Improving the Experience of Care: Results of the American Association of Birth Centers Strong Start Client Experience of Care Registry Pilot Program, 2015-2016

Neonatal morbidity and mortality in birth centers in the United States 2018-2021: An observational study of low-risk birthing individuals

BACKGROUND

Many studies reporting neonatal outcomes in birth centers include births with risk factors not acceptable for birth center care using the evidence-based CABC criteria. Accurate comparisons of outcomes by birth setting for low-risk patients are needed.

METHODS

Data from the public Natality Detailed File from 2018 to 2021 were used. Logistic regression, including adjusted and unadjusted odds ratios, compared neonatal outcomes (chorioamnionitis, Apgar scores, resuscitation, intensive care, seizures, and death) between centers and hospitals. Covariates included maternal diabetes, body mass index, age, parity, and demographic characteristics.

RESULTS

The sample included 8,738,711 births (8,698,432 (99.53%) in hospitals and 40,279 (0.46%) in birth centers). There were no significant differences in neonatal deaths (aOR 1.037; 95% CI [0.515, 2.088]; p-value 0.918) or seizures (aOR 0.666; 95% CI [0.315, 1.411]; p-value 0.289). Measures of morbidity either not significantly different or less likely to occur in birth centers compared to hospitals included chorioamnionitis (aOR 0.032; 95% CI [0.020, 0.052]; p-value < 0.001), Apgar score < 4 (aOR 0.814, 95% CI [0.638, 1.039], p-value 0.099), Apgar score < 7 (aOR 1.075, 95% CI [0.979, 1.180], p-value 0.130), ventilation >6 h (aOR 0.349; [0.281,0.433], p-value < 0.001), and intensive care admission (aOR 0.356; 95% CI [0.328, 0.386], p-value < 0.001). Birth centers had higher odds of assisted neonatal ventilation for <6 h as compared to hospitals (aOR 1.373; 95% CI [1.293, 1.457], p-value < 0.001).

CONCLUSION

Neonatal deaths and seizures were not significantly different between freestanding birth centers and hospitals. Chorioamnionitis, Apgar scores < 4, and intensive care admission were less likely to occur in birth centers.

The birth center model of care: Staffing, business characteristics, and core clinical outcomes

OBJECTIVES

Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes.

METHODS

This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission.

RESULTS

The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations.

CONCLUSIONS FOR PRACTICE

Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.

The impact of birth settings on pregnancy outcomes in the United States

In the United States, 98.3% of patients give birth in hospitals, 1.1% give birth at home, and 0.5% give birth in freestanding birth centers. This review investigated the impact of birth settings on birth outcomes in the United States. Presently, there are insufficient data to evaluate levels of maternal mortality and severe morbidity according to place of birth. Out-of-hospital births are associated with fewer interventions such as episiotomies, epidural anesthesia, operative deliveries, and cesarean deliveries. When compared with hospital births, there are increased rates of avoidable adverse perinatal outcomes in out-of-hospital births in the United States, both for those with and without risk factors. In one recent study, the neonatal mortality rates were significantly elevated for all planned home births: 13.66 per 10,000 live births (242/177,156; odds ratio, 4.19; 95% confidence interval, 3.62-4.84; P<.0001) vs 3.27 per 10,000 live births for in-hospital Certified Nurse-Midwife-attended births (745/2,280,044; odds ratio, 1). These differences increased further when patients were stratified by recognized risk factors such as breech presentation, multiple gestations, nulliparity, advanced maternal age, and postterm pregnancy. Causes of the increased perinatal morbidity and mortality include deliveries of patients with increased risks, absence of standardized criteria to exclude high-risk deliveries, and that most midwives attending out-of-hospital births in the United States do not meet the gold standard for midwifery regulation, the International Confederation of Midwives' Global Standards for Midwifery Education. As part of the informed consent process, pregnant patients interested in out-of-hospital births should be informed of its increased perinatal risks. Hospital births should be supported for all patients, especially those with increased risks.

