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Maternity Care in California: Delivering the Data
JUNE 2016
Introduction
Over half a million babies were born in California in 2014 — one in eight of all births in the US. Having a baby
is the number one reason for a hospital admission in the state. Maternity Care in California: Delivering the Data
provides an overview of the delivery of maternity care in California using available metrics, and compares the
state’s performance on these metrics by demographic groups, over time, and against national numbers.
KEY FINDINGS INCLUDE:
• Over the last 15 years, births in California have been on a downward trend, declining 5% from 2000 to
2014. Nearly all babies in California are born in hospitals and delivered by physicians.
• Medi-Cal covered nearly half of all births in California in 2014.
• California has made significant progress in reducing maternal mortality rates, in contrast to the nation,
whose rates continued to rise. While all race/ethnicity and age groups in California have experienced
reductions in maternal mortality rates, there were still substantial differences across racial/ethnic groups.
• Significant racial/ethnic disparities existed across a variety of maternal quality measures in California,
from prenatal visits to preterm births to maternal and infant mortality rates. For many of these measures,
African Americans performed worse than their peers in other racial/ethnic groups.
• One in five California women giving birth experienced either prenatal or postpartum depression in 2013.
• Consistent with national trends, California’s rate of cesarean sections (c-sections) has increased sharply,
Maternity Care in California
CONTENTS
Births and Demographics. . . . . . . . . . . . . . . . 3
Workforce and Supply. . . . . . . . . . . . . . . . . . . 11
Quality: Process Measures . . . . . . . . . . . . . . . 16
Quality: Outcome Measures. . . . . . . . . . . . . 24
Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Mental Health and Substance Use. . . . . . . 34
Patient Engagement. . . . . . . . . . . . . . . . . . . . . 39
Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
from one-fifth of all births in 1997 to one-third in 2014. While critical in some circumstances, c-sections
can pose serious risks for baby and mother.
• From 2010 to 2013, the total average payment for cesarean deliveries was nearly 50% higher than the
total average payment for vaginal births.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
2
Maternity Care in California
Births Trend
Births and Demographics
California, 2000 to 2014
Since 2007, total births in
NUMBER OF BIRTHS
California have been on a
600,000
downward trend, from a high of
531,285
502,973
500,000
566,000 in 2007 to a 15-year low
of 494,000 in 2013. The number
of births in the state increased to
400,000
2014 BIRTHS, UNITED STATES
TOTAL: 4 million
CA
13%
300,000
All Other States
87%
503,000 in 2014, which was the
most births of any state in the US.
That year, nearly one in eight births
in the nation were in California.
200,000
100,000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Note: Births by place of residence.
Sources: “CA-Vital Statistics Query,” California Department of Public Health (CDPH), accessed January 6, 2016, informaticsportal.cdph.ca.gov; “Birth Records: Number of Live Births by
Mother’s Age and Race/Ethnicity, California, 2010-2014,” CDPH; “VitalStats,” Centers for Disease Control and Prevention, accessed February 29, 2016, www.cdc.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
3
Maternity Care in California
Births, by Location
Births and Demographics
California, 2014
In 2014, nearly all births in
N=502,879
OUT-OF-HOSPITAL BIRTHS
BY LOCATION
TOTAL: 5,056
Of births that did not occur in a
Home
Out of Hospital
1%
72%
Freestanding Birth Center
19%
California occurred in a hospital.
hospital, the vast majority
occurred at home.
Clinic/Doctor’s Office
<1%
Other
9%
In Hospital
99%
Notes: Location of birth was not stated for 29 births. N on this page is slightly different from pages 3 and 5 due to the use of different data sources.
Source: “VitalStats,” Centers for Disease Control and Prevention, accessed December 14, 2015, www.cdc.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
4
Births, by Mother’s Race/Ethnicity and Country of Origin
California, 2014
Maternity Care in California
Births and Demographics
In 2014, Latinas made up nearly
N=502,973
Latina
237,326
half of all births in the state, at just
under 240,000 births. Whites were
the second largest group at 28%
White
138,417
and nearly 140,000 births. Nearly
40% of California’s births were to
Asian
74,880
African American
25,230
foreign-born mothers in 2014,
MOTHER’S COUNTRY OF ORIGIN
were not born in the US.
Two or More Races
11,579
while 27% of Californians overall
US Born
62%
Foreign
Born
38%
Pacific Islander
2,017
Native American
1,765
Notes: Births by place of residence. Latina origin is determined first and includes any race group. Unknown and other races are not shown. Foreign born means not born in the US
and does not pertain to citizenship or documentation status.
Sources: “Birth Records, Number of Live Births by Mother’s Age and Race/Ethnicity, California, 2010-2014,” California Department of Public Health; “VitalStats,” Centers for Disease
Control and Prevention, accessed December 14, 2015, www.cdc.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
5
Maternity Care in California
Births, by Mother’s Age
Births and Demographics
California, 2000 vs. 2014
100.000000
3%
13%
83.333333
24%
66.666667
4%
16%
29%
40 and older
35 to 39
30 to 34
25 to 29
20 to 24
Under 20
The age at which women in
California gave birth shifted
slightly from 2000 to 2014. The
proportion of births to women
age 24 and younger declined
from 34% to 24%, while births
to women age 30 to 39 increased
from 37% of all births to 45%.
50.000000
26%
33.333333
23%
16.666667
11%
0.000000
Less than 5% of births were to
26%
2000
mothers age 40 and older.
19%
5%
2014
Note: Segments may not sum to 100% due to rounding.
Source: “VitalStats,” Centers for Disease Control and Prevention, accessed February 29, 2016, www.cdc.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
6
Female Population and Births, by Household Income
California, 2012
Maternity Care in California
Births and Demographics
While only 25% of the female
population in California were at or
Female Population
below the federal poverty level,
Births
this group represented 43% of
women giving birth. Thirty-eight
percent of births in California
0-100%
FPL
25%
>200% FPL
53%
were to mothers with household
>200% FPL
38%
101-200%
FPL
22%
0-100%
FPL
43%
incomes above 200% FPL.
101-200%
FPL
19%
Notes: Female population is mothers age 15 to 45. The federal poverty level (FPL) for a family of four in 2012 was $23,050.
Sources: Maternal and Infant Health Assessment Snapshot, California Department of Public Health, Maternal, Child and Adolescent Health Program, 2015; www.cdph.ca.gov;
“AskCHIS,” University of California Los Angeles, ask.chis.ucla.edu.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
7
Maternity Care in California
Births, by Mother’s Insurance
Births and Demographics
California, 2014
In 2014, 45% of in-hospital
Other
3% 4%
Self-Pay
births were to mothers on
Medi-Cal, compared to 48% to
mothers with private insurance.
These rates have not changed
significantly since 2011
(not shown).
Private
48%
Medi-Cal
45%
Notes: In-hospital births at 251 hospitals that offer maternity services. In California, 99% of all births occur in a hospital.
