6667Meeting the Need for Innovation in Maternity Care

DIANA R. JOLLES AND PAULA PELLETIER-BUTLER

LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to:

1.  Evaluate the concepts of innovation and disruptive innovation as they relate to freestanding birth centers as the normative, Level 1 model of care for childbearing families in the United States

2.  Explore how contemporary birth centers use the nine standards of the American Association of Birth Centers (AABC) as the basis for disruptive innovation

Innovation refers to new ideas, devices, or methods, or the acts or processes of introducing new ideas, devices, or methods. Disruptive innovation is the term used to explain how “complicated, expensive products and services are eventually converted into simpler, affordable ones” (Hwang & Christensen, 2007, p. 1329). Birth centers have been demonstrated to be a disruptive innovation, capable of enhancing population health, consumer experiences, and value (Alliman & Phillippi, 2016; Rooks et al., 1989; Stapleton, Osborne, & Illuzzi, 2013). Drivers of innovation within birth centers include adversity, social crisis, and necessity. Throughout this book, readers will explore how the context of care in the United States has driven the birth center as an innovation.

ADVERSITY DRIVES INNOVATION

68Innovation is inspired by adversity. Beginning with the landmark Institute of Medicine’s (IOM) reports Crossing the Quality Chasm (2001) and To Err Is Human (2000), the national quality movement in the United States is aligned around the Triple Aim to improve the patient experience of care and improve population health, while reducing per capita cost (Berwick, Nolan, & Whittington, 2008; IOM, 2000, 2001). The mounting pressure to improve quality and decrease waste while reducing costs and increasing value is coming from multiple sectors of the health care system: consumers, providers, administrators, policy makers, and third-party payers (Carter et al., 2010; Howard & Jolles, 2015; Sakala & Corry, 2008).

The staggering U.S. outcome statistics for newborns and women who give birth is inspiration enough to unearth alternative solutions. In many parts of the United States, a woman has essentially one in three chances of having a cesarean birth just by walking through the hospital door, and in a few places almost one in two chances (Table 2.1; Kozhimannil, Law, & Virnig, 2013). Cesarean section is an endorsed quality measure capable of detecting system-level quality defects (Main et al., 2006). The World Health Organization and Healthy People 2020 both place cesarean benchmarks well below our current national rate. Birth centers have demonstrated the ability to exceed benchmarks across geographical, political, and contextual barriers over the past 40 years (Table 2.1; Alliman & Phillippi, 2016; Rooks et al., 1989; Stapleton et al., 2013).

Significant variation in the quality of health care in the United States is driven by nonmedical determinants rather than the needs and preferences of the population (Fisher, Goodman, Skinner, & Bronner, 2009). Facilities are independent drivers of cesarean and decreased breastfeeding rates (Clark, Belfort, Hankins, Meyers, & Houser, 2007; Corallo et al., 2014; Gregory, Ramicone, Chan, & Kahn, 1999; Howell, Richardson, Ginsburg, & Foot, 2002; Kogan, Singh, Dee, Belanoff, & Grummer-Strawn, 2008; Kozhimannil et al., 2013; Dartmouth Atlas Project, 2007). Variation in provider type is a known driver of cesarean birth (Clark et al., 2007; Sandall, Soltani, Gates, Shennan, & Devane, 2015). Healthy childbearing women at low medical risk have demonstrated a greater sensitivity to unwarranted variations in care that decrease quality and drive cost increases (Kozhimannil et al., 2013).

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SOCIAL CRISIS DRIVES INNOVATION

Throughout history, the solving of a crisis has always been a tangible driver of innovation. The ongoing, persistent promulgation of racial and ethnic disparities coupled with unreliable quality of the health care system 70takes the urgency of the call for innovation to a critical level. Lack of equity in maternity care and the resulting disparity has reached epic proportions (see Table 2.1). Institutionalized racism and the privilege of the medical system is a known driver of racial disparity and inequity (Agency for Healthcare Research and Quality, 2015; Markus & Rosenbaum, 2010; Robbins et al., 2014).

Preliminary data from the AABC’s Strong Start for Mothers and Newborns initiative project demonstrates a protective effect of birth center care against racial disparity, demonstrating superior outcomes on core national quality measures, including nulliparous term vertex singleton cesarean and breastfeeding (Jolles, 2016; Table 2.1). The data out of the AABC Strong Start sites is important because it demonstrates a diverse population, which mirrors the national sociodemographic profile. AABC’s Strong Start is a free program funded by Centers for Medicare and Medicaid Services (CMS) providing support and services to women who qualify. Statistically significant racial variations of intention to breastfeed occurred upon entry to care within the Strong Start site birth centers, with significantly more non-Hispanic White women intending to breastfeed upon entry to care. However, on admission in labor, these differences in breastfeeding intention disappeared as a result of the model of care. There were no statistically significant racial variations in breastfeeding on discharge. Women and newborns cared for within the AABC Medicaid sample used less formula among breastfed infants in the first 2 days of life; the rate of exclusive breastfeeding was increased on discharge, 18% higher than national benchmarks and 52% higher than the national average. When compared to the nationally reported data on breastfeeding from the Centers for Disease Control and Prevention (CDC) National Immunization Survey, birth center Strong Start sites far exceeded national performance across racial groups. The perinatal episode of care within the birth center model has been demonstrated to produce superior outcomes for breastfeeding, decrease disparity, increase equity, and improve population health.

