In the United States, the costs associated with maternity care have outpaced other nations while birth outcomes have been poorer. There is also a noted disparity in maternity and childbirth outcomes, such as infant mortality, by race, socioeconomic status, and geographic area in the United States.
This white paper explores the costs and outcomes of maternity care in the United States, compares them to other nations, identifies factors that contribute to poor outcomes, discusses case management programs that may improve outcomes and lower costs, and outlines a strategic data-driven road map for health plans to address cost and poor outcomes.
Maternity costs vs. outcomes
Many sources have documented discrepancies between healthcare costs and outcomes for various services in the United States. We will highlight some of the discrepancies associated with maternity and childbirth.
Based on 2019 figures from the Health Care Cost Institute and shown in Figure 1, the United States had costs in excess of 125% of the maternity costs for Switzerland, Germany, Spain, and five other countries. This increased spend corresponded to worse outcomes with a much higher maternal mortality rate. The United States experienced a maternal mortality rate nearly double or more than double of all the nations in the study.
Figure 1: 2019 maternity costs and maternal mortality ratios*
Sources: https://healthcostinstitute.org/hcci-research/international-comparisons-of-health-care-prices-2017-ifhp-survey, https://healthcostinstitute.org/images/pdfs/international_health_cost_comparison_report_2022.pdf, and https://ourworldindata.org/maternal-mortality.
* Reimbursed amounts include both plan-paid and patient cost sharing.
** UAE and Netherlands relied on 2017 costs, because 2019 costs were not available for this study. Kazakhstan used 2017 maternal mortality ratios because 2019 data was not available.
Maternal mortality ratio (MMR)—measured as deaths per 100,000 live births—among developed countries has decreased dramatically since the late 1800s, but while most countries have continued to see steady or declining maternal mortality ratios, the U.S. maternal mortality ratio has been markedly increasing for the past 20 years. See Figures 2 and 3.
Figure 2: Maternal mortality ratios over time
In 2017, the MMR was 19.0 in the United States. This is significantly higher than observed in other countries. For example, in the United Kingdom the MMR was 6.5, while in Canada the MMR was 6.6.
Figure 3: Maternal mortality ratios 1980 to 2020
In addition to high maternal mortality ratios, infant mortality rates—measured as a percentage of total childbirths—are also higher in the United States than many developed countries.
Figure 4: 2019 maternity costs and infant mortality rates*
Sources: https://healthcostinstitute.org/hcci-research/international-comparisons-of-health-care-prices-2017-ifhp-survey, https://healthcostinstitute.org/images/pdfs/international_health_cost_comparison_report_2022.pdf, and https://ourworldindata.org/grapher/infant-mortality?tab=chart.
* Reimbursed amounts include both plan-paid and patient cost sharing.
** UAE and Netherlands relied on 2017 costs, because 2019 costs were not available for this study. Kazakhstan used 2017 maternal mortality ratios because 2019 data was not available.
Drivers of poor outcomes
There are several potential causes for discrepancies between costs and maternal mortality1 in the United States, where 60%2 of maternal deaths are deemed preventable.
The demographic characteristics of U.S. mothers are changing. For instance, the age of motherhood in the United States is increasing, and there is a higher preponderance of chronic conditions3 across all ages.4 “Complications from pre-existing, chronic conditions are the fastest rising cause of maternal mortality in the United States, now accounting for half of all maternal deaths.”5
The World Health Organization (WHO) recommends at least four6 postpartum visits within the first six weeks after delivery. In the United States, most women only get one, and 52% of maternal mortalities are postpartum.7 “Nineteen percent of all maternal deaths occur between one and six days postpartum.”8 During this period, severe bleeding, high blood pressure, and infection are the leading causes of death.9 Cardiomyopathy is the leading cause of death after the first week postpartum, where 33% of all maternal deaths occur.10
There are a lower number of midwives and overall pregnancy care providers per birth in the United States than many developed nations, including the United Kingdom, France, Germany, Australia, the Netherlands, and Norway.11 The United States has less than half of the number of providers per 1,000 live births than any of these countries.12 “The WHO recommends midwives as an evidence-based approach to reducing maternal mortality”13 —an area of potential improvement in the United States.
