“They really braved a way forward in a really contentious environment and served as a model for a lot of other foundations that are moving into this space,” said Kara Williams, Director of Strategic Initiatives at the Allyn Family Foundation.
Led by Betsy McNamara of Full Circle Consulting, the fund focused on research and best practice dissemination, operational support and coalition building. It took risks, and was willing to get creative. “Birth is ever-present, and in the U.S., outcomes are getting worse and costs are getting higher and the midwifery model improves outcomes and lowers costs,” McNamara said.
So the Transforming Birth Fund set out to, well, transform systems.
It was an outsized task, and the Fund had about $500k a year with which to accomplish it. McNamara and the donor picked their spots carefully.
Part of the struggle in building acceptance of natural birth was that there were gaps in the national data. TBF worked to fill those gaps.
TBF funded research at Yale University that demonstrated factors that reduced the prevalence of C-section in first-time, low-risk moms. The dissemination of that research influenced how practitioners at the hospital think about early labor management and birth settings.
Data collection by the Midwives’ Alliance of North America resulted in major research publications. A pair of independent researchers synthesized those data in a study published in the British Medical Journal, which demonstrated the case for lessening medical interventions in low-risk pregnant women. That research gained attention at the national – and international – levels.
Childbirth Connection, a program of the National Partnership for Women & Families, commissioned an unprecedented review of health implications of both natural birth and common interventions for women and babies that furthered the case. Other TBF-supported efforts, such as broad dissemination and creation of classroom editions of the documentary “The Business of Being Born,” reached wide audiences.
All of that helped inform public understanding – and understanding among the medical community.
“TBF really was seminal in creating stronger data raising awareness of the issues and choosing to focus on policy at the national level to advance the conversation,” Williams said.
The Childbirth Connection has helped advance maternity care performance measurement – for accountability, improvement and public reporting – with the National Quality Forum and other groups. Increasingly used are indicators that proponents of natural birth have long advocated, like lowering rates of caesarean section for low-risk women, and increasing the numbers of moms breastfeeding their infants. Recent opportunities to advance maternity care payment reform offer important opportunities to accelerate maternity care quality improvement.
And Childbirth Connection’s 2020 Vision for a High-Quality, High-Value Maternity Care System and companion Blueprint for Action are also being used to help transform national policy on maternity care.
“The support from the Transforming Birth Fund helps to explain our opportunity to sit at policy tables and work groups,” said Carol Sakala, director of Childbirth Connection Programs at the National Partnership for Women & Families. “Our strategy has been to go as far as we could while keeping a seat at the table.” Persistence in key messages helped, she said, bring about a “dramatic shift” in the way the medical profession views, and talks about, natural birth.
The movement had been stalled, in part, by a contentious relationship between certified professional midwives (who assist at out-of-hospital births) and nurse-midwives, who practice primarily in hospitals and birthing centers. Philosophical differences among those groups meant that they were not working together, or speaking with a unified voice about the benefits of natural birth.
TBF waded into that relationship, funding a three-year process through which midwives’ organizations came together in one united coalition, the US Midwifery Education Regulation & Association (US-MERA). At the same time, TBF provided operating support to “backbone” organizations in the natural birth movement.
TBF “really helped to move the needle on the relationship and places where we were stuck for literally decades between nurse midwives and certified professional midwives,” said Mary Lawlor, Executive Director of the National Association of Certified Professional Midwives, which is part of the coalition. “The Transforming Birth Fund has been a significant factor in whatever progress we have been able to make.” Now, the coalition presents a unified set of messages in advocating for natural birth to the American College of Obstetrics and Gynecology and in other venues.
When the International Confederation of Midwives issued global standards for the profession, the new coalition agreed to embrace the standards. “Instead of arguing with each other,” Lawlor said. “We all said ‘yes, that’s the appropriate vision.’”
The groups worked together to reach consensus about how certified professional midwives were educated and regulated and to create model legislation for licensing and regulation – now being advanced in a number of states.
Some members of the coalition are working at the national level to enable certified professional midwives to be reimbursed by Medicaid. Doing so would greatly improve access to midwife-assisted birth for low-income women, including those who currently have the least access – African-American and Native American women. Nearly half of all births in the U.S. are already paid for by Medicaid, at costs typically much higher than those associated with midwife-assisted births.
Three TBF-funded Home Birth Consensus Summits brought together consumers, doctors and midwives, hospital administrators, legislators, public health experts and others to create a shared vision and best practice guidelines and protocols for improving access to safe, high quality maternity care across all settings.
And all of this happened at a fortuitous time – against the backdrop of the Affordable Care Act and major related pieces of legislation, which helped shift the focus to improving outcomes, and to support less, not more, medical interventions in maternity care.
Like the most flexible philanthropies, the Transforming Birth Fund was able to apply resources quickly and creatively. Some grants were hundreds of thousands of dollars across multiple years. Some were tiny, but mattered: A few hundred dollars for travel expenses to attend a meeting on re-visioning U.S. maternity care ensured that midwives had a seat at the table and a voice in the conversation.
Not everything that TBF funded was a startling success – but the strategic approach, willingness to take risks, to work to build a body of research and change systems meant that its overall effect has been greater than the dollars invested might suggest.
The Transforming Birth Fund, said Williams, asked “’How do we build the case nationally to transform the whole system?’ And I think the TBF laid both the groundwork and the path for that to happen… We have gotten more traction, seen more momentum. There are a variety of partners and stakeholders more involved, and it is interesting to see how much energy there is now. I feel incredible optimism.”
Momentum is gaining, but much work remains. More midwives need to be trained, more data collected and shared, access to midwife-assisted birth expanded. A movement has been ignited, next steps have been identified, and the landscape is primed for new funders to step in and make significant progress on improving maternity care for all women.
“Funders need to know that, from a population health point of view, we need to get this right,” Sakala said. “The way we have been going about [birth and maternity care] in the mainstream is deeply, deeply broken. There is a better way, and it is imperative that we get to that better way.”
Williams said that the Transforming Birth Fund got some important things started. “TBF really helped push the possibilities for how foundations could change the conversation and advance policies.”
The donor who created the fund, who simply wants more women and babies to experience natural, healthy childbirth, hopes that the advances that the fund helped make will be a foundation for change. “I hope that we have knitted together enough of a structure that it will continue in a positive direction and continue the forward momentum,” said. “Overall, what I am hearing more and more is that there is hope now,” she said. “The funding and bridge-building have restored hope.”
--Lois Shea, Senior Writer and Content Manager, NH Charitable Foundation