundation, 2017; Nurse-Family Partnership, 2019). [END BOX] Advanced Practice Registered Nurses (APRNs) APRNs have the broadest scope of practice among nurses, although the specific rules regarding their practice vary by specialty and by state. In the labor and delivery setting, APRNs—depending on their specialty—may administer epidurals and other pain medications, diagnose and treat complications during labor, attend births, and monitor and diagnose postpartum complications. APRNs often, but not always, begin their career as RNs, gain experience, and then pursue further education. APRNs hold either a master of science in nursing (MSN) degree, a doctor of nursing practice (DNP) degree, or a Ph.D. in nursing, and choose one of four specialty tracks on which to focus. APRNs must complete a specific number of hours of training in their specialty, and each specialty has its own clinical requirements and exam (see Table 2-4). TABLE 2-4 Educational and Licensure Requirements for Nurses Providing Maternal and Newborn Care Requirements Registered Nurse Advanced Practice Registered Nurse Required Diploma, ADN, or BSN MSN, DNP, or Ph.D. education Required training Training included in Depends on specialty track; usually at educational experience least 500 hours clinical training Exams NCLEX-RN NCLEX-RN; certification exam(s) depends on specialty NOTE: ADN = associate’s degree in nursing; BSN = bachelor of science in nursing; DNP = doctor of nursing practice; MSN = master of science in nursing. 2-17

PREPUBLICATION COPY, UNCORRECTED PROOFS Midwives Midwives specialize in the management of pregnancy, birth, and newborn care. The United States is unique among nations in that it has three types of midwives with nationally recognized credentials: certified nurse midwives (CNMs), certified midwives (CMs), and certified professional midwives (CPMs) (Cheyney et al., 2015; Vedam et al., 2018). Competencies are aligned across these three credentials and with those of the International Confederation of Midwives (U.S. Midwifery Education, Regulation, and Association Professional Regulation Committee, 2015b). Although distinct, these credentials share some key similarities. For example, all credentialed midwives in the United States are differentiated from “lay,” “traditional,” or “plain” midwives, who practice without having completed formal educational and national certification requirements (Davis-Floyd and Johnson, 2006; Cheyney et al., 2019). Each of the three types of nationally credentialed midwives must fulfill different education, training, and licensing requirements (Table 2-5), but they share a commitment to the midwifery model of care (Citizens for Midwifery, 2008). Some of the important distinctions among midwives are tied to the “unique cultural and sociopolitical histories of obstetrics and regional midwifery traditions in the United States” (Cheyney et al., 2015, p. 2). (See also Davis- Floyd, 2018, Chapter 6; and Davis-Floyd and Johnson, 2006, for detailed explications of the complexities of U.S. midwifery.) Nationally credentialed midwives attend births in all settings, including hospitals, birth centers, and homes. Most CNMs and CMs work in hospitals, although they also work in birthing centers and attend home births. CPMs provide care only in birth centers and at home births, as they have not been granted hospital privileges in most areas (Cheyney et al., 2015). There are approximately 12,000 CNMs, 100 CMs, and 2,500 CPMs in the United States (American College of Nurse-Midwives, 2019; National Association of Certified Professional Midwives, 2014).9 9 Some licensed midwives (LMs) are CPMs, but because the credential is not a requirement for licensing in all states, there are a number of LMs who do not hold the CPM credential. Examples of these states are California, Arizona, New Mexico, and Florida. 2-18

PREPUBLICATION COPY, UNCORRECTED PROOFS TABLE 2-5 Educational and Licensure Requirements for Credentialed Midwives Requirements Certified Nurse Midwife Certified Midwife (CM) Certified Professional (CNM) Midwife (CPM) Minimum Registered nurse (RN) + Master’s degree in High school diploma or required master’s degree in midwifery equivalent; some earn a education midwifery certificate or an associate’s, bachelor’, or master’s degree in midwifery Required Training offered during educational program, primarily in Training offered during training the hospital setting educational program, or through at least 2 years of apprenticeship, primarily in birth centers or home settings Exams National Council American Midwifery North American Registry of Licensure Examination Certification Board (AMCB) Midwives (NARM) exam (NCLEX-RN) + American exam Midwifery Certification Board (AMCB) exam Legal Statusa Legally permitted to Legally permitted to practice Legally permitted to practice practice and prescribe in Delaware, Maine, New in 33 statesb medication in all 50 states, Jersey, New York, Rhode District of Columbia, and Island, Hawaii; prescriptive U.S. territories authority in New York, Rhode Island, Maine a Status is considered legally permitted if licensure, permits, registration, or certification is available at the state level for the given credential (CNM, CM, or CPM). b As of May 2019, CPMs have a path to licensure in Alabama, Alaska, Arizona, Arkansas, California, Colorado, Delaware, Florida, Hawaii, Idaho, Indiana, Kentucky, Louisiana, Maine, Maryland, Michigan, Minnesota, Montana, New Hampshire, New Jersey, New Mexico, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Wisconsin, and Wyoming (National Association of Certified Professional Midwives, 2019). Certified Nurse Midwives CNMs are APRNs who are trained in both nursing and midwifery. CNMs provide a range of health and gynecologic services, including preconception care; family planning; and care during pregnancy, childbirth, and the postpartum period (American College of Nurse-Midwives, 2017a). CNMs can assess, diagnose, and treat conditions, conduct examinations, order diagnostic tests, and prescribe medications (American College of Nurse-Midwives, 2011). CNMs are licensed to practice in all 50 states plus the District of Columbia, but their ability to practice independently varies by state. Twenty-seven states allow CNMs full scope of practice including prescriptive authority; other states require supervision by or a collaborative agreement with a physician for some aspects of practice (American College of Nurse-Midwives, 2018). CNMs work in a wide variety of settings, including hospitals and birth centers; 94 percent of CNM- attended births in the United States occur in a hospital (Martin et al., 2019). 2-19