In addition to these broad-based drivers of poor outcomes, research into social determinants of health has demonstrated inequities in the United States that exist across race, socioeconomic status, age, language,14 and geography.15
The maternal mortality ratio (MMR) is much higher for certain characteristics:
- “In rural areas the MMR is 29.4, 1.6 times higher than the MMR of 18.2 in large, central metropolitan areas”16
- “The MMR for unmarried females was 1.7 times that of married females”17
- “The MMR for females with no prenatal care was 5 times that of females with any prenatal care”18
- Females on Medicaid have an MMR 3.5 times higher than females with private insurance19
- The MMR for Black females is 2.9 times higher than for white females20
Specific drivers for population subgroups could be explored through analysis of demographic and claims data.
Racial disparities
While U.S. maternal mortality rates are worse than many other countries regardless of race or ethnicity, poor outcomes are much more pronounced among non-Hispanic Black females; see Figure 5. The disparity in maternal mortality between Black and non-Hispanic white mothers does not improve with higher education levels, and the disparity still exists over all income levels. This may be related to the “weathering” hypothesis that Black females have more stress over the course of their lives, which deteriorates their health.21 It may also be due to racial discrimination within the healthcare system.22
Systemic and interpersonal racial discrimination against Black, Latina, Asian-American, Pacific Islander, and Native American females has been demonstrated to be correlated to having negative impacts on preterm births23 and birth weights.24
As reported by the Centers for Disease Control and Prevention (CDC), Black females have a maternal mortality ratio almost three times that of non-Hispanic white females in 2020 (see Figure 5) and that gap has existed for over 80 years25 without improving.
Figure 5: Maternal mortality ratios by race and ethnicity
Source: https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm.
U.S. infant mortality rates are worse for Black, non-Hispanic, Native Pacific Islander, and Native American infants; see Figure 6. The infant mortality rate for non-Hispanic Black infants is more than double that for non-Hispanic white infants.
Figure 6: 2019 infant mortality rates by race and ethnicity
Source: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm.
Preterm birth rates are also higher for all races and ethnicities than for non-Hispanic white females, as shown in Figure 7.
Figure 7: 2020 preterm birth rates by race and ethnicity
Disparities between the United States and other countries, along with disparities by race and ethnicity within the United States, show there is a need to improve maternity and delivery management, especially for races and ethnicities experiencing worse outcomes. Improving maternal health and reducing the impact of disparities will require a multifaceted approach.
Demonstrated success
Although the causes of the rising maternal mortality rates and racial disparities in outcomes of care in the United States are uncertain and complex, some organizations have had success in improving outcomes, such as reducing maternal mortality, preterm birthrates, NICU admissions, low birthweights, high rates of caesarean sections, and excessive costs.
The California Maternal Quality Care Collaborative (CMQCC), founded by state agencies, the CDC, and Stanford University,26 has reported success in lowering MMR. From 2006 to 2016, maternal mortality in California has declined 65%.27 CMQCC focuses on preventing deaths due to hemorrhage and preeclampsia. It also aims to reduce racial MMR disparities but has not yet been able to demonstrate results in this area.28
Many improvements have been realized through supportive care. A recent study found that women who received doula care reduced their chances of a cesarean delivery by 52.9% and postpartum depression or anxiety by 57.5%.29
Patients with clinical teams that included doulas and a midwife showed the most consistent improvements regardless of when during the pregnancy doula care was introduced.
Women receiving doula care during labor and birth, but not necessarily during pregnancy, realized a 64.7% reduction in postpartum depression or anxiety.30
A number of private companies have implemented comprehensive coordinated care, risk stratification, and early interventions to improve maternity and delivery outcomes.31 We have included some of these details in the endnotes for reference.
With a variety of options demonstrating potential improvements in both costs and outcomes, we take a look at what health plans and self-insured entities can do to help improve their maternity costs and outcomes. Developing and implementing approaches to improve care and outcomes and reduces costs tailored to the unique needs of the expectant populations served begins with the analytics.
Addressing maternity costs and outcomes with analytics
Given the high costs and unpredictable outcomes of maternity and deliveries in the United States, it is often important for health plans to directly address the condition of pregnancy. Fortunately, there are processes that health plans can follow to ensure they are properly assessing and addressing maternity costs and outcomes for their populations. This may be particularly important for Medicaid plans because the socioeconomic drivers of poor outcomes disproportionately affect Medicaid enrollees.
Quantification of issue: Benchmarking
In order for an entity to understand the maternity costs and outcomes of its specific population it needs to be able to compare maternity care costs, patient experience, and utilization, relative to its peers. The quantification and comparison will serve as the jump-off point from which a hypothesis is developed about the underlying causes of cost or outcome concerns that need to be addressed. Additionally, this quantification serves as a baseline from which key performance indicators (KPIs) will be chosen to monitor and track in the future.