Birth Center Breastfeeding Rates: A Literature Review

INTRODUCTION

Breastfeeding rates in the United States fall short of national targets and are marked by racial and ethnic disparities. Birth centers are associated with high rates of breastfeeding initiation and duration, yet no systematic review has compiled reported birth center breastfeeding data.

METHODS

A PRISMA-guided literature review was conducted in CINAHL, PubMed, and Web of Science to retrieve quantitative studies that reported breastfeeding data in birth centers. Inclusion criteria focused on English language studies published since 2011 with breastfeeding outcomes from birth centers in the United States.

RESULTS

Ten studies were included for analysis. Breastfeeding rates that exceeded actual and target national breastfeeding rates were reported among all 10 studies. Characteristics about breastfeeding outcomes were reported heterogeneously across the studies, which included a range of breastfeeding timepoints (immediately postpartum up to 6 weeks postpartum) and definitions of breastfeeding.

DISCUSSION

Although breastfeeding rates reported in birth centers are higher than national breastfeeding rates and targets, authors of the included studies did not explore or analyze these rates in-depth. Developing standard definitions and data collection may enhance research about breastfeeding outcomes in birth centers.

CLINICAL IMPLICATIONS

Giving birth in a birth center is associated with higher than national breastfeeding rates.

Strong Start Innovation: Equitable Outcomes Across Public and Privately Insured Clients Receiving Birth Center Care

INTRODUCTION

The Birth Center model of care is a health care delivery innovation in its fourth decade of demonstration across the United States. The purpose of this research was to evaluate the model's potential for decreasing poverty-related health disparities among childbearing families.

METHODS

Between 2013 and 2017, 26,259 childbearing people received care within the 45 Center for Medicare and Medicaid Innovation Strong Start birth center sites. Secondary analysis of the prospective American Association of Birth Centers Perinatal Data Registry was conducted. Descriptive statistics described sociobehavioral, medical risk factors, and core clinical outcomes to inform the logistic regression model. Privately insured consumers were independently compared with 2 subgroups of Medicaid beneficiaries: Strong Start enrollees (midwifery-led care with peer counselors) and non-Strong Start Medicaid beneficiaries (midwifery-led care without peer counselors).

RESULTS

After controlling for medical risk factors, Strong Start Medicaid beneficiaries achieved similar outcomes to privately insured consumers with no significant differences in maternal or newborn outcomes between groups. Perinatal outcomes included induction of labor (adjusted odds ratio [aOR], 0.86; 95% CI 0.61-1.13), epidural analgesia use (aOR, 1.00; 95% CI, 0.68-1.48), cesarean birth (aOR, 1.16; 95% CI, 0.87-1.53), exclusive breastfeeding on discharge (aOR, 1.11; 95% CI, 0.48-2.56), low Apgar score at 5 minutes (aOR, 1.23; 95% CI, 0.86-1.83), low birth weight (aOR, 1.12; 95% CI, 0.77-1.64), and antepartum transfer of care after the first prenatal appointment (aOR, 1.53; 95% CI, 0.97-2.40). Medicaid beneficiaries who were not enrolled in the Strong Start midwifery-led, peer counselor program demonstrated similar results except for having higher epidural analgesia use (aOR, 1.30; 95% CI, 1.10-1.53) and significantly lower exclusive breastfeeding on discharge (aOR, 0.57; 95% CI, 0.40-0.81) than their privately insured counterparts.

DISCUSSION

The midwifery-led birth center model of care complemented by peer counselors demonstrated a pathway to achieve health equity.

Outcomes of Cannabis Use During Pregnancy Within the American Association of Birth Centers Perinatal Data Registry 2007-2020: Opportunities Within Midwifery-Led Care

BACKGROUND

Healthcare providers require data on associations between perinatal cannabis use and birth outcomes.

METHODS

This observational secondary analysis come from the largest perinatal data registry in the United States related to the midwifery-led birth center model care (American Association of Birth Centers Perinatal Data Registry; N = 19 286). Births are planned across all birth settings (home, birth center, hospital); care is provided by midwives and physicians.