PREPUBLICATION COPY, UNCORRECTED PROOFS Like other APRNs, CNMs must be licensed RNs; obtain an MSN or DNP degree; and pass a specialty exam, which is administered by the American Midwifery Certification Board. There are currently 37 accredited nurse midwifery education programs in the United States, all affiliated with universities (American College of Nurse-Midwives, n.d.c.). CNMs are generally regulated under nursing boards in their respective states. Certified Midwives CMs provide all of the same services as CNMs; the primary difference between the two credentials is that CMs are not nurses. Like CNMs, CMs provide the full range of women’s health care, including primary care, preconception and prenatal care, and birth and postpartum care. The first accredited CM educational program began in 1996 for those seeking a pathway to midwifery without first obtaining a nursing credential (American College of Nurse-Midwives, 2019). Aspiring CMs obtain a bachelor’s degree in any field and go on to graduate from an accredited midwifery education program. Standards for education and certification in midwifery are identical for CNMs and CMs (American College of Nurse-Midwives, 2019). Only 2 of the 37 nurse midwifery programs are structured to also graduate CMs; in these programs, CNM and CM students sit in the same classrooms, learning the same midwifery skills and body of knowledge. Both CNMs and CMs must pass the American Midwifery Certification Board exam. CMs are licensed to practice in only six states (Delaware, Maine, Hawaii, New Jersey, New York, and Rhode Island) and have prescriptive authority in three (Maine, New York, and Rhode Island) (American College of Nurse-Midwives, 2019). Certified Professional Midwives CPMs are independent clinicians who offer care, education, counseling, and support to women and their families throughout pregnancy, birth, and the postpartum period, as well as preconception care and ongoing well-woman care. In states where CPMs are able to access licensure, they typically carry and administer life-saving medications, order and interpret laboratory and diagnostic tests, and order the use of medical devices. Like all midwives, CPMs are trained to recognize when the condition of a woman or infant requires consulting with or referring to another health care professional (American College of Nurse-Midwives, 2017a). CPMs attend the majority of home births (MacDorman and Declercq, 2016), and also attend births in freestanding birthing centers. The credential for CPMs was first offered in 1994 for those seeking a national professional credential for what had formerly been called “lay midwives” (Cheyney, 2010; Davis-Floyd and Johnson, 2006; North American Registry of Midwives, n.d.). Aspiring CPMs must have a high school diploma or the equivalent before beginning their midwifery training, and can pursue several different paths toward certification and licensure. The North American Registry of Midwives (NARM), the certifying organization for CPMs, uses a competency-based approach to certification that allows applicants to demonstrate and apply knowledge, skills, and experience they have gained through a variety of means. The two primary paths to certification are (1) the portfolio evaluation process (PEP) and (2) graduation from a program accredited by the Midwifery Education Accreditation Council (MEAC), which is recognized as an accrediting body by the U.S. Department of Education (American College of Nurse-Midwives, 2017a). Other, lesser-used paths toward certification include reciprocity for midwives licensed through 2-20

