Improving Maternity Care: A Mother and Child Reunion

When the pregnancy test is positive, women are faced with three options. One of the three – a choice that over four million women make each year in the United States – is to keep the baby. Readers of On Common Ground may come to the abortion debate caring fervently about the rights and wellbeing of either the women or the babies, but we can unite when it comes to best taking care of the women having babies.

When a woman is expecting a child, our hope for her is a safe birth, a healthy baby, and, for those keeping the child, an easy transition to motherhood. This is a helpful framework for designing maternity care policies, except we must apply it to a large and diverse population of childbearing women. Must we approach maternity care prioritizing either women or babies, or can a maternity care system optimize the wellbeing of both? And can we reasonably expect care in pregnancy and birth to influence whether the transition to motherhood is an easy one?It sounds like a tall order, but in the mantra of the Obama campaign, “Yes, we can.”


Care practices that optimize the mother’s physical and emotional health are always good for babies. Excellent education and support of expectant parents can help foster confidence and resilience for new mothers to draw upon. And systems of care can protect and promote the healthy biological processes of mother-infant attachment. Consider these scientific findings, all of which come from rigorous controlled trials:


  • A model of group prenatal care that emphasizes self-care, community-building, and coordinated access to social services resulted in a 33% reduction in preterm birth among low-income women. This is the only prenatal intervention shown to have this magnitude of effect on prematurity, a condition that leads to chronic illness, developmental delays, and behavioral and emotional problems and is the largest contributor to the U.S. infant mortality rate. Group prenatal care had other benefits, too, including higher breastfeeding initiation rates and greater satisfaction with care.


  • Providing a 4-hour labor support skills class to pregnant low-income women and the female companions the women selected to give them labor support increased the new mothers’ responsiveness to their infants about a month after giving birth. The supported women also were more likely to report easy transitions to motherhood and to have positive perceptions of themselves as women, their bodies’ physical strength, and their ability to be good mothers. Clinical benefits included shorter labors and higher Apgar scores.


  • The simple act of placing the newborn skin-to-skin with the mother for the hour after birth resulted in more affectionate behavior by the mothers toward their infants 1-2 days later. This included more time holding their infants and more affectionate touch during breastfeeding. A systematic review of studies of early skin-to-skin contact showed that differences in some maternal attachment behaviors persisted as long as one year after the contact occurred. In addition, infants held skin-to-skin established effective breastfeeding sooner, were more likely to be breastfeeding at one to four months, and breastfed longer than infants without such early contact. Skin-to-skin contact has no harmful effects and is associated with other clinical benefits including higher blood-sugar and a lower risk of hypothermia in newborns.

Unfortunately, none of these practices is standard in the current package of maternity care in our country. Prenatal care is characterized by brief, procedure-driven visits and fragmented access to services such as domestic violence support, smoking cessation programs, and nutritional assistance. Attendance at childbirth education classes is declining, so women have fewer opportunities to learn what they need to know to make informed choices, or to form connections with other expectant parents. A national survey of women who gave birth in 2005 revealed that only 3% had continuous labor support from skilled companions (doulas). In the same survey, 4 out of 10 women reported that their babies spent most of the first hour with staff for routine, non-urgent care.

Most troubling of all, far from gaining a sense of resilience and confidence from giving birth, nearly 1 in 5 women may suffer from childbirth-related post-traumatic stress. When the survey researchers administered a standard post-traumatic stress disorder (PTSD) screening test designed to evaluate effects of the childbirth experience, 18% of the mothers reported symptoms of post-traumatic stress and 9% met all of the criteria for PTSD. It is not difficult to imagine the impact of such stress on women’s ability to care for themselves or their babies after birth.


Physical health outcomes are no better. Maternal mortality and serious morbidity are on the rise and one-third of women begin motherhood recovering from major abdominal surgery. We are moving away from Healthy People 2010 goals for preterm birth, low birth weight, cerebral palsy and mental retardation and have stagnated far below goal rates for other measures including rates of stillbirth and newborn death. Rather than improving, disparities in outcomes for black non-Hispanic women and babies are growing. There is no doubt that we could be doing better in getting new and growing families off to a good start.


The solution is clear. Maternity care systems built on midwife-led primary care yield better health outcomes for women and infants, and offer cost savings to boot. This is the model that nearly every other industrialized country is moving toward – if they’re not already there. The midwifery model of care is holistic and family-centered, emphasizes education and empowerment, and recognizes that childbirth produces both a baby and a mother. Two proposals currently before lawmakers would expand access to midwives. The Medicaid Birth Center Reimbursement Act, introduced recently in both the House (H. R. 2358) and the Senate (S.1423), would ensure access to midwifery care in freestanding birth centers, while a nationally coordinated campaign advocating for regulation and licensure of Certified Professional Midwives would increase access to community-based midwifery care. Both are proven approaches to mother-baby maternity care and far less costly than our current system.

Eighty-five percent of women in this country give birth and, to state the obvious, 100% of babies experience birth. If we could change something to make birth healthier and safer and the transition to motherhood a little bit easier, shouldn’t we be doing it?

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  • invalid-0

    I really appreciate this article, one of the key points being: “Unfortunately, none of these practices is standard in the current package of maternity care in our country.”

