Six months after the launch of the Biden administration’s “birthing friendly” designation for hospitals, advocates are questioning the next steps for the tool aimed at incentivizing better care for patients.
Beginning last fall, hospitals that achieved the designation received an icon on Care Compare, a federal website aimed at helping consumers pick health care providers.
But it’s not difficult for hospitals to receive the designation, with 2,225 — that is, most eligible hospitals — having received it as of April.
Of the nearly 1,000 acute care hospitals that didn’t get the designation, more than 800 said they didn’t provide delivery or labor care.
And only 135 didn’t get the designation because they didn’t meet the requirements of participating in a statewide or national perinatal quality improvement collaborative program.
What’s more, many of the hospitals that have received the designation perform cesarean sections above the recommended levels, which could indicate overuse of the procedure. C-sections are considered riskier than vaginal birth, with a longer recovery time.
“Right now, it falls short in terms of what pregnant people would need,” said Sinsi Hernández-Cancio, vice president of health justice at the National Partnership for Women and Families.
While many people typically don’t have much of a choice on where they give birth because of insurance limitations or living in areas with few providers, for those with choices, the designation currently is of little use, she said.
“Given that the majority of hospitals have gotten the designation because the requirements for it are a pretty low bar, it’s not really a useful distinction even for those consumers that do have a choice,” Hernández-Cancio said. “Because if the majority of the hospitals have it, and all the ones in your area do, it doesn’t make a difference.”
The designation is part of the Biden administration’s efforts to improve maternal health amid concerns about persistent inequities in health outcomes.
It was rolled out last November with much fanfare, touted by Vice President Kamala Harris as an important step to increasing “high-quality maternity care.”
But all a hospital has to do to receive the designation is attest to participating in a statewide or national perinatal quality improvement collaborative program and implementing evidence-based interventions to improve maternal health, sometimes called bundles.
While the Centers for Medicare and Medicaid Services has said it will work toward including other factors in the designation, when that will happen is unclear. The designation was not mentioned in the 2025 proposed hospital inpatient payment rule, which would typically be the vehicle for such changes.
While there is evidence that participating in high-quality collaboratives and implementing evidence-based practices can improve birth outcomes, the designation currently doesn’t probe into how meaningful those efforts are.
“It is kind of a low bar for hospitals to self-describe that they have implemented it without defining what implementation of a bundle is,” said Elliott Main, former medical director of the California Maternal Quality Care Collaborative, a stakeholder organization that aims to improve maternal health outcomes in the state.
Main, who advised CMS on the designation, said it is typical for designations to begin with a soft launch to get hospitals involved in the process.
“What does it mean to be engaged, to become a member (of a collaborative)— those kinds of terms are still being defined, but it gets hospitals to sit up and pay attention,” he said.
For example, The Joint Commission, which accredits health care organizations, has a checklist for evidence-based safety practices that should be implemented in maternity units to reduce the risk of harm from hemorrhage and hypertension.
“I think that’s likely a direction CMS may go,” Main said.
Improving care
While hospital designations may have little utility for patients, they have evolved to become powerful ways to get hospitals to improve patient care, experts say.
For example, California’s Cal Hospital Compare awards the “maternity care honor roll” to hospitals that have C-section rates below 23.6 percent, a goal that aligns with the Department of Health and Human Services’ “Healthy People 2030” initiative to reduce C-section births among low-risk, first-time mothers.
“It’s really a great carrot for hospitals and other facilities to improve,” said Alex Stack, director of programs and strategic initiatives at Cal Healthcare Compare.
Cal Healthcare Compare is working on revamping the model to include data on severe complications, access to doula care and breastfeeding.
“The great thing about an honor roll is it gives additional emphasis and helps facilities to prioritize further what the collective state or region is trying to work towards together,” Stack said.
The honor roll in California is part of a multifaceted effort to reduce C-section rates. According to provisional data from the Centers for Disease Control and Prevention, California’s rate of C-sections in low-risk mothers was 25.9 percent, below the national average of 26.6 percent.
Throughout the country, there is extreme variability between different hospitals and different regions that can’t be explained solely by patient characteristics, Main said. The culture of a hospital and the training of the people who work there likely have more of an impact.
Better data collection could be part of the solution.
This is the first year CMS will require acute care hospitals report rates of severe obstetric complications and C-sections, which will give a fuller picture of the issue at individual hospitals. Currently, that data is not collected in a widespread manner.
“We intend to propose a more robust set of criteria for awarding the designation in future notice-and-comment rulemaking,” a CMS spokesperson said in a statement. “CMS is considering how to build upon the Maternal Morbidity Structural measure through the future inclusion of clinical outcome and patient experience measures.”
As CMS puts more requirements on the measure, hospitals could lose the designation if their care does not improve.
Of more than 1,300 birthing-friendly hospitals surveyed by the Leapfrog Group, a nonprofit focused on health care transparency, 58 percent — 782 hospitals —did not meet the Healthy People 2030 goal of a C-section rate of 23.6 percent, according to a CQ Roll Call analysis.
While there are still six years to meet that goal, 56 percent of those hospitals are also not meeting the Healthy People 2020 goal of 23.9 percent.
And nearly 21 percent of the birthing-friendly hospitals — 279 hospitals — had C-section rates of 30 percent or higher.
Main said adding disqualifiers to the designation could be an option.
“One thing that’s been discussed… is to be an awarded hospital you can’t have a high C-section rate. A C-section rate over 30, that would disqualify you,” he said. “There’s no reason for hospitals to have over 30 percent C-section rate.”
For example, Harrison Memorial Hospital in Kentucky had the highest rate of all of the “birthing friendly” hospitals at 58 percent of births done through C-section. The hospital did not respond to a request for comment.
Still, that doesn’t stop hospitals from touting their designation on social media without explaining to patients what that really means.
While Hernández-Cancio said she understands the intent behind making it simple for hospitals to initially achieve the designation, she said nothing is stopping a hospital from advertising the award in the future even if it loses that award as standards ramp up.
“If it’s being used for marketing and PR, that’s a bit problematic,” she said.
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