Outcomes of Care in Birth Centers: Demonstration of a Durable Model

Listening to Black Women's Perspectives of Birth Centers and Midwifery Care: Advocacy, Protection, and Empowerment

INTRODUCTION

Black women in Texas experience high rates of adverse maternal outcomes that have been linked to health inequities and structural racism in the maternal care system. Birth centers and midwifery care are highlighted in the literature as contributing to improved perinatal care experiences and decreased adverse outcomes for Black women. However, compared with White women, Black women underuse birth centers and midwifery care. Black women's perceptions in Texas of birth center and midwifery care are underrepresented in research. Thus, this study aimed to highlight the views of Black women residing in Texas on birth centers and midwifery care to identify their needs and explore ways to increasing access to perinatal care.

METHODS

Semistructured interviews were conducted with 10 pregnant and postpartum Black women residing in Texas. Questions focused on the women's access, knowledge, and use of birth centers and midwifery care in the context of their lived maternal care experiences. Interview transcripts were reviewed and analyzed using inductive, qualitative content analysis.

RESULTS

The Black women interviewed all shared experiences of discrimination and bias while receiving obstetric care that affected their interest in and overall perceptions of birth center and midwifery care. Participants also discussed financial and institutional barriers that impacted their ease of access to birth center and midwifery care services. Additionally, participants highlighted the need for culturally sensitive and respectful perinatal health care.

DISCUSSION

The Black women interviewed in this study emphasized the prevalence of racism and discrimination in perinatal health care encounters, a reflection consistent with current literature. Black women also expressed a desire to use birth centers and midwifery care but identified the barriers in Texas that impede access. Study findings highlight the need to address barriers to promote equitable perinatal health care access for Black women.

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.

Race, ethnicity, and indications for primary cesarean birth: Associations within a national birth center registry

BACKGROUND

Racial and ethnic disparities in cesarean rates in the United States are well documented. This study investigated whether cesarean inequities persist in midwife-led birth center care, including for individuals with the lowest medical risk.

METHODS

National registry records of 174,230 childbearing people enrolled in care in 115 midwifery-led birth center practices between 2007 and 2022 were analyzed for primary cesarean rates and indications by race and ethnicity. The lowest medical risk subsample (n = 70,521) was analyzed for independent drivers of cesarean birth.

RESULTS

Primary cesarean rates among nulliparas (15.5%) and multiparas (5.7%) were low for all enrollees. Among nulliparas in the lowest-risk subsample, non-Latinx Black (aOR = 1.37; 95% CI, 1.15-1.63), Latinx (aOR = 1.51; 95% CI, 1.32-1.73), and Asian participants (aOR = 1.48; 95% CI, 1.19-1.85) remained at higher risk for primary cesarean than White participants. Among multiparas, only Black participants experienced a higher primary cesarean risk (aOR = 1.49; 95% CI, 1.02-2.18). Intrapartum transfers from birth centers were equivalent or lower for Black (14.0%, p = 0.345) and Latinx (12.7%, p < 0.001) enrollees. Black participants experienced a higher proportion of primary cesareans attributed to non-reassuring fetal status, regardless of risk factors. Place of admission was a stronger predictor of primary cesarean than race or ethnicity.

CONCLUSIONS

Place of first admission in labor was the strongest predictor of cesarean. Racism as a chronic stressor and a determinant of clinical decision-making reduces choice in birth settings and may increase cesarean rates. Research on components of birth settings that drive inequitable outcomes is warranted.

Perinatal Mental Health: The Need For Broader Understanding And Policies That Meet The Challenges

Perinatal mental health is gaining recognition as a key antecedent of adverse maternal and child outcomes as the United States experiences a maternal mortality and morbidity crisis. Recent policy efforts have attempted to mitigate adverse outcomes through legislation such as the Taskforce Recommending Improvements for Unaddressed Mental Perinatal and Postpartum Health (TRIUMPH) for New Moms Act of 2021 and postpartum coverage through Medicaid expansion. Even with progress, perinatal mental health policy continues to grapple with a basic truth: The United States lacks an overarching health care system capable of meeting the mental health care needs of perinatal people and their families.  Moreover, the burden of undiagnosed and untreated perinatal mental health challenges remains greatest among racially minoritized populations, such as Black, Asian, and multiracial people. A broader understanding of perinatal mental health is needed, grounded in the tenets of reproductive justice. From this perspective, we articulate specific policies to meet perinatal mental health challenges and promote thriving for birthing people and their families.