Source: Special data request, California Maternal Quality Care Collaborative, 2016.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
8
Births, Medi-Cal vs. Non Medi-Cal, by Hospital Type
California, 2014
– 2%
– 3%
9%
83.333502
66.666801
50.000101
– 2%
– 3%
15%
26%
10%
18%
6%
7%
5%
– 1%
12%
60%
52%
University of California
Kaiser
District
City/County
Investor
Nonprofit
14%
56%
Maternity Care in California
Births and Demographics
The majority of all births in
California, including births to
women covered by Medi-Cal,
occurred in nonprofit hospitals.
Nonprofit, investor, city/county,
and district hospitals had a
greater share of Medi-Cal births
than non-Medi-Cal births. Kaiser,
in contrast, delivered a quarter of
all non-Medi-Cal births, but only
33.333401
3% of Medi-Cal births.
16.666700
0.000000
Medi-Cal
Non Medi-Cal
All Payers
Notes: In-hospital births at 251 hospitals that offer maternity services. Nonprofit hospitals include church-related hospitals. Investor hospitals are for profit.
Kaiser Permanente hospitals are also nonprofit. All payers includes uninsured patients. Segments may not sum to 100% due to rounding.
Source: Special data request, California Maternal Quality Care Collaborative, 2016.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
9
Maternity Care in California
Medi-Cal Births, by Aid Category
Births and Demographics
California, 2011
In 2011, nearly one-third of
Blind/Disabled (2%)
Medically Indigent
(child and minor consent, 2%)
Adoption/Foster Care (<1%)
All Other (1%)
UNDOCUMENTED BIRTHS, BY REGION
Los Angeles County
35%
Greater Bay Area
14%
San Joaquin Valley
13%
Pregnancy
Pathway
16%
Inland Empire
10%
Orange County
Undocumented
29%
Medi-Cal births were to
undocumented mothers. More
than one-third of all births to
undocumented mothers were
in Los Angeles County.
10%
Central Coast
9%
San Diego Area
5%
Sacramento Area
3%
Northern and Sierra
1%
Families
51%
Notes: In-hospital births only, where 99% of births occur in California. Pregnancy Pathway is restricted scope — that is, limited to pregnancy-related and postpartum services for women
who are not undocumented and whose family income is 200% FPL or below. Families refers to Section 1931(b) of the Social Security Act which ensures that families with children,
who are in financial need will get access to Medi-Cal. This eligibility category combines the eligibility criteria from several other programs including food stamps, AFDC, and CalWORKs.
Percentages may not sum to 100% due to rounding. See Appendix A for a regional county map.
Source: 2011 Medi-Cal Births Statistics, California Department of Health Care Services, 2014, www.dhcs.ca.gov (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
10
Maternity Care in California
Medi-Cal Births, Fee-for-Service vs. Managed Care
Workforce and Supply
by Race/Ethnicity and Country of Origin, California, 2011
■ Fee-for-Service
100
38%
68%
44%
43%
32%
In 2011, over 60% of Medi-Cal
■ Managed Care
55%
84%
80
60
16%
56%
fee-for-service system. About two
in three Latina mothers and four
in five foreign-born mothers in
Medi-Cal participated in the feefor-service system. Undocumented
68%
62%
births were covered through the
mothers are eligible only for
57%
restricted-scope benefits and
cannot participate in Medi-Cal’s
45%
40
managed care programs. These
32%
mothers represented 73,000, or
20
47%, of Medi-Cal FFS births in
2011 (not shown).
0
All Races/
Ethnicities
African
American
White
Asian
Latina
US Born
Foreign Born
Notes: In-hospital births only, where 99% of births occur in California. Foreign born means not born in the US and does not pertain to citizenship or documentation status.
Source: 2011 Medi-Cal Births Statistics, California Department of Health Care Services, 2014, www.dhcs.ca.gov (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
11
Maternity Care in California
Births, by Attendant
Workforce and Supply
California vs. United States, 2004 and 2014
100
8%
— 1%
<1%
– 3%
80
89%
– 1%
9%
5%
85%
100
80
8%
5%
87%
—1%
<1%
8%
7%
84%
Ninety percent of births in both
– 1%
Other
Other Midwife
Certified Nurse Midwife
Doctor of Osteopathic
Medicine (DO)
Doctor of Medicine (MD)
California and the US were
attended by physicians, primarily
MDs (versus DOs). From 2004 to
2014, the percentage of births
attended by midwives in
60
60
California increased slightly.
Midwives, the vast majority
40
of whom were certified nurse
40
midwives, attended nearly one in
ten California births in 2014.
20
0
20
2004
California
2014
0
2004
2014
United States
Notes: Attendant is the individual who is present and responsible for the delivery. For example, if a nurse midwife delivers an infant under the supervision of an obstetrician who is
present in the delivery room, the obstetrician should be reported as the attendant; however, if the obstetrician is not present, the midwife is the attendant. Evidence suggests that the
number of live births attended by certified nurse midwives (CNM) is understated, largely due to difficulty in correctly identifying the attendant when more than one provider is present.
Segments may not sum to 100% due to rounding.
Source: “VitalStats,” Centers for Disease Control and Prevention, accessed January 20, 2016, www.cdc.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
12
Obstetricians/Gynecologists per 1,000 Births, by Region
California, 2015*
Maternity Care in California
Workforce and Supply
In 2015, 4,500 obstetricians/
Greater Bay Area
14.0
Orange County
11.8
Sacramento Area
10.1
Los Angeles County
gynecologists (ob/gyns) were
licensed in California, not all of
whom were active in patient
care. The supply of licensed ob/
gyns varied across the state. The
American Congress of Obstetricians
9.1
and Gynecologists is concerned
San Diego Area
about an emerging shortage of
8.4
these providers, as the workforce
Central Coast
7.8
is aging and the female population
is growing.
Inland Empire
4.8
San Joaquin Valley
4.8
8.9
CA AVERAGE
*Supply of obstetricians/gynecologists (ob/gyns) based on licensed doctors of medicine (MDs) as of August 2015. Births are based on 2014 data.
Notes: San Benito County data are not included in Central Coast region. Northern and Sierra region data are not shown due to 2014 births in these counties not being available in
VitalStats system. See Appendix A for a regional county map.
Sources: Medical Board of California’s Physician Survey, “CHHS Open Data Portal,” California Health and Human Services Agency, accessed January 7, 2016, chhs.data.ca.gov;
“VitalStats,” Centers for Disease Control and Prevention, accessed February 18, 2016, www.cdc.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
13
Certified Nurse Midwives per 100,000 Births, by Region
California, 2013
4.4
Greater Bay Area
3.9
San Diego Area
3.1
Central Coast
3.0
Sacramento Area
2.0
Orange County
Inland Empire
Workforce and Supply
In 2013, 1,050 certified nurse
Northern and Sierra
midwives (CNMs) practiced in
California, primarily attending
births in hospitals. A 2010 survey
found that more than 20% of
CNMs in California were not
working as CNMs. The supply
of CNMs varied widely across
California, from a low of 0.9 CNMs
per 1,000 births in San Joaquin
1.7
Los Angeles County
Maternity Care in California
Valley to a high of 4.4 per 1,000
1.3
births in the Northern and
Sierra region.
1.1
San Joaquin Valley
0.9
2.1
CA AVERAGE
Notes: Certified nurse midwives (CNMs) are advanced practice nurses trained to provide midwifery care, including perinatal, well-woman, and newborn care. See Appendix A for a
regional county map.
