Running Head: WHEN N=2

When n=2: Challenges of Transforming

Maternity Care in the United States
Erin Biscone, MSN, CNM, APRN
Emory University Nell Hodgson Woodruff School of Nursing

WHEN N=2

When n=2: Challenges of Transforming Maternity Care in the United States

In the current information era, healthcare consumers are more informed than ever and
more aware that they have choices (Kostner, Bisbee, & Charan, 2014). Kostner, Bisbee, and
Charan make a strong case that each individual is unique, and that this individuality demands
patient-centered care tailored to each individual (2014). They present evidence that the
healthcare industry is rapidly undergoing transformation, and that those providers and
institutions who do not adapt will be left behind (Kostner, Bisbee, & Charan, 2014). In no area of
healthcare is this more applicable than in maternity care. The concepts introduced in n=1: How
the Uniqueness of Each Individual is Transforming Healthcare relate to recent evidence and
research on optimum maternal-child health, and can be applied to current efforts to improve
maternity care in the United States, where n=2.
Kostner, Bisbee, and Charan lay out the context for the transformation that is rapidly
taking place in healthcare.
Transformative forces act on individuals and healthcare with the framework of social
context. There are two key elements in social context: the unsustainable cost of
healthcare, which results in transference of risk, and the sacred trust of the healing
relationship between the patient and clinician (2014, p. 21).
These same forces are at work in maternity care, pushing organizations and consumers towards
the midwifery model of care, which offers greater value for cost and places significant
importance on the relationship between the midwife and the woman, resulting in the customized
care and improved outcomes every n=2 deserves (Sakala & Corry, 2008; Kennedy, 2009).
Women want expert care that is personalized for the n=2, from healthcare providers who are kind
and culturally competent, which is precisely what midwives offer (Renfrew, 2014).
Maternity care in the United States has inspired the phrase the perinatal paradox: doing
more and accomplishing less (Sakala & Corry, 2008, p. 3). It is the most expensive in the

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world, and healthcare consumers are not getting value for their money (Rosenthal, 2013).
Because 40 percent of births are covered by Medicaid, taxpayers are also being shortchanged
(CMS, 2015). In other developed countries, maternity care costs less, outcomes are better, and
women still have access to high quality care and the same technology used in the U. S.
(Rosenthal, 2013). The perinatal morbidity and mortality rates in the U. S. are at or near the
worst when compared to other industrialized nations (Rosenthal, 2013). What are the other
countries doing differently? They offer free or low cost comprehensive maternity care and they
use midwives to care for the majority of mother-baby dyads throughout pregnancy, birth, and the
postpartum period (Rosenthal, 2013; Emons & Luiten, n.d.; Kutinova, A., 2008).
The second element of Kostner, Bisbee, and Charans framework for change in the social
context, the sacred trust of the healing relationship between the patient and clinician, is at the
heart of the midwifery model of care (2014, p. 21; Kennedy, 2009). The power of the
relationship between the woman and the midwife is, indeed, the foundation for midwifery, where
midwifery care begins (Kennedy, 2009: Thompson, 2004). The word midwife itself means
with woman. A central theme in the midwife-woman relationship is to support the uniqueness
of the n=2 and to assist and guide the woman as she finds her own path through childbirth
(Lungren & Berg, 2007). The midwifery model of care seeks to use the sacred trust between the
midwife and the woman to empower a laboring mother with confidence in her body and her
ability to give birth (Kennedy, 2009). Midwives work to place the woman at the center, not the
periphery, of the care of the n=2 (Kennedy, 2009). Women report that their relationship with the
midwife, and the support they receive, has an effect on them for the rest of their lives, inspiring
confidence in their own ability to be a good mother, and to face and overcome other challenges