EMS Interventions during Planned Out-of-Hospital Births with a Midwife: A Retrospective Analysis over Four Years in the Polish Population

Planned out-of-hospital births, facilitated by highly skilled and experienced midwives, offer expectant parents a distinct opportunity to partake in a personalized, intimate, and empowering birth experience. Many parents opt for the care provided by midwives who specialize in supporting home births. This retrospective study is based on 41,335 EMS emergency calls to women in advanced pregnancy, of which 209 concerned home birth situations documenting obstetrical emergencies over four years (January 2018 to December 2022), of which 60 involved the assistance of a midwife. Data were obtained from the Polish Central System for Emergency Medical Services Missions Monitoring, encompassing all EMS interventions in pregnant women. The most frequent reason for emergency calls for obstetrical emergencies with the assistance of a midwife was a failure to separate the placenta or incomplete afterbirth (18 cases; 30%), followed by perinatal haemorrhage (12 cases; 20%) and deterioration of the newborn's condition (8 cases; 13%). Paramedic-staffed EMS teams conducted most interventions (43 cases; 72%), with only 17 (28%) involving the presence of a physician. Paramedics with extensive medical training and the ability to provide emergency care are in a unique position that allows them to play a pivotal role in supporting planned out-of-hospital births. The analysed data from 2018-2022 show that EMS deliveries in Poland are infrequent and typically uncomplicated. Continuing education, training, and adequate funding are required to ensure the EMS is ready to provide the best care. EMS medical records forms should be adapted to the specific aspects of care for pregnant patients and newborns.

The impact of transfer from an alongside midwifery unit to labor and delivery on birthing women: A qualitative study

OBJECTIVE

To explore laboring women's thoughts, feelings, and experiences of transferring from an Alongside Midwifery Unit or free-standing birth center to labor and delivery.

DESIGN

A qualitative online survey was used for this research.

SETTING

An Alongside Midwifery Unit in the southwestern United States.

PARTICIPANTS

Eight women over the age of eighteen who had transferred to labor and delivery from either the AMU or free-standing birth center.

FINDINGS

Five themes emerging from the women's transfer experiences. It was important for the women to maintain their physiologic birth ideals. The initiation of transfer, even a discussion, altered the atmosphere in the birthing room. Women experienced a range of emotions surrounding the transfer. The stories spoke to mourning the loss of physiologic birth experience. Some women expressed guilt about the potential effects on their infants. Post-birth women had realizations about their mental and physical capabilities and limitations.

KEY CONCLUSIONS

This pertinent study addressed the effect on women when a transfer needs to occur from an Alongside Midwifery Unit or free-standing Birth Center to the Labor and Delivery Unit. Regardless of the reason, a transfer affected all participants. The psychological impact can have significant consequences on mother and baby's wellbeing. Women need an opportunity to share their story. The fifth theme of learning about themselves mentally and physically is new and not identified in other studies.

IMPLICATIONS FOR PRACTICE

Clinical recommendations are proposed to improve understanding and integrate into one's mindset, care processes, and clinical practice. Post-birth care should continue for these women until they completely process and come to a resolution of their experience of transferring to labor and delivery.

Health outcomes and provider choice under full practice authority for certified nurse-midwives

Full practice authority grants non-physician providers the ability to manage patient care without physician oversight or direct collaboration. In this study, we consider whether full practice authority for certified nurse-midwives (CNMs/CMs) leads to changes in health outcomes or CNM/CM use. Using U.S. birth certificate and death certificate records over 2008-2019, we show that CNM/CM full practice authority led to little change in obstetric outcomes, maternal mortality, or neonatal mortality. Instead, full practice authority increases (reported) CNM/CM-attended deliveries by one percentage point while decreasing (reported) physician-attended births. We then explore the mechanisms behind the increase in CNM/CM-attended deliveries, demonstrating that the rise in CNM/CM-attended deliveries represents higher use of existing CNM/CMs and is not fully explainable by improved reporting of CNM/CM deliveries or changes in CNM/CM labor supply.