PREPUBLICATION COPY, UNCORRECTED PROOFS state-established programs that predate the CPM credential, midwives who are CNMs/CMs, and some internationally educated midwives. A 2015 study found that 48.5 percent of current CPMs utilized the PEP, 36.9 percent graduated from an MEAC-accredited school, 14.5 percent were already licensed by a state as a direct-entry midwife (i.e., a midwife who is not first a nurse) prior to the advent of the CPM credential, and 0.7 percent were already a CNM or CM (Cheyney et al., 2015). The PEP is a comprehensive evaluation of the skills, knowledge, and competencies of the midwife candidate. It requires, among other requirements, fulfillment of NARM’s general education requirements; verification of proficiency in specific skills, knowledge, and abilities; certification in adult cardiopulmonary resuscitation (CPR) and neonatal resuscitation; affidavits from preceptors attesting that the candidate has developed and utilized practice guidelines; an emergency care plan; three professional letters of reference; and completion of a cultural competency course (North American Registry of Midwives, 2019). Alternatively, aspiring midwives may attend MEAC-accredited midwifery education programs, which incorporate NARM competency requirements and the essential competencies of the International Confederation of Midwives (ICM) into their curricula. MEAC-accredited programs may include classroom-based courses, online courses, hybrid classroom/online courses, and/or independent study, and clinical education generally takes place in homes or birth centers. In contrast to the skills examination used by PEP candidates, students who attend MEAC programs have their skills verified by preceptors during the provision of care or using simulations (Cheyney et al., 2015, p. 2). Regardless of which education route they choose, all CPMs must pass the NARM board examination to be certified, and their education and training must meet NARM standards. NARM requires that the clinical component of a midwife’s training be at least 2 years in duration and include a minimum of 55 births. Clinical education must occur under the supervision of a licensed midwife or physician. In 2013, a coalition of midwifery organizations recommended that starting in 2020, all states newly offering licensure for CPMs require that applicants be educated through MEAC- accredited programs, and that CPMs who had already received certification through PEP complete an additional 50 hours of education to obtain a “bridge” certificate (U.S. Midwifery Education, Regulation, and Association Professional Regulation Committee, 2015a).10 10 U.S. MERA (for Midwifery Education, Regulation, and Association) worked to achieve consensus around educational and licensing standards, based on the ICM’s global standards for midwifery education and regulation. U.S. MERA published two legislative statements. The first, entitled “Statement on the Licensure of Certified Professional Midwives” (U.S. Midwifery Education, Regulation, and Association Professional Regulation Committee, 2015a), codified the coalition’s consensus resolution to support legislation in states that do not currently license CPMs. The coalition developed model legislative language stating that by 2020, new applicants for licensure should have a MEAC-accredited education and hold the CPM credential. For those who became CPMs via a nonaccredited pathway prior to 2020, NARM created a Midwifery Bridge Certificate comprising an additional 50 hours of continuing education on topics addressing the ICM essential competencies. The second legislative statement, entitled “Principles for Model U.S. Midwifery Legislation and Regulation” (U.S. Midwifery Education, Regulation, and Association Professional Regulation Committee, 2015b), proposed legislative language for the regulation of midwifery practice, including education requirements, standards for practice, and management of complaints. The U.S. MERA leadership team last met in 2016. 2-21

PREPUBLICATION COPY, UNCORRECTED PROOFS Physicians Physicians providing maternal and newborn care evaluate, diagnose, manage, and treat patients; order and evaluate diagnostic tests; prescribe medications; and attend births. After graduating from a 4-year college, all physicians must attend an accredited medical school and receive a doctor of medicine (MD) or a doctor of osteopathy (DO) degree. After 4 years of medical school, MDs and DOs must complete a residency program, which is usually 3 to 7 years, depending on the field of medicine. The first year of residency is commonly called an internship. Physicians complete a three-step licensing process, consisting of three separate exams, in order to practice medicine. MDs take the United States Medical Licensing Examination (USMLE), while DOs take the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA). After residency—and possibly additional training in a subspecialty—doctors may take the relevant board exam(s) to become a board-certified specialist. Education, training, and licensing requirements for physicians are summarized in Table 2-6. Physician specialists that may be involved in maternal and newborn care are as follows:  Obstetrician/gynecologists (OB/GYNs) specialize in women’s reproductive health. They may provide preventive care for women, counsel women about reproductive options and prescribe methods of contraception, provide prenatal and postpartum care, attend births, and perform surgeries such as cesarean birth.  Maternal-fetal-medicine specialists (MFMSs), also called perinatologists, are OB/GYNs who undertake additional years of training to specialize in high-risk pregnancies.  Family physicians often care for an entire family, including pregnant women and babies. The proportion of family physicians who offer maternity care has declined in recent years, and many provide only prenatal and postpartum care, with fewer attending vaginal births and even fewer offering cesarean birth (Rayburn et al., 2014).  Pediatricians specialize in the care of children from birth to young adulthood.  Neonatologists are pediatricians who undertake additional years of training to specialize in the care of premature and critically ill newborns.  Anesthesiologists provide women with pain relief during labor and birth, such as epidurals, and also provide anesthesia for surgeries, such as cesareans. 2-22