Normalized empirical data can be used to match the age, race or ethnicity, language, and geographic area mix of an entity’s population to allow for a fair comparison across a variety of dimensions. This comparison to normalized empirical data is the basis for quantifying typical claim and patient experience versus an entity’s own experience, to help in focusing in on what matters most.
Areas of focus center around comparisons of percentage cesarean versus vaginal delivery, distribution of lengths of stay in the hospital, average cost per vaginal and cesarean birth, percentage of infants born prematurely, percentage of pregnancies that are multiples, average office visits nine months prior, average office visits two months following, frequency of infant and early childhood care, average maternal mortality ratio, and behavioral health treatment.
Root cause analysis
It is important to identify the underlying issues that cause any undesirable results found through benchmark comparisons.
Health claims data, healthcare utilization information, and review of the impact of insurance coverage on maternity claims and utilization levels help assess how the observations identified may be driven by items such as: care location, demographics of the mothers, and coverage levels. Additionally, this process can be used to help understand the quality of the member experience.
Identification of levers addressing root causes
Once this analysis is complete, it is key to identify levers that can improve the key performance indicators (KPIs) identified through benchmarking. How these levers are addressed will differ among self-insured, commercial, and Medicaid plans.
These levers may include benefit redesign, patient steerage, or direct contract development, among other items.
Consideration of the impact of levers and potential changes will then lead to estimates of the financial impact that each change will have. There is a broad spectrum of options for addressing these kinds of challenges.
The health plan can then consider outside interventions such as available Centers of Excellence, third-party vendors providing maternity support and nontraditional roles (such as doulas and midwives), specific maternity provider contracting (such as alternative payment models), bundled payment arrangements, risk and gain sharing arrangements, and establishing quality measures to help encourage employees to use optimal providers for maternity and infant care.
Strategy development and implementation
Once the entity has chosen which levers to utilize, to form the basis of its strategy, then more refined estimates of the financial impact of the strategy can be developed. It is important to understand the overlap that different levers will have when mixed together, as well as to explore potential byproducts and issues with different strategies.
Monitoring
Once a strategy is in place, it is important to validate the actual KPIs and cost and outcome impact that follows the implemented changes.
Conclusion
Although the United States has been experiencing higher costs and poorer outcomes for maternity care than other countries, many entities are demonstrating that costs can be lowered and outcomes improved. It is important for health plans to examine their maternity experience by comparing it to benchmarks, identifying areas for improvement, taking corrective steps, and monitoring results. The details of this process will depend on the plan and the market—self-insured, commercial, or Medicaid—but may be impactful no matter the market.
Caveats
The observations described in this paper are not necessarily applicable to any specific organization. Users of the information provided in this paper should be advised by professionals with experience in relevant domains. The information presented here is subject to change based on new research findings, changes in regulations or legislation, and the emergence of actual experience.
The opinions provided in this presentation are those of the authors and should not be attributed to Milliman, Inc. Milliman does not endorse any product or organization.
1 A factor contributing to a sharp rise in U.S. maternal mortality for which it is difficult to normalize is that a pregnancy checkbox was added to the U.S. death certificate starting in 2003. See https://www.wilsoncenter.org/event/what-explains-the-united-states-dismal-maternal-mortality-rates#:~:text=than%20maternal%20health.-,Despite%20spending%20two%20and%20half%20times%20more%20per%20person%20on,States%20at%2046th%20in.
2 CDC (May 2019). Pregnancy-Related Deaths. Vital Signs. Retrieved August 23, 2023, from https://www.cdc.gov/vitalsigns/maternal-deaths/pdf/vs-0507-maternal-deaths-h.pdf.
3 Wilson Center. What Explains the United States’ Dismal Maternal Mortality Rates? Retrieved August 23, 2023, from https://www.wilsoncenter.org/event/what-explains-the-united-states-dismal-maternal-mortality-rates#:~:text=than%20maternal%20health.-,Despite%20spending%20two%20and%20half%20times%20more%20per%20person%20on,States%20at%2046th%20in.
4 Admon, L.K. et al. (December 2017). Disparities in Chronic Conditions Among Women Hospitalized for Delivery in the United States, 2005–2014. Obstet Gynecol. Retrieved August 23, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5709216/.
6 WHO (March 30, 2022). WHO urges quality care for women and newborns in critical first weeks after childbirth. Press release. Retrieved August 23, 2023, from https://www.who.int/news/item/30-03-2022-who-urges-quality-care-for-women-and-newborns-in-critical-first-weeks-after-childbirth#:~:text=High%20quality%20care%20in%20health,to%20care%20in%20the%20home.