Sources: Area Health Resources Files (AHRF), Department of Health and Human Services, 2015, ahrf.hrsa.gov; “CA-Vital Statistics Query,” California Department of Public Health, accessed
February 26, 2016, cdph.ca.gov; Survey of Nurse Practitioners and Certified Nurse Midwives, 2010, California Board of Registered Nursing, December 2011, www.rn.ca.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
14
Maternity Care in California
Licensed Midwives
Workforce and Supply
California, 2007 and 2014
Licensed Midwives
In California, the number of
2007
2014
% CHANGE
179
361
101.7%
licensed midwives, their clients,
and the births they delivered
doubled from 2007 to 2014.
Clients served
• As primary caregiver at onset of care
2,277
5,386
136.5%
• With collaborative care available by
licensed physician and surgeon
704
2,763
292.5%
• Under supervision of licensed
physician and surgeon
159
161
1.3%
• At onset of labor
1,687
3,397
101.4%
• Completed in out-of-hospital setting
1,438
2,833
97.0%
Planned out-of-hospital births
Notes: Data are self-reported. Births attended by licensed midwife as the primary caregiver. Licensed midwives are health professionals authorized to attend cases
of normal childbirth and to provide prenatal, delivery, and postpartum care for the mother and immediate care for the newborn.
Source: Annual Reports, Medical Board of California, 2007-2008 and 2014-2015, www.mbc.ca.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
15
Initiated Prenatal Care in First Trimester, by Race/Ethnicity
California, 2013
Quality: Process Measures
Prenatal care has been shown to
PERCENTAGE OF LIVE BIRTHS
HEALTHY PEOPLE 2020 TARGET:
86%
Maternity Care in California
85%
78%
improve pregnancy outcomes,
particularly by increasing
birthweight and decreasing risk
81%
80%
82%
76%
of delivery before 37 weeks.
Initiating prenatal care in the first
trimester is considered a marker
of high quality care. In California,
the likelihood of pregnant women
initiating prenatal care during
the first months varied by race/
ethnicity, from 76% of African
American mothers to 86% of
white mothers.
White
Asian/
Pacific Islander
Two or More
Races
Latina
African American
All Races/
Ethnicities
Notes: Births by place of residence. Latina origin is determined first and includes any race group. The US government’s Healthy People 2020 establishes science-based 10-year
national objectives for improving the health of all Americans, www.healthypeople.gov.
Source: Author calculation based on data from “CA-Vital Statistics Query,” California Department of Public Health, accessed February 25, 2016, cdph.ca.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
16
Maternity Care in California
Total Cesarean Deliveries
Quality: Process Measures
California vs. United States, 1997 to 2014
The rate of total cesarean delivery
(c-section) increased by over 50%
PERCENTAGE OF LIVE BIRTHS
35%
32.7%
32.2%
30%
25%
20%
in California and the nation, from
one in five births in 1997 to one
in three in 2014. While critical in
certain circumstances, c-sections
California
United States
21.0%
can pose serious risks for baby
(e.g., higher rates of respiratory
20.6%
complications and neonatal
intensive care stays) and mother
15%
(e.g., higher rates of hemorrhage,
10%
infections, and postpartum
depression).
5%
0%
1998
2000
2002
2004
2006
2008
2010
2012
2014
Sources: Quality of Care: Signals of Change, California Health Care Foundation, November 2014, www.chcf.org; Brady E. Hamilton et al., “Births: Final Data for 2014,” National Vital
Statistics Reports 64, no. 12 (December 23, 2015), Centers for Disease Control and Prevention, www.cdc.gov (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
17
Low-Risk, First-Birth Cesarean Rate, by Hospital
California, 2014
Maternity Care in California
Quality: Process Measures
In 2014, 26% (43,000) of
70%
in-hospital births were low-risk,
65%
first-birth cesareans (c-section).*
60%
Hospital rates ranged from a
55%
low of 12% to a high of 70%.
50%
Nearly 60% (148) of California
45%
60% do not meet the national target
40%
services did not meet the Healthy
35%
30%
25%
hospitals offering maternity
People 2020 goal of 23.9%. Low-
26.1%
23.9%
AVERAGE
HEALTHY PEOPLE 2020 TARGET
risk, first-birth c-sections should
20%
be performed only when medically
15%
necessary to avoid postsurgical
10%
complications and to improve
5%
0%
overall health outcomes for the
251 CA hospitals offering maternity services
Notes: Each line represents one hospital. Low-risk, first-birth cesarean rate represents the percentage of cesarean deliveries among first-time mothers delivering a single baby in a
head-down position after 37 weeks gestational age. The technical term for this measure is the nulliparous, term, singleton, vertex (NTSV) cesarean birth rate. The US government’s
Healthy People 2020 establishes science-based 10-year national objectives for improving the health of all Americans, www.healthypeople.gov.
Sources: Special data request, California Maternal Quality Care Collaborative, 2016; CalQualityCare.org, www.calqualitycare.org.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
mother and baby.
*Once a mother has had a c-section, she has a greater than
90% chance of having a c-section for subsequent births,
leading to higher risks of major complications.
18
Vaginal Birth After Cesarean Rate, by Hospital
California, 2014
Maternity Care in California
Quality: Process Measures
In 2014, only 9,000 women,
or 11%, who previously had a
45%
cesarean delivery (c-section) gave
40%
birth vaginally. Maternity experts
agree that for many women,
35%
vaginal births after cesarean
30%
deliveries (VBACs) are safe and
often preferable, because with
25%
each c-section, the risk of serious
20%
complications for both mother
15%
10%
and baby increases.
AVERAGE:
10.6%
5%
0%
251 CA hospitals offering maternity services
Notes: Each line represents one hospital. Vaginal birth after cesarean (VBAC) rate measures the number of women having a vaginal delivery among all women with a prior c-section.
Sources: Special data request, California Maternal Quality Care Collaborative, 2016; CalQualityCare.org, www.calqualitycare.org.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
19
Maternity Care in California
Early Elective Deliveries
Quality: Process Measures
California, 2014
Early elective deliveries (EEDs)
can result in serious complications
PERCENTAGE OF ALL HOSPITALS
for the baby, such as respiratory
33%
problems and insufficient brain
development. California’s average
29%
for EEDs was 3% in 2014, which
is a dramatic improvement from
2010 when 14.7% of births in
19%
the state were scheduled before
39 weeks (not shown). In 2014,
12%
four in five California hospitals
7%
performed better than the
Leapfrog Group goal of 5% or
fewer early elective deliveries.
Zero %
One to Two %
Three to Four %
Five to Nine %
Ten % or More
Percentage of EEDs
Notes: Deliveries were 1 to 3 weeks early when a scheduled delivery was not medically necessary. Data from April 1, 2014, to March 31, 2015 from 232 hospitals that submitted
sufficient data to have their scores reported.