PREPUBLICATION COPY, UNCORRECTED PROOFS TABLE 2-6 Education and Licensure Requirements for Physicians Providing Maternal and Newborn Care Requirements All physicians Required education Bachelor’s degree, followed by a doctor of medicine (MD) or doctor of osteopathy (DO) degree Required training 3–4 years residency in the specialty area; additional years of residency for subspecialties Exams United States Medical Licensing Examination (USMLE) or Comprehensive Osteopathic Medical Licensing Examination (COMLEX); board certification exam(s) depending on area of specialty and subspecialty Laborists/Obstetric (OB) Hospitalists Laborists, also referred to as OB hospitalists, are obstetricians, family physicians, or CNMs/CMs who provide care only during OB triage, birth, and the immediate postpartum period (Krolikowski-Ulmer et al., 2018). In the hospital setting, laborists focus solely on pregnant women who present for care and those who are admitted for birth, and they typically do not provide prenatal, postpartum, or gynecological care while in the laborist role. The aims of the laborist model are to provide timely high-quality care, to increase patient safety and reduce litigation by ensuring immediate availability of a provider in the labor and delivery unit, and to support obstetricians in reducing burnout and improving their well-being and professional satisfaction (Olson et al., 2012). The use of laborists may allow other providers to sleep, conduct office visits, or care for other patients, and laborists also can develop advanced skills in handling critical OB emergencies. Physician Assistants (PAs) PAs are health care professionals who work closely with physicians to extend and support the physicians’ practice. PAs can care for mothers and babies in a number of ways, including conducting well-woman exams, providing prenatal and postpartum care, and assisting with cesarean births. PAs attend an accredited 3-year graduate program and receive a master’s degree. The program includes both classroom instruction and clinical rotations in a variety of medical areas of practice. Graduates of a program take the Physician Assistant National Certifying Exam (PANCE), administered by the National Commission on Certification of Physician Assistants (NCCPA), and then seek state licensure (American Academy of Physician Assistants, 2019). Other Members of the Care Team While nurses, physicians, and midwives provide the majority of care for women during pregnancy, birth, and the postpartum period, others, such as doulas and community health 2-23

PREPUBLICATION COPY, UNCORRECTED PROOFS workers, can also play a critical role in ensuring that the needs of pregnant people and babies are met. Doulas The role of doulas is to provide nonclinical support during labor and birth, as well as during the prenatal and postpartum periods. While doulas, nurses, and midwives all provide labor support to the woman, doulas focus on only one laboring woman at a time, providing continuous support without other concurrent responsibilities, such recordkeeping or monitoring of equipment. Doulas do not perform any clinical tasks, such as giving medication or conducting examinations. In addition to supporting the woman, the doula can also offer emotional support to the woman’s partner and family. In the postpartum setting, the doula may assist the new mother with breastfeeding and newborn care, and may also help with light housekeeping and cooking duties at home. Doulas care for women in every birth setting—home, birth center, and hospital. Some women use doula support services in an “extended” model throughout all phases of childbearing—prenatal, labor and birth, and postpartum—while others use them during only one of the phases. Being a doula does not require formal education or training, although an individual who has experience working in health care may elect to train as a doula. Certification is not required to practice as a doula, though it may be required for reimbursement. Doulas who pursue certification generally must complete a training session of several days, and practice their doula skills at a certain number of births. Community Health Workers Community health workers provide family-centered support. Usually, they live in the communities they serve and meet individuals in their homes, in clinics, or in community settings (American Public Health Association, 2019). Many community-based perinatal health worker organizations are forming across the country to provide culturally concordant support to childbearing women and families in maternity care deserts and other areas where standard maternity services are sparse and outcomes are poor. These groups, rooted in social, reproductive, and birthing justice frameworks, recognize that women of color face systemic racism, inequities, and other barriers. The groups work to provide trauma-informed, multigenerational support that is tailored to communities and individuals, and focus on respect, empowerment, and choice without judgment. The diverse services of these groups can include mental health, labor, breastfeeding, and parenting support; referral to needed social and community services; and midwifery care. They have various degrees of sustainability and sources of revenue, and some have training programs and are active in shaping policy (National Partnership for Women and Families, 2019). Education and training requirements for community health workers vary by state and by the type of work they perform. Some states offer certifications for community health workers. For example, certified community health workers in Texas must complete a 160-hour training or have at least 1,000 hours of experience in community health work (Texas Department of State Health Services, 2019). 2-24

