When employees have pregnancy complications, the medical costs can be eye-boggling for employers. With a pregnancy management program, employees can get personalized advice from a nurse who teaches them how to avoid the scary and expensive complications.

Nationwide Better Health's maternity management program has an ROI of 2:1 when it's integrated with the other disease management programs, according to Dr. Chris Wilhide, director of program development and research for the Columbus, Ohio-based disease management firm.

The savings come from a reduction in the number of preterm babies, low-weight babies and days spent in the neonatal intensive care unit, which can be very costly.

Nationwide Better Health estimates that, in 2006, the maternity management program reduced the average length of stay in the NICU by 24%, which equals an average savings of $52,060 per stay.

Among program participants, the 2006 preterm birth rate was 10.3%, compared to the national average of 12.5%. Just 6.6% of participants' pregnancies in 2006 resulted in low or very low birth weights, compared to the national average of 8.1%.

Any program isn't likely to yield great results if participation rates are low, so Nationwide Better Health tries to boost participation rates.

"One of the most unique aspects is that we want to engage all mothers-to-be as early as possible," instead of just targeting the high-risk pregnancies, Wilhide says. The company integrates the maternity management program with its other health care services and disease management programs to help identify potential participants early.

"Another key differentiator is that we have a patient-centered model" with each patient assigned to one coach, who is a registered nurse, throughout the pregnancy, Wilhide adds. "We want continuity of care."

It's hard to determine exactly how many employers are including high-risk pregnancy or maternity management as part of their disease management programs. However, statistics show a rapidly growing interest in addressing this topic.

About 67% of employers provided a prenatal wellness program for employees this year, up from 25% in 2005. In addition, 77% of employers offered a well-baby program (for postnatal care) this year, up from 40% in 2005, according to the Society for Human Resource Management.

"We've seen an increase in interest throughout the years," Wilhide confirms.

That's not surprising, considering that direct health care costs to employers for premature babies during their first year of life averaged $41,610, compared to just $2,830 for babies born healthy and full term, according to the March of Dimes, a nonprofit advocacy organization for newborn health.

How it works

The primary goals of the maternity management program are to prevent preterm labor, prevent low birth weight and reduce the number of days that the infant and mom need to spend in the hospital after the delivery.

During the first phone call, a health coach asks questions to assess whether the patient has any risk factors or preexisting conditions that may add complications to the pregnancy. Then the coach identifies the risk as low, moderate, high or very high, which determines the level of intervention needed.

The coach typically educates the patient about diet, nutrition, fetal movement and the importance of drinking enough water and getting appropriate exercise during pregnancy. The coach can answer questions and help the patient understand the signs and symptoms of preterm labor, preeclampsia and postpartum depression - plus explain steps she can take to prevent those problems. They also discuss the details of the patient's doctor appointments, medical test results and symptoms.

After the baby is born, the coach continues to provide support with a postpartum assessment and educational materials related to newborn care and early childhood development.

Healthy triplets

With the help of a health coach, Silvia Garcia Luengo of Shaker Heights, Ohio, had a successful delivery of three healthy babies - Alexander, Isabella and Victoria - in November 2007. It was her first pregnancy, and she had trouble with preeclampsia, a form of high blood pressure in pregnant women.

"I was high-risk," she comments. "It was so nice to have somebody who can be an additional resource to talk about what's going on. It was somebody you can trust. It was a very positive experience."

Luengo's health coach, Michelle Webb, says, "I like to try to form a special relationship and trust [with the patient]. People usually give a lot of positive feedback" about the program.

Luengo, an account manager at New Page Corp., is confident that the maternity management program helped her prolong the pregnancy and prevent further complications. "It was very important to get as far along as I could in the pregnancy," she recalls. "[The health coach] really stressed the rest and the water consumption."

As a result, Luengo delivered the triplets at 31 weeks, which is relatively close to her goal of a full-term pregnancy (37 weeks). Women carrying twins or triplets have much higher rates of preterm labor.

In addition to providing the clinical advice, "the program helps you navigate the bureaucracy of the insurance world and the paperwork," Luengo notes. She appreciated the coach's guidance.

As a coach, "you want to educate and help the patient," Webb says. "Quality is first. You're trying to have a successful pregnancy for the patient and cost savings for the employer."

Report reveals serious problems in maternity care and value

Overuse of cesarean section, other interventions put women, babies at risk  and increase costs

From wire reports

Over 31% of U.S. births are now by cesarean section, although a 5% to 10% rate is best for mothers and babies. The extra cost is well over $2.5 billion per year, yet the excessive c-sections buy no reduction in maternal and newborn deaths, but rather expose mothers and babies to more adverse outcomes.