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 first alongside midwifery unit in Spain: A retrospective cohort study of maternal and neonatal outcomes

BACKGROUND

Midwife-led units have been shown to be safer and reduce interventions for women at low risk of complications at birth. In 2017, the first alongside birth center was opened in Spain. The aim of this study was to compare outcomes for women with uncomplicated pregnancies giving birth in the Midwife-led unit (MLU) and in the Obstetric unit (OU) of the same hospital.

METHODS

Retrospective cohort study comparing birth outcomes between low-risk women, depending on their planned place of birth. Data were analyzed with an intention-to-treat approach for women that gave birth between January 2018 and December 2020.

RESULTS

A total of 878 women were included in the study, 255 women chose to give birth in the MLU and 623 in the OU. Findings showed that women in the MLU were more likely to have a vaginal birth (91.4%) than in the OU (83.8%) (aOR 2.98 [95%CI 1.62-5.47]), less likely to have an instrumental delivery, 3.9% versus 11.2% (0.25 [0.11-0.55]), to use epidural analgesia, 19.6% versus 77.9% (0.15 [0.04-0.17]) and to have an episiotomy, 7.4% versus 15.4% (0.27 [0.14-0.53]). There were no differences in rates of postpartum hemorrhage, retained placenta, or adverse neonatal outcomes. Intrapartum and postpartum transfer rates from the MLU to the OU were 21.1% and 2.4%, respectively.

CONCLUSIONS

The high rate of obstetric interventions in Spain could be reduced by implementing midwife-led units across the whole system, without an increase in maternal or neonatal complications.

Midwife-led birthing centres in four countries: a case study

BACKGROUND

Midwives are essential providers of primary health care and can play a major role in the provision of health care that can save lives and improve sexual, reproductive, maternal, newborn and adolescent health outcomes. One way for midwives to deliver care is through midwife-led birth centres (MLBCs). Most of the evidence on MLBCs is from high-income countries but the opportunity for impact of MLBCs in low- and middle-income countries (LMICs) could be significant as this is where most maternal and newborn deaths occur. The aim of this study is to explore MLBCs in four low-to-middle income countries, specifically to understand what is needed for a successful MLBC.

METHODS

A descriptive case study design was employed in 4 sites in each of four countries: Bangladesh, Pakistan, South Africa and Uganda. We used an Appreciative Inquiry approach, informed by a network of care framework. Key informant interviews were conducted with 77 MLBC clients and 33 health service leaders and senior policymakers. Fifteen focus group discussions were used to collect data from 100 midwives and other MLBC staff.

RESULTS

Key enablers to a successful MLBC were: (i) having an effective financing model (ii) providing quality midwifery care that is recognised by the community (iii) having interdisciplinary and interfacility collaboration, coordination and functional referral systems, and (iv) ensuring supportive and enabling leadership and governance at all levels.

CONCLUSION

The findings of this study have significant implications for improving maternal and neonatal health outcomes, strengthening healthcare systems, and promoting the role of midwives in LMICs. Understanding factors for success can contribute to inform policies and decision making as well as design tailored maternal and newborn health programmes that can more effectively support midwives and respond to population needs. At an international level, it can contribute to shape guidelines and strengthen the midwifery profession in different settings.

Planned Out-of-Hospital Birth as a Risk Factor for Nonreceipt of Hepatitis B Immunization

BACKGROUND

The hepatitis B vaccine (HBV) is recommended at birth to prevent perinatal hepatitis B transmission; however, many newborns still do not receive HBV. The extent to which planned out-of-hospital births, which have increased over the past decade, are associated with nonreceipt of the HBV birth dose is unknown. The purpose of this study was to determine whether a planned out-of-hospital birth location is associated with the nonreceipt of the HBV birth dose.

METHODS

We performed a retrospective cohort study of all births from 2007 to 2019 recorded in the Colorado birth registry. χ2 analyses were used to compare maternal demographics by birth location. Univariate and multiple logistic regression were used to evaluate the association of birth location with nonreceipt of the HBV birth dose.