Sources: Centers for Medicare & Medicaid Services, accessed January 5, 2015, data.medicare.gov; Brittany Patterson, “Early Elective Deliveries Down in California, Still More Work
to be Done,” KQED News, October 3, 2014, ww2.kqed.org.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
20
Maternity Care in California
Episiotomy Rate, by Hospital
Quality: Process Measures
California, 2014
Recent studies indicate that
65%
episiotomies, in which a
60%
surgical cut is made in the vaginal
55%
opening to make more space for
50%
birth, do not make birth easier
45%
and may lead to complications.
40%
In 2014, California hospital
35%
episiotomy rates ranged from
30%
67% do not meet the national target
25%
0% to 63%. Two-thirds of
hospitals had rates higher than
the Leapfrog recommended
20%
15%
AVERAGE:
rate of 5%.
11.7%
10%
5%
LEAPFROG
RECOMMENDATION:
5.0%
0%
251 CA hospitals offering maternity services
Notes: Each line represents one hospital. The Leapfrog Group, a national leader and advocate for hospital transparency, created and administers the hospital safety score.
Sources: Special data request, California Maternal Quality Care Collaborative, 2016; CalQualityCare.org, www.calqualitycare.org; Fact Sheet: Maternity Care, Leapfrog Hospital Survey,
April 1, 2015, www.leapfroggroup.org (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
21
Exclusive In-Hospital Breastfeeding, by Race/Ethnicity
California, 2014
Maternity Care in California
Quality: Process Measures
Breastfeeding helps infants
White
80.4%
Two or More Races
74.9%
Native American
infection, helps mothers recover
faster from childbirth, and reduces
mothers’ cancer risk. Two-thirds
of California newborns were fed
69.6%
exclusively breast milk during
Latino
their hospital stays in California.
61.7%
Rates of breastfeeding varied
Asian
among racial/ethnic groups, with
60.0%
80% of white infants fed only
Pacific Islander
breast milk compared to only
59.8%
56% of African Americans.
African American
56.4%
gain resistance to disease and
Breastfeeding rates also varied
66.8%
CA AVERAGE
Notes: Exclusive breastfeeding represents all feedings from birth to time of specimen collection, usually 24 to 48 hours since birth and represents infants fed “Only Human Milk.”
Excludes data for infants in NICU at time of specimen collection.
widely by hospital and region
(not shown).
Sources: “Newborn Screening Data,” California Department of Public Health, 2014, www.cdph.ca.gov (PDF); “California In-Hospital Breastfeeding as Indicated on the Newborn Screening
Test Form, Statewide, County and Hospital of Occurrence by Race/Ethnicity:2014,” California Department of Public Health, 2014, www.cdph.ca.gov (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
22
Maternity Care in California
Postpartum Care, by Health Insurance
Quality: Process Measures
California, 2012
Postpartum care for women who
recently gave birth helps identify
Medi-Cal
95%
Private
Uninsured
medical complications. Medical
visits can also assist providers
83%
in identifying postpartum
depression and anxiety, which
affects approximately one in
60%
eight mothers. In 2012, nearly
90% of California mothers had
a postpartum medical visit, but
31%
22%
6%
Had a postpartum medical visit
Mom or infant needed
but could not afford postpartum care
only 60% of uninsured mothers
had such a visit. Mothers with
Medi-Cal were less likely to have
a postpartum visit than those
with private insurance.
Notes: Mother’s prenatal health insurance. Data from population-based survey of 6,810 California-resident women with a live birth in 2012.
Sources: Maternal and Infant Health Assessment Snapshot, California Department of Public Health (CDPH), 2012, www.cdph.ca.gov; Maternal Child and Adolescent Health Statewide
Directors’ Meeting: “Maternal Mental Health in California,” CDPH, October 7, 2015, cloudfront.net (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
23
Childbirth-Related Quality Measures, by Race/Ethnicity
California, 2014
BIRTH RATES
6.3%
5.8%
11.5%
7.2%
8.0%
African American
Asian/Pacific Islander
Latino
White
2.6%
1.4%
1.1%
CA AVERAGE
Preterm
7.7%
8.3%
7.5%
1.0%
1.3%
1.0%
those born preterm are at
increased risk for lifelong
health problems or even dying
6.7%
Very Low Birthweight
Very Preterm
Quality: Outcome Measures
Low birthweight babies and
Low Birthweight
1.0%
1.1%
0.9%
Maternity Care in California
US AVERAGE
12.1%
9.6%
8.3%
before they reach one year.
California’s rates of low birthweight
births and preterm births were
better than the US average. In both
cases, however, African Americans
fared the worst, with significantly
higher rates than other racial/
ethnic groups.
2.9%
1.6%
1.3%
Notes: Low birthweight is less than 2,500 grams. Very low birthweight is less than 1,500 grams. Preterm is less than 37 completed weeks of gestation. Very preterm is less than
32 completed weeks of gestation. Latina origin is determined first and includes any race group.
Sources: User Guide to the 2014 Natality Public Use File, Centers for Disease Control and Prevention (CDC), 2015; “CDC Wonder,” CDC, accessed March 17, 2016, wonder.cdc.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
24
Maternity Care in California
Preterm Birth Rates, by County
Quality: Outcome Measures
California, 2013
Del
Norte
Humboldt
Babies who are born preterm
Siskiyou
Preterm Birth Rates (by quartiles)
Shasta
Trinity
Glenn
5.5 to 7.8
7.9 to 8.5*
8.5* to 9.5
9.6 to 13.7
Lassen
Tehama
Mendocino
are at high risk of dying in infancy
Modoc
Plumas
Butte
Sierra
Nevada
Placer
Yuba
Sutter
El Dorado
Yolo
Sonoma
Alpine
SacraNapa
mento Amador
Solano
Calaveras
Marin
Tuolumne
San
Contra Joaquin
Costa
San Francisco
Alameda Stanislaus Mariposa
San Mateo
Santa
Merced
Clara
Madera
Santa Cruz
Fresno
San
Benito
Lake Colusa
Monterey
CA Average: 8.8
and of having lifelong health
issues, including breathing
problems, vision problems,
cerebral palsy, and intellectual
delays. Preterm birth rates varied
Mono
widely across California.
Inyo
Tulare
Kings
San Luis
Obispo
Santa Barbara
Kern
San Bernardino
Ventura
Los Angeles
Orange
*Due to rounding, categories may appear to overlap.
Notes: Preterm is less than 37 completed weeks of gestation. Includes
California resident live births with valid gestational age range 17 to 47 weeks.
Rates are not shown for counties with fewer than ten preterm births.
Riverside
San Diego
Imperial
Sources: “Preterm Birth Rates by County of Residence,” California Department of Public Health, www.cdph.ca.gov (PDF); “Preterm Birth,” Centers for Disease Control and Prevention,
www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
25
Maternity Care in California
Maternal Mortality Rate
Quality: Outcome Measures
California vs. United States, 2000 to 2013
After an unsteady rise in the
MATERNAL DEATHS PER 100,000 LIVE BIRTHS
maternal mortality rate (MMR),
25
California experienced a dramatic
California
United States
20
22.0
decline from 2008 to 2012.
The overall MMR dropped to a
14-year low of 6.2 in 2012 before
increasing slightly in 2013. Since
15
2010, California’s MMR has been
below the Healthy People 2020*
10.9
10
objective of 11.4. The state’s
9.8
7.3
5
0
maternal mortality rate was
significantly lower than the
US rate.