These conclusions are among the ones found in, "Evidence-Based Maternity Care: What It Is and What It Can Achieve," a report released in October by Childbirth Connection, The Reforming States Group, and the Milbank Memorial Foundation.

The report cites an extensive body of evidence to make the case that, despite paying top dollar, American women do not receive the best maternity care. It is the most comprehensive review to date of how maternity care is delivered, financed, and experienced by mothers, families, and health care payers. It concludes that maternity care can be significantly improved using evidence-based care.

Main recommendations for improvement

To speed adoption of evidence-based maternity care, the report recommends lawmakers, employers, insurers and other stakeholders work together to:

• Develop a standardized evidence-based set of maternity care performance measures to address overuse and underuse.
• Incorporate these measures into Medicaid quality improvement activities, and encourage private insurers and other entities to adopt them.
• Reform the reimbursement system -- with such strategies as reducing payment for overused services, increasing payment for underused services, and rewarding high-performing providers and facilities.  
• Support more research into evidence-based maternity care, including long-term effects of common maternity practices.
• Increase the use of evidence-based maternity care by educating a wide range of stakeholders.

"If implemented, these recommendations can help close the evidence-practice gap in maternity care," said Maureen Corry, co-author of the study and executive director of Childbirth Connection. "There's a role for everyone -- clinicians, health systems, payers, policymakers, consumers and the media. It's time to seize the opportunities to ensure that all mothers and babies receive safe, effective and satisfying maternity care." 

"The report shows maternity care is one more example of what's wrong with American health care.  We're paying too much and getting the worst results in the developed world because of unneeded care," said Reforming States group vice chair, Wyoming State Senator Charles Scott.

"The main causes are that providers earn more from unneeded care while fear of malpractice litigation encourages the same unneeded care. In my state nearly half the births are paid for by the taxpayers through the Medicaid program. If we can implement the recommendations of this report, we can both reduce costs and improve the care our mothers and babies get."

The cost of maternity care

Most maternity care provided to women who give birth in U.S. hospitals is resource and technology intensive. Six of the 15 most commonly performed hospital procedures in the entire population are associated with childbirth. Hospital charges for maternal and newborn care are greater than charges for any other condition: $79 billion in 2005, jumping to $86 billion in 2006.

Maternal and newborn care are the most costly hospital conditions for private insurers (shouldering 51%). The report finds that lower intensity care, like that provided by midwives, is safe and effective, avoids many procedures with established risks and cheaper. Yet, just a fraction of women who give birth in hospitals today receive low-intensity care. 

And while the US spends much more on health care, its performance lags far behind other developed nations on quality indicators including low birthweight, perinatal and maternal mortality and cesarean rates.

Overused maternity practices

Cesarean section is one notable example of frequently overused maternity care interventions documented in the report. C-sections are now the most common operating room procedure in the United States. Although clearly beneficial and life-saving in selected circumstances, the absolute indications for cesarean section apply to only a small proportion of births. Yet rates have steadily risen from 20.7% in 1996 to a record high of 31.1% in 2006, a 50% increase.

Wide variation in medical practice exists -- for example, differences in rates of performing c-section vary across physicians, hospitals, or geographic areas. Just a fraction of these differences are due to differences in the health needs of mothers and babies.

Rather, this variation reflects differences in professional styles of practice and other factors such as the number of providers and hospitals offering the surgery, concerns about being sued, and financial incentives that favor surgery. The evidence showed that areas with higher rates of cesareans had more inappropriate care and more surgery in healthier women. The report clarifies that many other common maternity interventions, such as labor induction and epidural, are also overused. It is available at www.childbirthconnection.org/ebmc/.

About the study authors: The Milbank Memorial Fund is an endowed operating foundation that works to improve health by helping decisionmakers in the public and private sectors acquire and use the best available evidence to inform policy for health care and population health. The Fund has engaged in nonpartisan analysis, study, research and communication on significant issues in health policy since its inception in 1905. The Reforming States Group, organized in 1992, is a voluntary association of leaders in health policy in the legislative and executive branches of government from all 50 states, Canada, England, Scotland and Australia. Founded in 1918, Childbirth Connection is a nonprofit organization working to improve the quality of maternity care through research, education, advocacy and policy. As a voice for the needs and interests of childbearing families, Childbirth Connection uses best research evidence and the results of its periodic national Listening to Mothers surveys to inform policy, practice, education and research.