Federal plans to reduce maternal mortality draw praise and some criticism

As maternal mortality and morbidity rates have reached alarming levels, the federal government has proposed new standards to reduce the number of deaths related to childbirth.

The federal government has proposed minimum standards for hospitals in obstetric care, which has elicited praise and criticism.

The Centers for Medicare & Medicaid Services is proposing the first minimum safety standards for hospitals, and critical access hospitals, for obstetrics services. The proposal includes standards for staffing, training, emergency services readiness and transfer protocols for obstetric patients.

“For the first time, we have created national health and safety standards for maternal care,” Vice President Kamala Harris said Wednesday. “For the first time, national standards … which means nearly every hospital in our country will soon be required to provide new mothers with delivery rooms that are fully stocked with lifesaving medical equipment.”

Healthcare leaders agree that too many patients are dying or suffering severe complications due to pregnancy, and President Biden’s administration received praise for taking substantial steps to improve maternal health.

KJ Hertz, senior director of federal affairs for the March of Dimes, tells Chief Healthcare Executive® that the proposals could help improve outcomes.

“We're really pleased to learn about the continued efforts to take advantage of really all possible policy levers to create minimum, evidence-based standards for obstetrical services focused on quality, safety and equity,” Hertz says.

But some are taking issue with tying efforts to improve maternal care to conditions of participation with Medicare.

Some healthcare advocates say that potentially reducing aid to hospitals would only make it harder to offer top-quality care for pregnant patients, at a time when some providers have been curbing labor and delivery services.

• Read more: March of Dimes leader: ‘We’re not prioritizing Moms’

‘Dramatically reduce access’

Lisa Satterfield, senior director of health and payment policy, the American College of Obstetricians and Gynecologists, said Wednesday afternoon that the organization is still reviewing the CMS proposals. But the group is concerned about reducing access to care.

“As maternal mortality remains high and health care disparities continue to worsen, we need smart and innovative policy solutions that do not further stress an overstretched health care system,” Satterfield said in a statement. “With that in mind, ACOG is concerned that implementing additional Conditions of Participation requirements for obstetric units could inadvertently impact the stability of obstetric care and dramatically reduce access to critical obstetric services for those who need it most. This would be counterproductive.”

“If the goal is to eliminate preventable maternal mortality and inequities in maternal health outcomes, any new policies must be crafted in a thoughtful, meticulous manner that utilizes evidence, recognizes barriers, and improves access to quality care for all patients seeking obstetric services,” Satterfield said.

Soumi Saha, senior vice president of government affairs for Premier, criticized the CMS’ proposal to tie meeting obstetrics standards with funding from Medicare. While she said Premier supports standard data collection and measurement, Saha said the government shouldn’t reduce access to care, which she said could happen with the “Condition of Participation” requirement around obstetric care.

“An obstetric services CoP that results in the loss of Medicare certification for compliance failure is far too harsh a penalty, resulting in further limits to obstetrical care and potentially higher rates of maternal morbidity and mortality,” Saha said in a statement. “In trying to address the maternal crisis, the last thing we want to do is intensify disparities we know are already present in obstetrical care.”

The U.S. Department of Health and Human Services is collaborating with more than 200 hospitals and Premier to collect and examine data on maternal mortality and morbidity. Premier is asking the government to postpone the condition of participation until more of that research is available and focus instead on improving the collection of data on maternal health.

Ashley Thompson, senior vice president for public policy analysis and development for the American Hospital Association, denounced what she called CMS’ “excessive use of Conditions of Participation to drive its policy agenda.”

“We believe a less punitive and more collaborative and flexible approach is far superior,” Thompson said in a statement. “We will carefully review CMS’ proposals to determine whether they are feasible, sufficiently flexible for the wide variety of hospitals to which they would apply and do not inadvertently exacerbate maternal care access challenges.”

Federal proposals

The CMS is calling for certain standards in staffing and delivery of obstetric services at hospitals and critical access hospitals, which are small rural hospitals with 25 beds or less. The agency is seeking public comment on whether the rules should apply to rural emergency hospitals that don’t have inpatient beds and provide solely stabilizing and outpatient care.

The government is proposing that obstetric units be supervised by those with sufficient training, such as a doctor, experienced registered nurse or certified midwife. The CMS also proposes that obstetric privileges “be delineated for all practitioners providing OB care, and a roster of practitioners specifying the privileges of each practitioner must be maintained.”

The CMS also is calling for labor and delivery rooms to have basic resuscitation equipment, including a call-in system, cardiac monitor, an fetal doppler or monitor.

The agency proposes that hospitals ensure they have “evidence-based guidelines” for OB emergencies, complications, post-delivery care and other safety events. The CMS said it isn’t requiring specific items, but offered examples such as blood and other equipment needed for emergency cases.

In addition, the CMS is also looking at revisions to discharge planning requirements for hospitals.

Maternal deaths rose 40% in 2021 compared to the previous year, according to figures from the National Center for Health Statistics. The maternal mortality rate has risen 89% from 2018 to 2021, federal data shows.

More than 4 out of 5 (84%) pregnancy-related deaths are preventable, according to a report from the Centers for Disease Control and Prevention. The CMS pointed to the high number of preventable deaths in its proposal.

Beyond deaths, many patients suffer severe complications related to childbirth. As many as 60,000 women annually suffer serious pregnancy complications, the Commonwealth Fund estimates.

Maternal mortality figures also illustrate gaps in equity. Black women are 2.6 times more likely to die of maternal causes than white women, according to federal data.

• Read more: Black maternal health: Addressing the national crisis

‘There has to be a benchmark’

The federal proposal deserves credit for addressing a number of factors that affect maternal health, says Hertz of the March of Dimes.

“It gets to some of the root causes as far as access to care, equitable care, and quality of care,” he says.

While some healthcare groups pushed back against federal proposals tying obstetric standards to Medicare funding, Hertz says there needs to be minimum requirements.

“I think that there has to be a benchmark that these facilities need to meet,” Hertz says. “And I think that's kind of the driving force behind these new proposals. And we're already seeing a lot of facility closures due to consolidation and other factors. So I think that this is a positive step in making sure that the quality of care is there, and that people that are providing care are trained at the highest level.”

Hertz also singled out the CMS provisions to include discharge planning, which he says is particularly important in light of “maternity care deserts.”

Nationwide, more than 1 in 3 counties have no obstetric services, according to a 2022 report from the March of Dimes.

Since 2011, 267 rural hospitals have stopped providing obstetric services, according to an analysis released in February by the Chartis Center for Rural Health.

Given the rise of maternal deaths and decline in the number of providers offering obstetric services, Hertz says the CMS’ proposals could make a difference.

“We really see the proposed rule as something that really represents another important step as we seek to tackle the root causes of our nation's unacceptable maternal health crisis,” Hertz says.