As someone who works routinely with hospitals and individual providers to improve the quality of maternity care, I spend a lot of my time in the details of data — the trees, so to speak. Maternity Care in California: Delivering the Data, a report released recently by the California Health Care Foundation (CHCF), offers an opportunity to step back and see the whole forest of maternal health and health care in our state.
Looking across this report’s data landscape, four major storylines about maternity care in California emerge:
1. Maternity Care Matters — a Lot
More babies are born in California than any other state — over half a million each year, representing one of every eight US births. In fact, having a baby is the primary reason for hospitalization in California. If you care about the health of the US as a whole or just California, the quality and cost of maternity care in the Golden State should be top of mind.
2. The Demographics of Women Giving Birth Are Changing
Overall, California’s mothers today are older, more ethnically diverse, and lower income. Too many have babies while coping with financial hardship.
Between 2000 and 2014, the age group with the largest increase in births was mothers age 30-34, followed by those age 35-39. Meanwhile, the number of women under 25 having babies is lower than it has been in generations.
The population of new mothers is strikingly multiracial. Only slightly more than one-quarter of births are to white non-Hispanic mothers; nearly half are Latina.
Nearly half of the deliveries in California were covered by Medi-Cal, and 43% of births were to mothers with household incomes below the federal poverty level.
3. Care and Outcomes Vary Dramatically Among Hospitals
In California 99% of women give birth in a hospital. So how are our hospitals doing overall? Between 1997 and 2014, medical interventions, such as cesarean deliveries, rose more than 50%, both in California and nationwide. But the story for individual hospitals is stunning. The standard, risk-stratified, low-risk, first-birth cesarean rates in California hospitals range from 12% to 70%. There is also huge variation in rates of vaginal births (0% to 42%) among women with a prior cesarean (VBAC) and rates of episiotomy (0% to 63%). In health care such extreme variation serves as an alarm bell that there is a problem needing prompt attention.
What drives this variation among hospitals? Studies indicate that differences in patient characteristics do not account for these disparities. Instead, signs point to the role of individual hospital culture and provider practice patterns, and the way California’s health care system reimburses for maternity care. For example, most hospitals are paid more for cesarean deliveries.
One effort that aims to address these multifactorial drivers is underway: With support from CHCF, the California Maternal Quality Care Collaborative has launched a comprehensive, multidisciplinary, statewide quality improvement initiative to reduce the first-birth, low-risk cesarean delivery rate. By the end of 2016, more than 90 participating California hospitals will be actively taking steps to bring down their higher cesarean delivery rates. Alongside this provider work, key players — including Covered California, our health insurance exchange — are starting the hard work of aligning payment and purchaser requirements with desired evidence-based outcomes.
4. African American Mothers Face the Greatest Risks
African American women are three to four times more likely than all other racial groups to die from complications of pregnancy or childbirth. Additionally, while the overall preterm birth rate in California is 8.3%, for African Americans the rate is 12.1%. What accounts for this variation? Underlying medical conditions, or comorbidities, may explain a portion. For example, data show that African American mothers:
Have much higher rates of hypertension and asthma (but lower rates of diabetes) than other racial groups
Are more than twice as likely as whites and Latinas to be morbidly obese prior to pregnancy
Have higher rates of depressive symptoms and smoking, and are more likely to have infants going through withdrawal from opioids
Health researchers suspect that exposure to chronic stress and lower levels of social and family supports also contribute to the disparities.
These differences are unacceptable. California cannot reach its full health potential if an entire population of mothers and infants is being left behind. Each new mother and child is an investment in our state’s future. California has incredible health care talent and resources, and we must collaborate to make maternity care work better for all Californians.
Elliott Main is the medical director of the California Maternal Quality Care Collaborative (CMQCC). He has led multiple state and national quality improvement projects and served for 14 years as chair of the ob/gyn department at California Pacific Medical Center in San Francisco. He is clinical professor of obstetrics and gynecology at both UCSF and Stanford University and has been actively involved in and chaired multiple national committees on maternity care quality. CMQCC is a grantee of CHCF.