PREPUBLICATION COPY, UNCORRECTED PROOFS POLICY AND FINANCING Although there are multiple options for where to give birth in the United States and a variety of providers of maternity care, the choice of setting and provider is greatly constrained by policies and financing. Federal and state laws and regulations help determine which settings and providers are legally able to provide maternity care, and set rules about Medicaid eligibility. Additionally, federal and state laws and private insurance policies determine what services are covered and which providers will be reimbursed. For example, Medicaid typically looks to Medicare when making coverage decisions, and Medicare does not reimburse certain types of midwives. State regulation of insurance coverage, Medicaid coverage and eligibility, licensing of providers and facilities, and scope of practice for health professionals vary widely by state. These variations may in part explain some of the differences across states between the number of women who give birth in the hospital and those who give birth at home or in a birth center (Yang et al., 2016; MacDorman and Declercq, 2019). For example, in a state where policy and financing facilitate easy access to midwifery care and birth in home or birth center settings, women of many socioeconomic backgrounds may be able to access these options if they choose to do so. By contrast, in a state where policies restrict these choices—for example, by not offering licensure or coverage for settings other than the hospital, or through reduced scope of practice for providers and limited Medicaid options—giving birth at home or in a birth center will likely remain the domain of women who can afford to pay out of pocket. Financing Women pay for maternity care in several ways: private insurance (either employer- sponsored or individually purchased), Medicaid, self-payment, or Medicare (for some disabled women). The availability and type of coverage greatly influence a woman’s choice of care provider and her access to various types of care. States can require that certain minimum benefits be covered by private insurance and Medicaid, and states also can set eligibility rules for Medicaid, which determine when and whether individuals may access different types of maternity care above the federal minimum standards. Because of federal and state policies, some women are not able to access any form of insurance, leaving them with the entire bill for pregnancy care. For example, the working poor in some states fall into the “coverage gap,” in which their income is too high to qualify for Medicaid but too low to receive tax credits for marketplace plans through the Affordable Care Act (ACA) (Garfield et al., 2019). Undocumented immigrants in the United States are not eligible to enroll in Medicaid or to purchase ACA marketplace plans, leaving many without any type of insurance. Undocumented immigrants face additional barriers to care, such as fears about becoming ineligible for lawful permanent residency (Ponce et al., 2018). However, 16 states do permit undocumented women to receive some pregnancy care by extending Children’s Health Insurance Program (CHIP) coverage to their unborn child (Artiga and Diaz, 2019). Costs Giving birth in the United States is expensive. A national analysis using proprietary data of payments made on behalf of the woman and newborn across the full episode, from pregnancy through postpartum and newborn care, revealed significant expenditures in 2010 (which would 2-25

PREPUBLICATION COPY, UNCORRECTED PROOFS be higher as of this writing because of inflation) (Truven Health Analytics, 2013). Payments differed by type of payer and mode of birth. Total payments for privately insured births averaged $18,329 for vaginal and $27,866 for cesarean births. Total payments for Medicaid-insured births averaged $9,131 for vaginal and $13,590 for cesarean births. Payments for privately insured births were about twice as high as those for births covered by Medicaid. When the birth was cesarean, payments were about 50 percent higher than when the birth was vaginal. For privately insured individuals, these payments included substantial average out-of-pocket costs for both vaginal ($2,244) and cesarean ($2,669) births, whereas such costs were negligible for individuals with Medicaid coverage. A major finding from this analysis is that about 4 of 5 dollars paid on behalf of the woman and newborn across the full episode of care went to intrapartum care, while only 1 in 5 dollars went to prenatal and postpartum/newborn care. As these figures indicate, the amount actually paid to the provider and the facility may differ depending on whether it is paid for by private insurance, Medicaid, or self-pay. Actual expenditures for maternity care depend on the type of provider, the specific services used, and the birth setting. Because most of the births in the United States occur in a hospital, the numbers discussed above reflect primarily the cost of delivery in a hospital. However, those costs can vary significantly from hospital to hospital. For example, the rate of cesarean birth will impact average costs, and these rates can vary dramatically between hospitals (Main et al., 2011). Birth center and home birth costs are typically lower in price for vaginal births than hospital vaginal births. An Urban Institute study comparing birth center births with hospital births found a savings (in 2008 constant dollars) of $1,163 per birth for Medicaid births (Howell, et al., 2014). Another study in Washington state found the impact of the cost savings from the practice of licensed midwifery on the cost of deliveries to all payers to be significant; the study found that there would be an additional $2,713,072 in costs if births that took place out of the hospital or in the hospital with a midwife attendant were moved into the hospital setting with a nonmidwife attendant (Health Management Associates, 2007). Payers Private insurance, which includes both insurance purchased by individuals directly from an insurer or on the marketplace, as well as employer-sponsored insurance, financed about half (49.6%) of all births in the United States in 2018, with Medicaid close behind at 42.3 percent of all births (Martin et al., 2019) About 4 percent of births were self-paid, and another 4 percent were paid for by other means. Medicare plays a very limited role in financing maternity care, primarily for beneficiaries who are disabled. Coverage by the various payers is detailed below. Box 2-4 summarizes coverage for doulas and other nonclinical support. Private Insurance Under the ACA, nearly every insurance plan is required to cover maternity care in general (Cuellar et al., 2012). According to the American Association of Birth Centers, most major private health insurers will cover care and delivery at birth centers in some, but not all, states. A national survey indicated that Aetna/US Healthcare, Blue Cross/Blue Shield, TRICARE, and Humana are among those that cover birth center care (American Association of Birth Centers, 2016e). Fewer private insurers cover home births; for example, Aetna (2019) does not cover home births because it “considers planned deliveries at home and associated services not medically appropriate.” Aetna notes, however, that it will consider coverage when mandated 2-26