RESULTS

Population data show that both early and persistent self-reports of cannabis use were associated with higher rates of preterm birth, low-birth-weight, lower 1-minute Apgar score, gestational weight gain, and postpartum hemorrhage. Once controlled for medical and social risk factors using logistic regression, differences for childbearing people disappeared except that the persistent use group was less likely to experience "no intrapartum complications" (adjusted odds ratio [aOR] = 0.49; 95% confidence interval [CI], 0.32-0.76; P < .01), more likely to experience an indeterminate fetal heart rate in labor (aOR = 3.218; 95% CI, 2.23-4.65; P < .05), chorioamnionitis (aOR = 2.8; 95% CI, 1.58-5.0; P < .01), low-birth-weight (aOR = 1.8; 95% CI, 1.08-3.05; P < .01), and neonatal intensive care unit (NICU) admission (aOR = 2.4; 95% CI, 1.30-4.69; P < .05).

CONCLUSIONS

Well-controlled data demonstrate that self-reports of persistent cannabis use through the third trimester are associated with an increased risk of low-birth-weight and NICU admission.

Place of Birth Preferences and Relationship to Maternal and Newborn Outcomes Within the American Association of Birth Centers Perinatal Data Registry, 2007-2020

PURPOSE

The purpose of this study was to describe sociodemographic variations in client preference for birthplace and relationships to perinatal health outcomes.

METHODS

Descriptive data analysis (raw number, percentages, and means) showed that preference for birthplace varied across racial and ethnic categories as well as sociodemographic categories including educational status, body mass index, payer status, marital status, and gravidity. A subsample of medically low-risk childbearing people, qualified for birth center admission in labor, was analyzed to assess variations in maternal and newborn outcomes by site of first admission in labor.

RESULTS

While overall clinical outcomes exceeded national benchmarks across all places of admission in the sample, disparities were noted including higher cesarean birth rates among Black and Hispanic people. This variation was larger within the population of people who preferred to be admitted to the hospital in labor in the absence of medical indication.

CONCLUSION

This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation.

We Are Not Asking Permission to Save Our Own Lives: Black-Led Birth Centers to Address Health Inequities

PURPOSE

While favorable outcomes of birth centers are documented, Black-led birth centers and maternal health models are rarely highlighted. Such disparities are manifestations of institutional racism. A nascent body of literature suggests that culturally affirming care provided by Black-led birth centers benefit all birthing people-regardless of race. Birth Detroit is one such maternal health model led by Black women that offers a justice response to inequitable care options in Black communities.

METHODS

This article describes a departure from traditional White supremacist research models that privilege quantitative outcomes to the exclusion of iterative processes, lived experiences, and consciousness-raising. A community organizing approach to birth center development led by Black women and rooted in equity values of safety, love, trust, and justice is outlined.

RESULTS

Birth Detroit is a Black-led, community-informed model that includes integration of evidence-based approaches to improving health outcomes and that embraces community midwifery prenatal care and a strategic trajectory to open a birth center in the city of Detroit.

CONCLUSION

Birth Detroit demonstrates the operationalization of a Black feminist standpoint, lifts up the power of communities to lead in their own care, and offers a blueprint for action to improve inequities and maternal-infant health in Black communities.

Salary and Workload of Midwives Across Birth Center Practice Types and State Regulatory Structures

INTRODUCTION

Expansion of the midwifery-led birth center model of care is one pathway to improving maternal and newborn health. There are a variety of practice types among birth centers and a range of state regulatory structures of midwifery practice across the United States. This study investigated how those variations relate to pay and workload for midwives at birth centers.

METHODS

Data from the American Association of Birth Centers Practice Survey and the Bureau of Labor Statistics' report on occupational employment and wage statistics were analyzed to explore how midwife salaries and workload at birth centers compare within and beyond the birth center model.

RESULTS

Survey results from 161 birth centers across the United States demonstrate wide variation in nurse-midwife salaries and are inconsistent with nurse-midwife salaries across all settings as reported by the Bureau of Labor Statistics. The reported number of hours worked by midwives within the birth center model is high. Salaries of midwives who work in birth center-only practices were consistently lower than salaries of midwives who worked in blended birth center and hospital practices, independent of the midwife's level of experience, geographic region of the country, and state regulatory structure.