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Notes: Maternal mortality refers to deaths 42 days or less postpartum. The National Center for Health Statistics has not published official US maternal mortality rates since 2007;
the 2008-2013 rates were calculated by CDPH through the CDC Wonder online database.
Source: Maternal Mortality Rates, California Department of Public Health, 2013, www.cdph.ca.gov (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
*The US government’s Healthy People 2020 establishes
science-based 10-year national objectives for improving
the health of all Americans, www.healthypeople.gov.
26
Maternity Care in California
Maternal Mortality, by Age
Quality: Outcome Measures
California, 2000 to 2013, Selected Years
Compared to 2000, maternal
mortality rates (MMR) were lower
MATERNAL DEATHS PER 100,000 LIVE BIRTHS
20 to 24
25 to 29
30 to 34
35 to 39
40 to 54
70
65
60
55
The drop was greatest for mothers
age 40 to 54, whose mortality
rate peaked at 64.3 deaths per
50
100,000 live births in 2005-2007
45
40
for all groups in California in 2013.
and has since declined to 22.4 in
42.8
35
2011-2013. Mothers in this age
30
group, who represented only 4%
25
20
15
10
5
0
15.4
10.1
8.2
7.6
22.4
of mothers, still had an MMR that
10.2
6.9
5.3
4.3
other age group.
was more than twice that of any
2000-02 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13
Notes: Maternal mortality refers to deaths 42 days or less postpartum. Three-year moving average is used.
Source: Maternal Mortality Rates, California Department of Public Health, 2013, www.cdph.ca.gov (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
27
Maternity Care in California
Maternal Mortality, by Race/Ethnicity
Quality: Outcome Measures
California, 2000 to 2013, Selected Years
Throughout the 21st century,
there have been significant
MATERNAL DEATHS PER 100,000 LIVE BIRTHS
African American
Asian/Pacific Islander
Latina
White
60
55
50
racial disparities in the maternal
mortality rate (MMR) in California.
During this period, African
45
American mothers had MMRs
40
that were as much as four times
35
higher than white mothers.
30
29.0
26.4
25
20
15
10
5
0
9.5
9.2
8.5
7.8
7.0
4.9
2000-02 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13
Notes: Maternal mortality refers to deaths 42 days or less postpartum. Three-year moving average is used.
Source: Maternal Mortality Rates, California Department of Public Health, 2013, www.cdph.ca.gov (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
28
Maternity Care in California
Infant Mortality Trend, Neonatal and Postneonatal
Quality: Outcome Measures
California, 2000 to 2013
From 2000 to 2013, California’s
infant mortality rate declined
INFANT DEATHS PER 1,000 LIVE BIRTHS
4.5
4.0
3.7
3.5
13% (not shown). Over this
Neonatal
Postneonatal
period, the neonatal mortality
rate, which is deaths less than
3.3
while deaths from 28 days until
3.0
one year declined 18%. California’s
2.5
2.0
28 days from birth, declined 11%,
2013 rates for each measure were
1.7
better than the national average
1.4
1.5
(not shown).
1.0
0.5
0.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Notes: Neonatal mortality is deaths less than 28 days from birth. Postneonatal is deaths 28 days to 1 year.
Sources: Infant Mortality, California Department of Public Health, www.cdph.ca.gov (PDF); Jiaquan Xu et al., “Deaths: Final Data for 2013,” National Vital Statistics Reports 64, no. 2,
Centers for Disease Control and Prevention, February 16, 2016, www.cdc.gov (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
29
Maternity Care in California
Infant Mortality, by County
Quality: Outcome Measures
California, 2013
Del
Norte
Humboldt
In 2013, California’s infant
Siskiyou
Infant Deaths per 1,000 Live Births
Shasta
Trinity
Glenn
2.2 to 3.8
4.1 to 4.7
4.9 to 5.9
6.1 to 8.7
Lassen
Tehama
Mendocino
mortality rate varied across the
Modoc
Plumas
Butte
Sierra
Nevada
Placer
Yuba
Sutter
El Dorado
Yolo
Sonoma
Alpine
SacraNapa
mento Amador
Solano
Calaveras
Marin
Tuolumne
San
Contra Joaquin
Costa
San Francisco
Alameda Stanislaus Mariposa
San Mateo
Santa
Merced
Clara
Madera
Santa Cruz
Fresno
San
Benito
Lake Colusa
Monterey
CA Average: 4.7
state, from a low of 2.2 infant
deaths per 1,000 live births in
San Mateo County to a high of
8.7 infant deaths per 1,000 live
births in Fresno County.
Mono
Inyo
Tulare
Kings
San Luis
Obispo
Santa Barbara
Kern
San Bernardino
Ventura
Los Angeles
Orange
Riverside
San Diego
Imperial
Notes: Infant is under one year. Rates are not shown for counties with fewer than five deaths.
Source: Infant Mortality, California Department of Public Health, www.cdph.ca.gov (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
30
Maternity Care in California
Infant Mortality, by Race/Ethnicity
Quality: Outcome Measures
California, 2013
California’s overall infant mortality
rate of 4.7 per 1,000 live births
INFANT DEATHS PER 1,000 LIVE BIRTHS
in 2013 was lower than the
11.9
overall US rate of 6.0. However,
10.6
there were significant racial and
ethnic disparities, with African
American infants dying at rates
twice as high as all other racial
groups, except those who are two
5.1
4.7
3.9
or more races. Latinos accounted
for more than half of the state’s
infant deaths.
2.5
Asian/
Pacific Islander
White
176
533
Latino
African American
N U M B E R O F D E AT H S
1,212
Two or More
Races
All Races/
Ethnicities
133
2,348
275
Notes: Infant is under one year. In 2013, there were 9 Native American infant deaths, and 10 infant deaths whose race/ethnicity was unstated or unknown.
Source: “CHHS Open Data Portal,” California Department of Health and Human Services, accessed January 7, 2016, chhs.data.ca.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
31
Maternity Care in California
Maternal Medical Conditions, by Race/Ethnicity
Risk Factors
California, 2014
Medical conditions during
pregnancy or at childbirth
Asthma
2.4%
2.9%
8.1%
African American
Asian/Pacific Islander
Latina
White
4.9%
3.7%
AVERAGE
Gestational Diabetes
during birth. In 2014, 9% of
mothers had gestational diabetes,
8% had hypertension, and 4%
had asthma. Rates of each
6.7%
14.2%
9.6%
6.8%
condition varied by race/ethnicity:
African American mothers had
the highest rates of asthma and
9.4%
hypertension, and Asian/Pacific
Hypertension
6.2%
increase the risk of complications
13.6%
Islander mothers had the highest
rate of gestational diabetes.
8.0%
8.4%
8.2%
Notes: Based on preliminary vital records files and OSHPD hospital discharge diagnosis files for in-hospital births at 251 hospitals that offer maternity services. Gestational diabetes is
ICD-9 code 648.8. Hypertension includes eclampsia, mild pre-eclampsia, severe pre-eclampsia, chronic, and gestational.