PREPUBLICATION COPY, UNCORRECTED PROOFS by state law. A few states, including New Hampshire, New York, New Mexico, and Vermont, do require private insurers to cover home births (Rathke, 2011). However, even in states where insurers must cover home births, insurance companies may have certain requirements for coverage, which can sometimes result in denial of reimbursement. For example, an insurance company might deny coverage for a midwife who does not carry malpractice insurance (which many do not) (Fisch, 2012; The Editorial Board, 2014). In addition, if home and birth center providers are considered out-of-network, the process of getting reimbursement can be onerous, and payment levels may be set at rates that limit the providers’ ability to provide services to certain enrollees. Medicaid Medicaid is a joint federal and state program, and therefore its policies are determined at both the federal and state levels. Federal and state laws dictate who is eligible for Medicaid, the care that must be covered, and what facilities or providers can be reimbursed. The federal government mandates certain groups that must be eligible for Medicaid, including pregnant women whose income level is at or below 133 percent of the federal poverty level (FPL) (Kaiser Family Foundation, 2017). Further, federal Medicare policy related to covered providers typically drives Medicaid policy; Medicare currently covers nurse midwives but not CPMs. States set additional rules about who is eligible for Medicaid; for example, a state may extend eligibility to women with higher income levels than the federal minimum (Kaiser Family Foundation, 2017). Undocumented women are not eligible for Medicaid under federal law, although some states find other avenues to pay for the care of these women (Artiga and Diaz, 2019). There are different eligibility pathways to Medicaid for pregnant women:  Pregnancy-only eligibility: Medicaid coverage available prior to the ACA for pregnant women through 60 days postpartum; all states required to cover pregnant women with incomes up to at least 133 percent of the FPL.  Traditional Medicaid: Medicaid coverage available prior to the ACA based on an individual having income below a state’s threshold, as well as being in one of the program’s eligibility categories: pregnant woman, parent of children 18 and younger, disabled, or over age 65.  ACA Medicaid Expansion: The ACA allowed states to eliminate categorical requirements and extend Medicaid to most women and men with family incomes at or below 138 percent of the FPL. States that have adopted this expansion must cover all recommended preventive services without cost sharing for beneficiaries in this pathway (Kaiser Family Foundation, 2017, p. 2). In addition, some states have implemented presumptive eligibility, in which pregnant women may receive immediate care while their eligibility for Medicaid is being determined (Kaiser Family Foundation, 2017). Coverage for prenatal services (e.g., ultrasounds, genetic testing) and labor and birth services (e.g., induction, epidurals, elective cesareans) depend on a woman’s eligibility status and state of residence, and it can be difficult for women to determine ahead of time which services will be covered (Haney, 2017). For women with incomes at or below 133 percent of the 2-27

