Pregnancy, childbirth and U.S. health care: A painful experience

March 31, 2021 / By Steve Delaronde

Childbirth is safer now than at any other time in U.S. history. Despite this, nearly 1 in 3 babies are born by Cesarean delivery, 1 in 7 are born into poverty, 1 in 10 are born with a low birthweight, and 21,000 infants die every year. Even more disturbing is that these rates vary dramatically depending upon the mother’s demographic and social factors, as well as by the hospital in which she chooses to deliver her baby. There is an opportunity to reduce the overall risks posed by childbirth, as well as the variation in practice patterns and outcomes that continues to persist.

Cesarean section variation

Nearly 99 percent of the nearly 4 million babies born in the U.S. every year are born in a hospital. Thirty-two percent are born by Cesarean delivery, compared to the 10-15 percent recommended by the World Health Organization. These rates vary significantly by country, state, hospital, provider type, and obstetrician. Differences in practice patterns revealed a 10-fold difference in Cesarean delivery rates from 7 percent to 70 percent across 593 U.S. hospitals.

There are specific indications for a Cesarean delivery for women that experience a high-risk pregnancy. However, the Cesarean delivery rate for low risk women is still 25.5 percent. While further risk adjustment is needed, the variation that persists across multiple factors suggests that physician and hospital preference is a leading contributor to excessive Cesarean delivery rates. Maternal preference, convenience, and the price differential between Cesarean and vaginal delivery are additional contributors that need to be addressed.

Poverty and health disparities

The fact that 13 percent of all children are born poor in the U.S. and 42 percent of all births are paid by Medicaid is a clear indication that all children are not born with the same opportunities for a healthy start in life. The disparity is even more pronounced across racial categories with 40 percent of Black children and 9 percent of white children born poor. The same racial disparities exist for infants born with a low birth weight and those that die during their first year of life.

Poverty is associated with poor health outcomes. There is also a known link between income inequality and health disparities. Health disparities among expectant mothers can be addressed through prenatal care that considers both medical and social risks. However, barriers to prenatal care must first be identified before they can be addressed.  Financial barriers often manifest in the form of transportation challenges, unsafe housing conditions, food scarcity, childcare affordability and the constant stress associated with poverty.  

Once identified, mothers and their children benefit from supportive services that not only occur prior to childbirth, but postnatally, as well. Investments made in the first year of a child’s life have clear benefits. Services that address breast-feeding, maternal nutrition, chronic disease management, post-partum depression, safe housing and stress management can all lead to positive health outcomes.  

Low birth weight and infant mortality

Preterm birth (before 37 weeks gestation) is a significant predictor of low birth weight (less than 2500g), very low birth weight (less than 1500g), and infant mortality (death within one year from birth). Preventing preterm birth should be the top priority of any health care system to avoid low birth weight births and the ensuing admission to the Neonatal Intensive Care Unit (NICU). 

Even if a baby is stabilized and discharged from the NICU, the risk of long-term complications and health issues remain.  Fastidious attention to maintaining good maternal nutrition, smoking cessation, and management of comorbid conditions, as well as addressing social risk factors are key preterm birth prevention techniques.

Next steps

There are three important factors that must be considered to achieve successful pregnancy outcomes. First, clinical and social risks must be addressed together. Currently, more than three-quarters of pregnant women begin prenatal care during the first trimester. While prenatal care does a good job focusing on the clinical aspects of care, social risk factors also need to be considered. Second, the entire episode of care needs to include the prenatal, as well as the postnatal periods, lasting up to a year post-delivery. Third, the health outcomes of mother and child are intertwined and must be treated as one outcome. When this shift occurs, we will not only experience better short-term outcomes in the form of fewer NICU stays but improved long-term outcomes that extend well beyond pregnancy and childbirth.

Steve Delaronde is senior manager of product, population and payment solutions at 3M Health Information Systems.