There is agreement among many midwifery organizations that birth center care may be one of the most plausible solutions to the racial disparities surrounding birth, particularly when providers of the same race and ethnicity serve their communities. Midwives and birth workers of color and members of the National Association of Birth Centers of Color are working hard to employ innovative solutions to address these disparities with encouraging results. The AABC’s own Strong Start program is also documenting progress in the 40+ birth centers that are providing this level of care. Racial disparities surrounding birth require a strong call to action 71with a variety of innovative approaches, and although there is no quick fix, the tangible crusade for solutions on a national level is a reason for hope.

NECESSITY DRIVES INNOVATION

Innovation is also born out of necessity. According to the American Association of Medical Colleges (AAMC), the total demand for physicians is projected to grow up to 17% with significant shortages projected by 2025 due to the aging population and overall population growth. The AAMC projects that by 2025 there will be a shortage of up to 12,300 “medical specialists” and up to 20,200 “other specialists” (Dall, West, Chakrabarti, & Lacobucci, 2016). At first glance, we can correlate this information to conclude that we need more midwives. In addition, consumers will be forced to look beyond the more traditional approach to the physician/inpatient-based health care system due to the projected lack of physicians. The outpatient, often home-like environment of the birth center provides communities with specialty provider care in a proven safe environment.

DISRUPTIVE INNOVATION: LEVEL 1 CARE FOR ALL

Birth centers are poised to fulfill the Triple Aim as the demonstration model for “Level 1” care for childbearing families in the United States. In 2014, the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine released an Obstetric Care Consensus statement, detailing “Levels of Maternal Care” (Obstetric Care Consensus no. 1: Safe Prevention of the Primary Cesarean Delivery, 2014). One of the purposes of the statement was to foster the development and equitable distribution of maternal care systems, which promote risk-appropriate care.

According to the latest evidence, the majority of childbearing women in the United States are at low medical risk, suggesting that the health care delivery system should reliably provide access to integrated, evidence-based, Level 1 care (Carter et al., 2010; Robbins et al., 2014). Rather than having access to family-centered, home-like environments, it is well known that the predominant model of labor and delivery in the United States resembles “an intensive care unit” (Shah, 2015, p. 2182). In 2016, the conversation regarding “risk-appropriate” care has been largely predominated by the appropriate care for high-risk women (Korst et al., 2015). The lack 72of risk-appropriate care for the majority of childbearing women, who are at low medical risk, is not well appreciated (Institute of Medicine [IOM] and National Research Council [NRC], 2013).

Level 1 care is a high-value care model, although commonly presented within the hierarchical description of the levels of care as a “low” level of care (Korst et al., 2015; Menard et al., 2015). Instead, birth centers offer enhanced care services, family-centered care, and a system well designed to refer to a higher level of care when appropriate. The birth center model of care is designed to engage consumers in life-course care, addressing the social determinants of health that are understood to influence 80% of health outcomes (Howell, Palmer, Benatar, & Garrett, 2014; Lubic & Flynn, 2010).

THE STRUCTURE AND PROCESS OF INNOVATION

In order for the birth center model to spread, it must maintain the effective components of the model of care, while adapting to the requirements of the local political and professional community: adherence to the nine American Association of Birth Center standards (Table 2.2; see Chapter 8). Midwife and nonmidwife entrepreneurs recognize the social and economic imperative of introducing the birth center innovation to more and more communities across the United States. Adherence to the model is best preserved through achieving accreditation through the Commission for the Accreditation of Birth Centers (CABC). Accreditation is an essential component of the structure of innovation, moving the birth center model to scale and the innovative and normative Level 1 care for the majority of childbearing families in the United States (Alliman, Jolles, & Summers, 2015).

Throughout the book, readers will be exposed to innovation within the AABC standards (Table 2.2). Birth centers are using community participatory design to engage communities in the planning of services, evaluation of care, and design of culturally humble care delivery. Community-based planning is an ongoing and continuous process and the root of disruptive innovation. Readers will explore a variety of legal entities and business and administrative structures used to support birth center growth. From sole proprietors through partnerships with federally qualified health centers, birth centers have adapted to the unique opportunities within each community to support viable and creative business models. Birth facilities and staff drive cost in the United States. Throughout the book, readers will explore how birth centers provide an innovative, high-value alternative to hospital facilities offering enhanced access to interprofessional and diverse staff as well as aesthetically pleasing, nonmedicalized environments. These innovations increase consumer opportunities for holistic, noninterventive care while providing increased access to therapeutic hydrotherapy, family spaces, kitchen access, and outdoor space, all while saving money.

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