    I also appreciated your comments about PTSD–these aren’t “small” issues or concerns about “birth experiences,” birth has individual, familial, social, and cultural impact that is far-reaching.

    Your conclusion is spot-on too.

  • invalid-0

    The results from the studies you cited are encouraging, and they affirm what I would intuitively suspect. Whenever I read an article like this, I immediately wonder about the actual implementation process. How do providers go about accessing the funding? How do they market their specialty services to low income women who may be more likely to choose a “mainstream” maternity health provider? There are other questions that swim in my brain, but this gives me reason to hope that a better outcome is possible- and that everyone involved in providing maternity care should be actively seeking the answers to these and other questions!

  • smjesq

    Excellent article, which really highlights some of the major issues regarding maternity care services in the context of our health care system. As for the implementation process, it is crucial that ALL providers of maternity services are available to pregnant women, so they may really exercise their choice. We need the voices of women supporting access to certified professional midwives, in addition to physicians and certified nurse-midwives, and to free-standing birth centers, so that ALL women, including those on Medicaid, can receive care is personalized, woman-centered, evidence-based, and of proven high quality. Please urge your federal legislators to co-sponsor H.R. 2358/S. 1423, the Medicaid Birth Center Reimbursement Act, and to support the inclusion of Certified Professional Midwives in Medicaid and any health care reform bills that are considered.

  • invalid-0

    Susan’s swimming thoughts are quite valid, and may seem overwhelming. There is hope and there is action to improve birth outcomes. It’s called Healthy Start.

    Florida is the only state to have a state wide system of services for pregnant women who are at risk for poor birth outcomes and infants who are at risk for problems with health and development. (There is also a Federal Healthy Start Program found in certain locations across the U.S. where risks are the greatest.) All Florida counties have a Healthy Start Program. It is risk based, not income based. Most of the funding is provided by the Florida Department of Health.

    The Florida Healthy Start Program begins with risk assessments for pregnant women at their first prenatal care appointment and for newborns at the delivery facility. If the screening score indicates risk, Healthy Start will receive a referral then make contact to determine the individual’s risks and assets (all based on research of risk factors which can cause poor birth outcomes). The assigned Care Coordinator will offer a variety of education and counseling services as indicated, and follow the client as long as needed, which is up to age 3 for the infant. The goals are to reduce/prevent fetal death, prematurity, low birth weight and infant death.

    The Healthy Start Coalition of Sarasota County is embarking on our next five year service delivery plan and are taking a new approach. We want to establish what conditions must be present in our county to promote the health and well-being of pregnant women and infants 0-1, and then identify and prioritze needs and gaps in services. It’s a lofty goal, but we feel the establishment of these parameters will help everyone in our county see what their role may be, whether they are an employer, health care provider, the lay public, etc. We hope this will guide us to improved health and well-being women and children for years to come.

  • marysia

    I live in a very poor, majority-black urban neighborhood, and am a former maternal/child social worker.

    So I have frequently witnessed the substandard maternal/child care that unfortunately is considered standard.

    this kind of “care” makes pregnancy and childbirth times of fear and trauma for women, when this critical period of the life span, for mother & child alike, needs to be anything but!

    getting a good start in pregnancy & childbirth is so important for the development of both mother & baby.

    i am so grateful for the dedicated midwives who in so many countries take the lead in fostering mother-friendly prenatal care & childbirth. i can only hope that more health care professionals will listen to their wisdom–and the wisdom of women about their own experiences, positive & negative.

    and thank you smjesg for the action alert–i am going to publicize it through the site i edit.

    Nonviolent Choice Directory,

  • invalid-0

    Dear Marysia,
    Your comment is only too true. So many hospitals and clinics fail to provide woman-centered maternity care and, instead, treat poor women and members of racial and ethnic minorities as “educational material” for their residents. Please check out these two websites for excellent models of midwifery care for low income African-American women:
    (a CNM birth center in the District of Columbia)

    (a CPM birth center in Florida)

    Both facilities demonstrate excellent outcomes and empower the women they serve.
    I look forward to checking out your website.

  • invalid-0

    Florida is no model of appropriate care for maternity practices. The sky high cesarean rate and all that goes along with it is the proof in the pudding, including the fact that women are arrested for planning homebirths after having a cesarean, and taken to hospital for forced surgery. Instead we should be looking at countries like the Netherlands, Sweden, and Great Britian and asking ours legislators “How can we do even better?”

  • invalid-0

    All of your recommendations would be so effective at not only increasing the autonomy and satisfaction in the birth process of the mothers, but it would create a cycle of improved bonding and improved parenting along with the improved health outcomes.

  • invalid-0

    Hospitals and clinics fail to provide woman-centered maternity care and, instead, treat poor women and members of racial and ethnic minorities as “educational material” for their residents.Grateful for the dedicated midwives who in so many countries take the lead in fostering mother-friendly prenatal care & childbirth.

  • invalid-0

    This was a thoughtful and well researched article. The challenge lies in making hospitals to change the way they treat some members of the community. Whether it is through legislation or lobbying, it’s clear that we have to push if anything substantial is to change