DISCUSSION

Further research is needed to understand how to bring salaries and workload for midwives at birth centers into alignment with national averages.

Breastfeeding as a Quality Measure: Demonstrating Levers of the National Quality Strategy

The purpose of this study is to explore the National Quality Strategy (NQS) levers (measurement and feedback, public reporting, learning and technical assistance, and certification) on state and national breastfeeding performance. The research evaluates the NQS levers of measurement and feedback and public reporting using secondary data analysis of publicly reported data from the National Immunization Survey and the Centers for Disease Control and Prevention Breastfeeding Report Cards between 2008 and 2018, the latest years available. Linear regression explores the association between the prevalence of state-level Baby-Friendly hospitals and state-level breastfeeding rates. Subsequent analyses use event study to test whether state-level Baby-Friendly hospital adoption is associated with higher breastfeeding rates. A 10% increase in Baby-Friendly hospitals at the state level is associated with increased population breastfeeding rates by nearly 5% and a decrease in early formula use (before 2 days of life) by 2% to 9%. Breastfeeding increased by 2% to 5% in the first 2 years following state-level Baby-Friendly initiatives, with subsequent increases up to 10% in the next 4 years. The National Quality Strategy levers of measurement and public reporting combined with certification and learning and technical assistance are associated with increases in exclusive breastfeeding, a national quality metric.

Implementing an Evidence-Based Bundle to Reduce Early Labor Admissions and Increase Adherence to Labor Arrest Guidelines: A Quality Improvement Initiative

BACKGROUND

At many hospitals, the cesarean birth rate among nulliparous term singleton vertex (NTSV) pregnancies is higher than World Health Organization benchmarks. Reducing NTSV cesarean birth is a national quality imperative. The aim of this initiative was to implement an evidence-based bundle at an urban community teaching hospital in at least 50% of labors in 60 days in order to reduce early labor admissions and increase adherence to evidence-based labor management guidelines shown to decrease cesarean birth.

METHODS

Chart audits, root-cause analysis, and staff engagement informed bundle development. An early labor triage guide, labor walking path, partograph, and pre-cesarean checklist were implemented to drive change. Four Rapid Cycle Plan Do Study Act cycles were conducted over 8 weeks.

RESULTS

The bundle was implemented in 58% of births. The bundle reduced early labor admissions labor from 41% to 25%. Team knowledge reflecting current guidelines in labor management increased 35% and 100% of cesareans for labor arrest met criteria. Patient satisfaction scores exceeded 98%.

CONCLUSIONS

Implementing an evidenced-based bundle was effective in reducing early labor admissions and increasing utilization of and adherence to labor management guidelines.

IMPLICATIONS FOR NURSING

Implementation of evidence-based bundles has the potential to achieve meaningful quality improvements in maternity care.

Non-physiological and Physiological Delivery Method: Comparison of Maternal Attachment Behaviors and Anxiety

Introduction: Attachment is a stable connection or emotional knot between two individuals as one of the parties tries to maintain this connection. Delivery time as a turning point between two stages of attachment is very important. Methods: In a descriptive-analytical study based on specific inclusion criteria, 262 pregnant women were selected in the age range of 15-45 years old and the gestational age of 37 to 42 weeks who were candidates for physiological or non-physiological delivery. After obtaining written consent forms, the demographic information questionnaire was given to the participants. One hour after delivery, the attachment questionnaire was completed by the researcher in the postpartum ward. Also, the Spielberg anxiety inventory was completed up to 1 hour after delivery. Independent sample t test was used to compare the results between the two groups. Data were analyzed by SPSS software version 21. Results: The participants in the physiological delivery group showed more positive attachment behaviors in comparison with the other group. In all three dimensions of attachment (emotional, contiguous, and caring behavior), physiological delivery showed higher scores than the other group. Also in non-physiological delivery group, the participants had experienced higher levels of anxiety and the differences between the groups were not significant. Conclusion: Results of the current study indicated that mothers engaged in physiological delivery had higher scores in mother to child attachment behaviors. It means they are more successful than the non-physiological delivery group in getting attached to their babies.