PREPUBLICATION COPY, UNCORRECTED PROOFS FPL, the federal government requires that the state Medicaid plan provide, at a minimum (The Medicaid and CHIP Payment and Access Commission, 2017), the following:  “Those services that are necessary for the health of the pregnant woman and fetus, or that have become necessary as a result of the woman having been pregnant. These include, but are not limited to, prenatal care, delivery, postpartum care, and family planning services.”  “Services for other conditions that might complicate the pregnancy [including] those for diagnoses, illnesses, or medical conditions which might threaten the carrying of the fetus to full term or the safe delivery of the fetus.” As of 2019, 36 states and the District of Columbia had expanded Medicaid under the ACA (Kaiser Family Foundation, 2019a), making low-income women eligible for coverage before, during, and after the period of pregnancy, labor and birth, and the conventional 2-month postpartum period. Several other states have passed Medicaid expansion ballot initiatives, which have not been implemented. Section 2301 of the ACA requires state Medicaid programs to cover the costs of services at freestanding birth centers, to the extent that the state licenses or otherwise recognizes these providers and facilities under state law (Centers for Medicare & Medicaid Services, 2011). However, this provision has been implemented inconsistently and inadequately by states, meaning that birth centers are not covered in every state in which they are licensed (Bauer et al., n.d.). In a 2017 survey, 32 states plus the District of Columbia reported that they covered births at birth centers, and 11 states reported that they did not (the remaining states did not respond) (Kaiser Family Foundation, 2019c). Because Medicaid is administered by the state, coverage and reimbursement of birth center services face other barriers. Medicaid managed care organizations (MCOs), which administer Medicaid in 38 states plus the District of Columbia (Kaiser Family Foundation, 2019b), can limit which providers are in their networks, negotiate very low rates such that only hospitals can afford to take Medicaid patients, and make it difficult for providers to get paid through requirements such as prior authorization. Coverage of birth center services may be contingent on meeting certain state requirements, for example, accreditation of the birth center or certain limits on liability insurance. If these requirements are not met, Medicaid may not cover the costs of the birth. Home birth expenses are less likely to be covered by Medicaid either in policy or in practice. Many states will cover home birth only if certain requirements are met; for example, the midwife must have malpractice insurance. A 2018 survey found that 21 states allowed Medicaid coverage for home births, out of 41 states that responded (Kaiser Family Foundation, 2017). There is also great variation in the extent to which Medicaid covers certain providers. Currently, all states reimburse for CNM and CM services, some at the level of a physician providing the same service and some at a lower level. Whether states reimburse CPMs for services is determined on a state-by-state basis (Kaiser Family Foundation, 2017). Medicare Medicare pays for relatively few births compared with private insurance and Medicaid. However, Medicare coverage rules have a large impact on coverage and payment in other plans, in that most private plans and Medicaid follow Medicare’s lead on which types of providers are covered and on reimbursement amounts for providers and services. This is relevant to maternity coverage in two areas. First, Medicare does not recognize CPMs as eligible 2-28

PREPUBLICATION COPY, UNCORRECTED PROOFS providers at the federal level. By extension, many private insurers and Medicaid state plans do not cover CPM services. Second, federal law dictates that Medicare pay the same rate for the same services provided by CNMs and physicians. Previously, CNMs were reimbursed at 65 percent of the physician level; advocacy from the American College of Nurse-Midwives (ACNM), ACOG, and others resulted in equitable reimbursement as part of the ACA (American College of Nurse-Midwives, 2009). This equitable reimbursement of CNMs and physicians is expected to trickle down into the reimbursement policies from other insurance plans, including Medicaid (American College of Nurse-Midwives, n.d.b.). Self-Financing Only about 4 percent of all births are self-paid, although women who use birth centers or home birth are more likely to self-pay. More than two-thirds (67.9%) of planned home births and almost one-third (32.2%) of birth center births were self-paid in 2017, while only 3.4 percent of women self-paid for hospital birth (MacDorman and Declercq, 2019). BOX 2-4 Coverage for Doulas and other Nonclinical Support As of this writing, few insurance plans cover the costs of doula or other nonclinical support services. Initially, use of doulas was concentrated among interested families with the ability to pay out of pocket. However, there is a growing trend in the rise of programs to provide low-income women of color with community-based, culturally concordant support services, with various types of financing. Many states are now considering or implementing legislation to create such programs as a way to address disparities in maternal health outcomes (Association of State and Territorial Health Officials, 2018). A primary way of covering the costs of nonclinical support is through Medicaid reimbursement. In 2013, a Centers for Medicare & Medicaid Services (CMS) Expert Panel on Improving Maternal and Infant Health Outcomes in Medicaid/CHIP recommended that doula support during labor be covered (Centers for Medicare & Medicaid Services, 2013). In the years since, only a few states have passed legislation to obtain Medicaid reimbursement for doulas, and the reimbursement rates can be low (Quinn, 2018). Some organizations have negotiated Medicaid reimbursement for non-clinical support directly from managed care organizations (MCOs). For example, Mamatoto Village in Washington, DC, has secured reimbursement from four MCOs for the services of community health workers who support women of color through pregnancy and birth (Commonwealth Fund, 2018). However, getting reimbursement from Medicaid for nonclinical services entails challenges even in the states that have passed legislation to do so. For example, the New York pilot project requires doulas to be enrolled as providers with the state Medicaid program, which in turn requires completion of a doula training course, as well as completion of a specific number of hours of education and training. These requirements can be burdensome for doulas who are part of the lower-income communities of color that the pilot project is designed to help (New York State, 2019). [END BOX] 2-29