Source: Special data request, California Maternal Quality Care Collaborative, 2016.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
32
Maternal Pre-Pregnancy Overweight and Obesity
by Race/Ethnicity, California, 2014
4.5%
24.9%
■ Morbidly Obese
■ Obese
■ Overweight
7.2%
25.0%
3.7%
19.5%
Latina
African American
White
pregnancy. In 2014, about one
in four California mothers was
obese or morbidly obese prior
to pregnancy, and an additional
half of African American and
Latina mothers were overweight,
– 0.8%
20.6%
risk of complications during
one in four was overweight. Over
15.4%
24.5%
Risk Factors
Being overweight increases the
3.2%
28.6%
Maternity Care in California
8.0%
24.1%
to pregnancy compared to under
16.6%
Asian/
Pacific Islander
obese, or morbidly obese prior
40% of white mothers.
All Races/
Ethnicities
Notes: In-hospital births at 251 hospitals that offer maternity services. Overweight and obesity are based on body mass index (BMI), from weight information reported by the mother
on the birth certificate. Women with a pre-pregnancy BMI of 25.0 to 29.9 are classified as overweight; those with a BMI of 30 to 39.9 are classified as obese; those with BMI of 40 or
greater are classified as morbidly obese. Accepted weight ranges are 50 to 400 pounds. African American, Asian/Pacific Islander, and white are non-Latina.
Sources: Special data request, California Maternal Quality Care Collaborative, 2016; “Healthy Weight, Healthy Pregnancy,” CDC, www.cdc.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
33
Maternal Depressive Symptoms, Prenatal and/or Postpartum,
California, 2013
Maternity Care in California
Mental Health and Substance Use
In 2013, one in five California
MATERNAL DEPRESSIVE SYMPTOMS,
PRENATAL OR POSTPARTUM, BY RACE
African American
20.5%
27.6%
Latina
23.9%
Asian/Pacific Islander
White
15.3%
12.8%
prenatal or postpartum depressive
symptoms.
Rates of prenatal and postpartum
depressive symptoms varied by
15.9%
14.9%
women who gave birth had either
CA AVERAGE
20.5%
the mother’s race/ethnicity. In
2013, about one in four African
American and Latina mothers
reported depressive symptoms. In
7.2%
contrast, about one in six Asian/
Pacific Islander and white mothers
reported these symptoms.
Prenatal or Postpartum
Prenatal
Postpartum
Prenatal and Postpartum
Note: Data from population-based survey of California-resident women with a live birth in 2013. Data are weighted to represent all women with a live birth in California.
Source: Maternal Child and Adolescent Health Statewide Directors’ Meeting: “Maternal Mental Health in California,” California Department of Public Health, October 7, 2015, cloudfront.net.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
34
Maternity Care in California
Maternal Smoking Habits, by Race/Ethnicity
Mental Health and Substance Use
California, 2012 to 2013
Smoking during pregnancy
Before Pregnancy
During Pregnancy
increases the risk of complications
for both mother and baby, such
19.8%
as miscarriages, problems with
17.3%
delivery, birth defects, and sudden
infant death syndrome. Statewide,
CA AVERAGE
11.6%
2.5% of women reported
smoking in the last three months
of pregnancy, with higher rates
8.8%
7.3%*
among African Americans (7.3%)
6.5%
4.4%
CA AVERAGE
2.5%
1.3%
African American
White
and whites (4.4%).
Latina
1.1%*
Asian/Pacific Islander
*Estimates should be interpreted with caution due to low statistical reliability.
Notes: Data from 2012 and 2013 surveys were combined, resulting in a statewide sample size of 13,821. Data are weighted to represent all live births in California. Before pregnancy is
smoked any cigarettes during the three months before pregnancy. During pregnancy is smoked any cigarettes during the last three months of pregnancy.
Sources: Smoking: Before, During, and After Pregnancy Fact Sheet, 2012-2013, California Department of Public Health, 2015, www.cdph.ca.gov (PDF); “Tobacco Use and Pregnancy,”
Centers for Disease Control and Prevention, www.cdc.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
35
Maternity Care in California
Maternal Alcohol Use, by Race/Ethnicity
Mental Health and Substance Use
California, 2012
Drinking alcohol during pregnancy
can cause miscarriage, stillbirth,
ANY ALCOHOL USE DURING 1ST OR 3RD TRIMESTER
and fetal alcohol spectrum
disorder, which involves a range
32.7%
of physical, behavioral, and
intellectual disabilities. One in
27.2%
CA AVERAGE
20.9%
five California mothers reported
drinking alcohol during the first
or third trimester, with nearly
one in three white mothers
15.7%
reporting alcohol use during
11.7%
this time. The lower limit for
safely consuming alcohol during
pregnancy is not known.
White
African American
Latina
Asian/Pacific Islander
Notes: Data from population-based survey of 6,810 California-resident women with a live birth in 2012. Data are weighted to represent all women with a live birth in California.
Source: Maternal and Infant Health Assessment Snapshot, California Department of Public Health, 2012, www.cdph.ca.gov.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
36
Maternal Substance Use, by Payer Group and Race/Ethnicity
California, 2011
7.6%
4.2%
White
drugs, including alcohol; however,
in substance use rates by payer
and by race/ethnicity. Overall
Two or More Races
4.6%
1.1%
African American
Medi-Cal Births
Non-Medi-Cal Births
4.3%
1.7%
substance use was nearly four
times higher among mothers on
Medi-Cal than among mothers not
on Medi-Cal in 2011. Substance
use was highest among Native
1.0%
American mothers on Medi-Cal.
However, some studies have
Asian/Pacific Islander
0.8%
0.1%
0.5%
mothers were dependent on
there were significant differences
4.9%
0.6%
0.5%
Mental Health and Substance Use
Only a small portion of California
Native American
Latina
Maternity Care in California
documented bias in the reporting
of substance use based on race
CA AVERAGE
1.9%
CA AVERAGE
0.000
0.875
1.750Classifications Software
2.625 (CCS) codes 660
3.500
4.375as a state of dependence
5.250 on any drug,
6.125including alcohol.
Note: Substance use
is identified by Clinical
and 661 and is defined
and socioeconomic status.
Source: 2011 Medi-Cal Births Statistics, California Department of Health Care Services, 2014, www.dhcs.ca.gov (PDF) Ira J. Chasnfoff, M.D., et al. “The Prevalence of Illicit-Drug or Alcohol
Use During Pregnancy and Discrepancies in Mandatory Reporting in Pinellas County, Florida,” The New England Journal of Medicine, 322, No. 17, (April 26, 1990): 1202-1206.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
37
Maternity Care in California
Infants Born with Neonatal Abstinence Syndrome
Mental Health and Substance Use
by Race/Ethnicity, California, 2014
From 2008 to 2012, there was
a 75% increase (not shown)
RATE PER 1,000 DELIVERIES
in California babies born with
MOTHER’S COUNTRY OF ORIGIN
10.0
neonatal abstinence syndrome
Foreign
Born
24%
(NAS), a condition that results
US Born
76%
7.7
from a baby’s exposure to
drugs, most often opioids, in
the womb. Newborns with NAS
5.6
can suffer from seizures and
other complications and require
hospitalization. In 2014, African
3.9
American and white infants had
higher rates of NAS than Latino
and Asian/Pacific Islander infants.