7 Tikkanen, R. et al. (November 18, 2020). Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries. Commonwealth Fund. Retrieved August 23, 2023, from https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries.
14 Novoa, C. (January 31, 2020). Ensuring Healthy Births Through Prenatal Support. Center for American Progress. Retrieved August 23, 2023, from https://www.americanprogress.org/article/ensuring-healthy-births-prenatal-support/.
15 Douthard, R.A. et al. (February 2021). U.S. Maternal Mortality Within a Global Context: Historical Trends, Current State, and Future Directions. J Womens Health (Larchmt). Retrieved August 23, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020556/.
20 Hoyert, D.L. Maternal Mortality Rates in the United States, 2020. CDC. Retrieved August 23, 2023, from https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm.
21 Forde, A.T. et al. (May 2019). The weathering hypothesis as an explanation for racial disparities in health: A systematic review. Ann Epidemiol. Retrieved August 23, 2023, from https://pubmed.ncbi.nlm.nih.gov/30987864/.
22 National Partnership for Women and Families. Racism Hurts Moms and Babies. Retrieved August 23, 2023, from https://www.nationalpartnership.org/our-work/health/moms-and-babies/racism-hurts-moms-and-babies.html.
24 Collins, J.W. et al. (May 2000). Low-Income African-American Mothers’ Perception of Exposure to Racial Discrimination and Infant Birth Weight. Epidemiology. Retrieved August 23, 2023, from https://journals.lww.com/epidem/Fulltext/2000/05000/Low_Income_African_American_Mothers__Perception_of.19.aspx.
25 Douthard, R.A. et al. (February 2021), op cit.
26 CMQCC. Partner Organizations. Retrieved August 23, 2023, from https://www.cmqcc.org/about-cmqcc/partner-organizations.
27 CMQCC. Who We Are. Retrieved August 23, 2023, from https://www.cmqcc.org/who-we-are.
28 Douthard, R.A. et al. (February 2021), op cit.
29 Falconi, A.M. et al. (July 1, 2022). Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching. The Lancet. Retrieved August 23, 2023, from https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00261-9/fulltext.
31 A number of organizations self-report significant improvements in maternity and delivery outcomes, as well as reduced costs. Milliman has not reviewed the claims of these organizations and makes no representation as to their validity. We have chosen to list the reported outcomes in order to highlight some current areas of focus in the industry.
Mahmee is a Los Angeles-based prenatal and postpartum care management platform that looks to increase positive outcomes for moms and babies by providing comprehensive coordinated care. It reports that its patients are 10% less likely to have a caesarean section and 50% less likely to deliver prematurely. (See: https://www.businessinsider.com/mahmee-founder-calls-on-silicon-valley-investors-to-be-more-courageous-2019-2 and https://edition.cnn.com/2022/05/08/business/mahmee-goldman-sachs-maternal-health/index.html.)
Lucina Analytics, a software as a service (SaaS) company based in Florida, is a women’s maternity analytics platform. It uses maternity-specific algorithms powered by artificial intelligence (AI) and risk stratification technology to identify women who are at risk of preterm birth. Lucina has reported a 10% reduction in preterm births, a 9% reduction in NICU costs, a 19% reduction in unnecessary caesarean sections, and a reduction in total per member per month (PMPM) costs of $2.50. (See: https://lucinaanalytics.com/results/.)
Obstetrical Homecare from Optum reports that it has helped reduce spontaneous preterm birth risk by 63%, reduced antepartum hospital admission by 62%, and reduced emergency room (ER) visits by 93%. (See: https://www.optum.com/business/health-plans/members/womens-health-benefits/obstetrical-homecare.html.)
FirstCare Health plans reports a reduction in NICU admissions by 38%, low birth-weight babies by 33%, very low birth-weight babies by 73%, and an estimated savings of $1,000 per infant. (See: https://www.firstcare.com/FirstCare/media/First-Care/PDFs/FC-AHIP-Member-Spotlight-ETB_041817.pdf?ext=.pdf.)
American Health, a medical management company based in Ohio, reports returns on investment (ROIs) from 4.2% to 14.9% for its maternity management program. : https://www.americanhealthholding.com/OurResults/MetricsOfSuccess.)
BlueCross Blue Shield of Illinois reports a $4,000 per case savings for high-risk pregnancies when using case management. This increases to an $8,000 per case savings when paired with its Special Beginnings® program. (See: http://fvlab.com/app/uploads/2016/06/BCBS-Maternity-Special-Beginnings-Program_0.pdf.)