PREPUBLICATION COPY, UNCORRECTED PROOFS Licensing and Scope of Practice States are responsible for licensing health care professionals and for dictating where they can practice, what services they can provide, and whether they are required to be supervised. Physicians and nurses are licensed and recognized in all states, although scope-of-practice rules vary for APRNs. For example, 22 states allow full-practice nurse practitioners (NPs), meaning that NPs can prescribe medication, diagnose patients, and provide treatment without the presence of a physician. Seventeen states allow reduced-practice NPs; in these states, NPs need a physician’s authority to prescribe medication. Twelve states restrict the autonomy of NPs and require a physician’s oversight for all practice (American Association of Nurse Practitioners, 2019). Still other states stipulate the type of medication that NPs can prescribe. Arkansas, Georgia, Louisiana, Missouri, Oklahoma, South Carolina, Texas, and West Virginia, for instance, do not allow NPs to prescribe any Schedule II medications (American Medical Association, 2017). Midwife licensing and scope-of-practice rules vary by state and type of midwife. Currently, CNMs are licensed in all 50 states, CPMs are licensed in 33 states, and CMs are licensed in only 6 states. Twenty-seven states and the District of Columbia allow CNMs to practice independently, 19 require a collaborative agreement with a physician, and the remaining 4 allow CNMs to practice independently but without the ability to prescribe medications (American College of Nurse-Midwives, 2015). States can also place specific limits on the settings in which providers can practice. In Nebraska, for example, it is illegal for CNMs to attend home births (Nebraska Legislature, 2007). States also license and regulate facilities such as hospitals and freestanding birth centers. Some states have birth center regulations, such as a requirement for a medical director who is a physician, which makes it difficult for new birth centers to obtain recognition and licensure if no physician is willing or able to serve in this role. Steps taken to meet other requirements, such as a written agreement with the area hospital regarding transfers, can easily be lost with administrative changes within hospitals, causing existing birth centers to close. One state—North Dakota—does not permit freestanding birth centers to operate at all (Alliman and Phillippi, 2016). CONCLUSION Pregnant people who give birth in the United States can have vastly different experiences depending on the setting in which they give birth, the providers who participate in their care, how the birth is financed, and the state in which they give birth. Hospitals, home births, and birth centers offer different resources, services, and care options. For example, hospitals offer more intensive interventions, such as induction and augmentation of labor, epidural pain relief, and cesarean birth, whereas birth centers and home births do not offer similar interventions and instead put more emphasis on supporting physiologic birth. Even among different hospitals, the resources, providers, services, and outcomes can vary widely, depending on such factors as the level of care, geographic location, staffing, and culture. In some circumstances, individuals may need to be transferred from home or a birth center to a hospital, and such transfers are more complicated and difficult in areas where midwives and out-of-hospital birth options are not well integrated into the health care system. 2-30

PREPUBLICATION COPY, UNCORRECTED PROOFS A number of different clinicians participate in birth care, including physicians, nurses, and midwives, in addition to other members of the health care team, such as doulas. In the United States, all credentialed providers must meet specific education and training requirements, and must pass standardized exams in order to be licensed by the state. While the vast majority of women give birth in a hospital, the percentage of women choosing to give birth at home or in a freestanding birth center has been rising steadily; however, the rate still represents a small proportion of overall births, and the increase has been primarily among certain groups of women. In 2017, 0.99 percent of all births took place in the home and 0.52 percent in a freestanding birth center (MacDorman and Declercq, 2019). These rates vary substantially by state and region of the country, and women who plan to give birth at home or in a birth center are more likely to be White, more highly educated, older, and able to pay for the birth out of pocket. State financing and policy choices have a large impact on women’s access to different birth options. For example, women who are covered through Medicaid may not be covered for births at home or in a birth center, depending on the state in which they live. Other state policies may restrict the types of providers who are licensed, the types of birth settings that are legal, and the scope of practice for different providers. In addition to these factors, pregnant people’s birth experiences may be shaped by social determinants and medical risk profile. Social determinants include such factors as racism, geographic location, and socioeconomic conditions; these factors can substantially impact the choices they have, their access to care, and the outcomes of their birth experience. A pregnant individual’s experience and outcomes are also impacted by medical risk profile, such as whether complicating health conditions are present, whether the individual is carrying twins, and the position and health of the fetus. These factors can restrict choice of setting and provider because of the possibility that quick access to medical expertise or knowledge of the condition and its management along with interventions may be necessary. Social determinants and medical risk profile, and how they affect choices and outcomes, are discussed in the subsequent chapters. 2-31

PREPUBLICATION COPY, UNCORRECTED PROOFS 2-32

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The delivery of high quality and equitable care for both mothers and newborns is complex and requires efforts across many sectors. The United States spends more on childbirth than any other country in the world, yet outcomes are worse than other high-resource countries, and even worse for Black and Native American women. There are a variety of factors that influence childbirth, including social determinants such as income, educational levels, access to care, financing, transportation, structural racism and geographic variability in birth settings. It is important to reevaluate the United States' approach to maternal and newborn care through the lens of these factors across multiple disciplines.

Birth Settings in America: Outcomes, Quality, Access, and Choice reviews and evaluates maternal and newborn care in the United States, the epidemiology of social and clinical risks in pregnancy and childbirth, birth settings research, and access to and choice of birth settings.

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