0.9
African American
n=264
White
n=1,036
Latino
n=909
Asian/Pacific Islander All Races/Ethnicities
n=69
N=2,763
Notes: In-hospital births at 251 hospitals that offer maternity services. Neonatal abstinence syndrome based on ICD-9 codes 779.5 and 760.72. Not included: Other (rate: 18.1, n = 485).
Sources: Maternal and Child Health Services Title V Block Grant, California, September 22, 2015 Draft, California Department of Public Health, www.cdph.ca.gov (PDF); Special data request,
California Maternal Quality Care Collaborative, 2016.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
38
Mothers’ Experience of Pressure to Have Birth Intervention
United States, 2012
Maternity Care in California
Patient Engagement
Relatively little data exists on
mothers’ perceptions of their
Did you feel pressure from any health professional to have …?
28%
birth experiences. A 2012
28%
national survey found that
25%
22%
19%
many mothers reported
experiencing pressure from a
health professional to have an
intervention during childbirth.
Of mothers who had the
13%
8%
intervention, one in four felt
pressured to induce labor or
7%
have a first cesarean, and one
in five felt pressured to have
Labor Induction
Mothers who…
Epidural Analgesia
First Cesarean
Did not have intervention
Repeat Cesarean
a repeat cesarean.
Had intervention
Notes: Nationally weighted data from an online survey conducted in 2012. Survey was completed by 2,400 mothers between age 18 and 45 who had given birth to single babies
between July 2011 and June 2012.
Source: E. R. Declercq et al., Listening to Mothers III: Pregnancy and Birth (New York: Childbirth Connection, May 2013), transform.childbirthconnection.org (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
39
Maternity Care in California
Provider Discussions About Repeat Cesarean
Patient Engagement
United States, 2012
Mothers who previously had a
How much did you and your maternity care provider talk about the reasons you might want to schedule another cesarean?
Discussed Reasons for
Repeat Cesarean
Discussed Reasons Against
Repeat Cesarean
cesarean (c-section) reported that
discussions with their providers
tended to focus more on reasons
for rather than against a repeat
Not at All
3%
cesarean. Nearly 80% reported that
A Lot
20%
A Little
20%
A Lot
43%
Some
35%
the provider focused a lot or some
of the conversation on reasons for
having a repeat c-section, while
Not at All
40%
Some
18%
more than 60% reported little or
no discussion of reasons against
having the intervention.
A Little
23%
Notes: Nationally weighted data from an online survey conducted in 2012. Survey was completed by 2,400 mothers between age 18 and 45 who had given birth to single babies
between July 2011 and June 2012.
Source: E. R. Declercq et al., Listening to Mothers III: Pregnancy and Birth (New York: Childbirth Connection, May 2013), transform.childbirthconnection.org (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
40
Maternity Care in California
Mothers’ Knowledge of Cesarean Complications
Patient Engagement
United States, 2012
A national survey of mothers
revealed that many were not aware
How much do you agree or disagree with each of the following statements concerning cesarean birth?
38% 37%
Increases the chances of serious problems with the placenta
in any future pregnancies
Lowers the chance that a baby will have breathing problems
at the time of birth
of possible adverse outcomes from
a cesarean birth. Nearly one-third
of mothers incorrectly agreed
with the statement that cesarean
births lower the risk of respiratory
24%
18%
14%
problems in newborns, and nearly
18%
15%
one-quarter incorrectly disagreed
with the statement that cesarean
15%
births increase the risk of placental
12%
problems in future pregnancies.
8%
In both cases, over one-third of
mothers were not sure.
Disagree Strongly
Disagree Somewhat
Agree Somewhat
Agree Strongly
Not Sure
Note: Nationally weighted data from an online survey conducted in 2012. Survey was completed by 2,400 mothers between age 18 and 45 who had given birth to single babies
between July 2011 and June 2012. Half of the respondents were asked these questions; the other half were asked questions about labor induction knowledge.
Source: E. R. Declercq et al., Listening to Mothers III: Pregnancy and Birth (New York: Childbirth Connection, May 2013), transform.childbirthconnection.org (PDF).
©2016 CALIFORNIA HEALTH CARE FOUNDATION
41
Maternity Care in California
Payments for Birth, Cesarean vs. Vaginal
Spending
by Covered California Region, 2010 to 2013
CESAREAN BIRTHS
In California, the total average
VAGINAL BIRTHS
payment for cesarean deliveries
TOTAL PAYMENT
PATIENT PAYMENT
TOTAL PAYMENT
PATIENT PAYMENT
Central San Joaquin
$14,309
$1,176
$11,082
$716
Eastern Counties
$14,444
$472
$12,415
$526
Inland Empire
$16,270
$1,806
$11,292
$1,324
L.A. County East
$17,567
$1,877
$12,978
$1,422
Orange County
$18,597
$2,205
$13,956
$1,812
L.A. County West
$21,510
$2,218
$14,528
$1,757
payments was not as large (one-
Central Coast
$21,554
$2,315
$14,201
$1,691
third higher for cesarean births).
San Diego County
$22,717
$2,001
$14,618
$1,620
San Joaquin Valley
$22,833
$1,054
$15,381
$881
Northern Counties
$26,237
$2,529
$15,637
$1,855
Santa Clara County
$26,553
$1,847
$17,491
$1,514
Sacramento Valley
$28,828
$152
$17,937
$98
North Bay Area
$29,632
$362
$18,000
$293
Contra Costa County
$31,162
$984
$18,704
$736
San Francisco County
$31,568
$1,519
$19,788
$1,383
Alameda County
$32,399
$1,351
$19,075
$1,060
Monterey Coast
$33,336
$3,048
$19,774
$2,518
San Mateo County
$35,725
$1,155
$20,884
$928
CA Average
$22,188
$1,781
$15,162
$1,329
was nearly 50% higher than the
total average payment for vaginal
births. The difference for patient
For both cesarean and vaginal
births, total and patient payments
varied considerably by region.
Notes: Data for commercially insured patients only based on claims billed in California between January 2010 and September 2013. Patient payments include copayments,
coinsurance deductibles, and payment penalties. Average amounts. No data available for Kern County. See Appendix B for a county breakdown of Covered California regions.
Source: California Healthcare Compare, accessed January 13, 2016, www.cahealthcarecompare.org.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
42
Resources
California Department of Health Care Services
Annual Medi-Cal Birth Reports
www.dhcs.ca.gov
California Department of Public Health
CA-Vital Statistics Query
informaticsportal.cdph.ca.gov
Maternity Care in California
ABOUT THIS SERIES
The California Health Care Almanac is an online
clearinghouse for data and analysis examining
the state’s health care system. It focuses on issues
of quality, affordability, insurance coverage and
California Department of Public Health, Maternal, Child and Adolescent Health Program
Data and reports on maternal mortality, infant mortality, and other childbirth-related quality
indicators, as well as annual survey on mother and infant health
www.cdph.ca.gov
California Healthcare Compare
Data on payments for births by California region
www.cahealthcarecompare.org
California Maternal Quality Care Collaborative
Resources and toolkits designed to improve quality of maternal care in California; also hosts
California Maternal Data Center
www.cmqcc.org
the uninsured, and the financial health of the
system with the goal of supporting thoughtful
planning and effective decisionmaking. Learn
more at www.chcf.org/almanac.