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(Kennedy, 2009). The opposite is true when the mother is not treated with dignity and her
autonomy is not respected (Thompson, 2004).
Why, then, are so few n=2s cared for by midwives in the United States? In 2012,
according to the statistics compiled by the National Center for Health Statistics at the Center for
Disease Control (CDC), certified nurse-midwives (CNMs) attended 7.9% of total births in the
U.S., which represent 11.8% of vaginal births (Martin, et al., 2013). According to Kostner,
Bisbee, and Charan:
Many consumers value choice. They want to manage their own healthcare services so
that they can choose according to their beliefs. . . Many times, an individuals beliefs will
be driven by inadequate or inaccurate information (2014, p. 69).
In the United States, both the ability to choose a midwife and adequate and accurate information
about midwifery care are in short supply (Kennedy, 2009).
Midwives in the United States often face barriers to practice and restrictions on practice,
limiting the access women have to the midwifery model of care (Reed & Roberts, 2000). In
addition, the predominant view of pregnancy and childbirth in the United States is one of high
likelihood for complication and pathology, and only seen as normal when proven so in retrospect
(Kennedy, 2009). The media promotes this view of pregnancy being fraught with danger (Sakala
& Cory, 2008). Furthermore, interventions that are shown to be of no benefit or actually harmful
have become standard practice in obstetrics and serve to increase the incidence of complications,
reinforcing this view (Sakala & Corey, 2008).
Perhaps the most profound statement in n=1: How the Uniqueness of Each Individual is
Transforming Healthcare is this: There is not a healthcare system in the United States
(Kostner, Bisbee, & Charan, 2014, p. 109). Yet, a groundbreaking series on midwifery published
in The Lancet last year concludes that in order to provide optimum care to every n=2, there must

WHEN N=2

be a system-level change, from a fragmented obstetric model focused on pathology, to a

midwifery model centered on childbearing women and newborns and focused on optimizing
healthy pregnancy and birth for all (Renfrew, et. al, 2014). Even without a national healthcare
system, the needs of the n=2 necessitate the integration of midwives and the midwifery model of
care into mainstream maternity care (Renfrew, et. al, 2014).
Horizontal and vertical integration of midwifery care into mainstream maternity care will
not look like merging hospitals and buyouts of practices. Instead, it will be interprofessional
collaboration, as well as welcoming the n=2 who choose to birth outside the hospital and the
midwives who serve them, instead of ostracizing them. In the United Kingdom, where out-ofhospital birth and in-hospital birth are both accepted and part of the mainstream delivery of
maternity care, evidence suggests that about 45% of women have better outcomes delivering in
community-based, midwife-led units (Tanday, 2014). The Royal College of Obstetricians and
Gynaecologists recommends that more women deliver in midwife-led units, which can be in or
out of the hospital, and that the number of obstetric units be reduced, reserving them for
specialized care (Stoker, 2011). This allows both the midwife and the obstetrician to practice at
the top of [their] license (Kostner, Bisbee, & Charan, 2014, p. 132). Through interprofessional
teamwork, midwives can focus on normal pregnancy and birth, which they do best, and
obstetricians can focus on the treatment of pathology and complications due to co-morbidities,
which they do best, creating a new paradigm where outcomes are improved and satisfaction for
the n=2 is increased (Renfrew, et al., 2014: King, 2015). As healthcare transforms, collaboration
is becoming more important and efforts to improve maternity care must address barriers to
high-quality midwifery including interprofessional rivalry (Kostner, Bisbee, & Charan, 2014, p.
105; ten Hoope-Bender, et al., 2014).

WHEN N=2

How will the transformation of maternity care from the current, fragmented one focused
on pathology to the optimum one centered on the needs of each unique n=2 take place?
Interprofessional collaboration between the American College of Nurse-Midwives (ACNM) and
the American College of Obstetricians and Gynecologists (ACOG), as well as the Society for
Maternal-Fetal Medicine (SMFM) is taking place at a previously unheard of level (King, 2015).
That is an important step, and signals the achievement of the necessary foundation of mutual
respect for the expertise of all providers of maternity care (ten Hoope-Bender, et al., 2014). In
addition, while midwives are the ideal providers of midwifery, other healthcare providers can
receive education and training and provide midwifery care (Renfrew, et al, 2014). As
obstetricians and family practitioners learn of the benefits of evidence-based midwifery care,
they can incorporate it into their own practice (Renfrew, et al, 2014).
More importantly though, the n=2 must learn about the benefits of midwifery care.
Educating and providing information to the [n=2] will be an opportunity for innovators
(Kostner, Bisbee, & Charan, 2014, p. 70). ACNM has a public awareness campaign, Our
Moment of Truth: A New Understanding of Midwifery Care which is designed to educate the
public in general and women in particular about the benefits of the midwifery model of care
(Budin, 2013). However, that alone is not enough. Each midwife, each public health
professional, each person in a position of influence over healthcare policy who knows the
overwhelming evidence that our maternity care is lacking what midwifery brings to the table, has
a role to play. Each n=2 deserves care designed to meet their unique needs, through the sacred
trust between woman and midwife. The barriers to midwives giving that care and to the n=2
receiving that care must be torn down through innovation. Are you up for the challenge?

WHEN N=2

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