AU T H O R
Jen Joynt, health care consultant
ACKNOWLEDGMENTS
The California Maternal Quality Care Collaborative
contributed invaluable guidance and data for
this report.
Centers for Disease Control and Prevention
VitalStats
www.cdc.gov/nchs/vitalstats.htm
Childbirth Connection
Listening to Mothers surveys
transform.childbirthconnection.org/reports/listeningtomothers
Medical Board of California
Annual reports which include surveys of licensed midwives, and physician surveys
www.mbc.ca.gov
©2016 CALIFORNIA HEALTH CARE FOUNDATION
F O R M O R E I N F O R M AT I O N
California Health Care Foundation
1438 Webster Street, Suite 400
Oakland, CA 94612
510.238.1040
www.chcf.org
43
Maternity Care in California
Appendix A: California Counties Included in Regions
NORTHERN
AND SIERRA
SACRAMENTO
AREA
GREATER
BAY AREA
NORTHERN
AND SIERRA
REGION
COUNTIES
Central Coast
Monterey, San Benito, San Luis Obispo, Santa Barbara,
Santa Cruz, Ventura
Greater Bay Area
Alameda, Contra Costa, Marin, Napa, San Francisco,
San Mateo, Santa Clara, Solano, Sonoma
Inland Empire
Riverside, San Bernardino
Los Angeles County
Los Angeles
Northern and Sierra
Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn,
Humboldt, Inyo, Lake, Lassen, Mariposa, Mendocino,
Modoc, Mono, Nevada, Plumas, Shasta, Sierra, Siskiyou,
Sutter, Tehama, Trinity, Tuolumne, Yuba
Orange County
Orange
Sacramento Area
El Dorado, Placer, Sacramento, Yolo
San Diego Area
Imperial, San Diego
San Joaquin Valley
Fresno, Kern, Kings, Madera, Merced, San Joaquin,
Stanislaus, Tulare
CENTRAL
COAST
SAN JOAQUIN
VALLEY
INLAND
EMPIRE
LOS ANGELES
COUNTY
ORANGE
COUNTY
©2016 CALIFORNIA HEALTH CARE FOUNDATION
SAN DIEGO AREA
44
Appendix B: Counties Included in Covered California Regions
REGION
COUNTIES
REGION
COUNTIES
Alameda County
Alameda
Northern Counties
Central Coast
San Luis Obispo, Santa Barbara, Ventura
Central San Joaquin
Fresno, Kings, Madera
Alpine, Amador, Butte, Calaveras,
Colusa, Del Norte, Glenn, Humboldt,
Lake, Lassen, Mendocino, Modoc,
Nevada, Plumas, Shasta, Sierra, Siskiyou,
Sutter, Tehama, Trinity, Tuolumne, Yuba
Contra Costa County
Contra Costa
Orange County
Orange
Eastern Counties
Imperial, Inyo, Mono
Sacramento Valley
El Dorado, Placer, Sacramento, Yolo
Inland Empire
Riverside, San Bernardino
San Diego County
San Diego
Kern County
Kern
San Francisco County
San Francisco
L.A. County East
L.A. County East
San Joaquin Valley
L.A. County West
L.A. County West
Mariposa, Merced, San Joaquin,
Stanislaus, Tulare
Monterey Coast
Monterey, San Benito, Santa Cruz
San Mateo County
San Mateo
North Bay Area
Marin, Napa, Solano, Sonoma
Santa Clara County
Santa Clara
Maternity Care in California
Notes: These modified regions apply to page 42 only. Other regional slides use the regional designations from Appendix A.
©2016 CALIFORNIA HEALTH CARE FOUNDATION
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Maternity Care in California
Appendix C: Maternity Care Workforce Overview
BRIEF DESCRIPTION
EDUCATION REQUIRED
LICENSING ORGANIZATION
Certified Lactation Counselor*
Provider of education and counseling to support breastfeeding.
CLC training course completion and pass
certification exam
None
Certified Nurse Midwife
Advanced practice nurses educated to provide midwifery care,
including perinatal, well-woman, and newborn care. CNMs
primarily attend births in hospitals.
Master’s degree in nursing with specialty in
nurse-midwifery.
California Board of Registered Nursing
Clinical Psychologist
Clinician trained to diagnose and treat a range of mental health
disorders and generally providing psychotherapy.
Ph.D. or Psy.D. in Psychology plus one year internship.
Additional continuing education in perinatal mental
health is available, but not required.
California Board of Psychology
Doula
Provider of physical, emotional, and informational labor support
to mother before, during, and after birth.
No special requirements
None
International Board Certified
Lactation Consultant*
Support specialist in the clinical management of human
lactation and breastfeeding.
Must pass certification exam
None
Labor and Delivery Nurse
Registered nurse providing direct patient care in obstetrics
and labor, and/or delivery and reproductive care.
Associate degree, bachelor of science in nursing, or
entry-level master’s program in nursing
California Board of Registered Nursing
Licensed Marriage Family
Therapist / Licensed Professional
Clinical Counselor / Licensed
Clinical Social Worker
A clinician who provides counseling or therapy services to
groups or individuals to address wellness, personal growth
and pathology.
Master’s degree. Additional continuing education in
perinatal mental health is available, but not required.
California Board of Behavioral Sciences
Licensed Midwife†
Health care professional authorized to attend cases of normal
childbirth and provide prenatal, delivery, and postpartum care
for the mother and immediate care for the newborn. Typically
attend births out of hospital.
Three-year postsecondary education program in an
accredited midwifery school‡
Medical Board of California
Obstetrician/Gynecologist
Doctor of medicine or doctor of osteopathic medicine specially
trained to provide medical and surgical care to women,
including providing pregnancy care.
Medical school plus four-year residency in obstetrics
and gynecology
Medical Board of California or
Osteopathic Medical Board of California
Psychiatrist
Doctor of medicine specially trained to provide psychiatric care
to adults using medications and/or psychotherapy.
Medical degree plus four years postdoctoral training
in adult psychiatry. Additional fellowship training in
reproductive psychiatry is available in some parts of
the US, but is not required.
Medical Board of California
(CNM)
(also designated as Certified
Professional Midwife)
*Lactation Consultants and Counselors are certifed by the International Board of Lactation Consultant Examiners and the Academy of Lactation Policy and Practice, respectively.
†Unlicensed midwives also likely practicing in California. Little information exists on their typical background.
‡School approved by the Medical Board of California (MBC). Prior to January 1, 2015, midwives could also be licensed through a challenge mechanism whereby an applicant obtains credit for previous midwifery education and clinical experience.
Notes: This list is based on CHCF correspondence with 2020 Mom, Maternal Mental Health NOW, and Emily C. Dossett, M.D. (Keck School of Medicine, LAC+USC), June 2016. It captures only the most common maternal mental health providers.
Sources: Medical Board of California; California Board of Registered Nurses; DONA International; International Board of Lactation Consultant Examiners; The Academy of Lactation Policy and Practice.
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