RESULTS

In total 1.5% of neonates born in freestanding birth centers and 0.1% of neonates born at a planned home birth received HBV compared to 76.3% of neonates born in a hospital location. After adjusting for confounders, this translated to a large increase in the odds of not receiving HBV compared to in-hospital births [freestanding birth center (aodds ratio (aOR): 172.98, 95% confidence interval (CI): 136.98-219.88); planned home birth (aOR: 502.05, 95% CI: 363.04-694.29)]. Additionally, older maternal age, White/non-Hispanic race and ethnicity, higher income, and private or no insurance were associated with nonreceipt of the HBV birth dose.

CONCLUSIONS

Planned out-of-hospital birth is a risk factor for nonreceipt of the HBV birth dose. As births in these locations become more common, targeted policies and education are warranted.

Prenatal care in US birth centers: Midwives' perceptions of contributors to birthing People's confidence in physiologic birth

OBJECTIVE

The purpose of this study was to describe US freestanding birth center models of prenatal care and to examine how the components of this care contribute to birthing people's confidence in their ability to have a physiologic birth.

DESIGN

This was a qualitative descriptive study utilizing semi-structured interviews with birth center midwives. Data were analyzed using thematic analysis, constant comparative method and consensus coding to ensure rigor.

SETTING AND PARTICIPANTS

Midwives from six urban and rural freestanding birth centers in a Midwestern US state were interviewed. Twelve birth center midwives participated.

FINDINGS

Six themes emerged: the birth center physical space and organization of care, dimensions of midwifery care within the birth center, continuity of care and seamless service, the empowered birthing person, physiologic birth as normative, and the hospital paradigm and US cultures of birth.

KEY CONCLUSIONS

We identified significant components of birth center models of prenatal care that midwives believe enhance birthing people's confidence for physiologic childbirth. These components may be considered for application to other settings and may improve perinatal care and outcomes.

American Midwifery Certification Board Certification Demographic and Employment Data, 2016 to 2020: The Certified Nurse-Midwife and Certified Midwife Workforce

INTRODUCTION

Expansion and diversification of the midwifery workforce is a federal strategy to address the maternal health crisis in the United States. Understanding characteristics of the current midwifery workforce is essential to creating approaches to its development. Certified nurse-midwives and certified midwives (CNMs/CMs) certified by the American Midwifery Certification Board (AMCB) constitute the largest portion of the US midwifery workforce. This article aims to describe the current midwifery workforce based on data collected from all AMCB-certified midwives at the time of certification.

METHODS

Midwife initial certificants and recertificants were administered an electronic survey about personal and practice characteristics at the time of certification by AMCB between 2016 and 2020 for administrative purposes. Given the standard 5-year certification cycle, every midwife certified during this period completed the survey once. The AMCB Research Committee conducted a secondary data analysis of deidentified data to describe the CNM/CM workforce.

RESULTS

In 2020 there were 12,997 CNMs/CMs in the United States. The workforce was largely White and female with an average age of 49. There has been a slow increase (15% to 21%) of initial certificants identifying as midwives of color. The proportion of CMs to all AMCB-certified midwives remained less than 2%. Physician-owned practices were the most common employer. Approximately 60% of midwives attend births, and hospitals were the most common birth setting. Over 10% of those certified to practice reported not working within the discipline of midwifery.

DISCUSSION

Targeted recruitment and retention of midwives must take into consideration not just expansion but dispersion, scope of practice, and diversification. The proportion of midwives attending births was lower than reported in previous years. Expansion of the CM credential and accessible educational pathways are 2 potential solutions to workforce growth. Developing strategies to retain those who are trained but not practicing presents an opportunity for workforce maintenance.

Challenges and lessons learned birthing during the COVID-19 pandemic: A scoping review

Background and Aims

The impact of the COVID-19 pandemic on the healthcare system facilitated a change in policies to redress the consequences of increased demand and fear of disease transmission. Restrictive measures throughout the healthcare system limiting access to accompanying partners of birthing people in addition to fears of contracting COVID-19, an increasing number of birthing people chose to have an out-of-hospital birth. Out-of-hospital births are not prevalent in the United States. However, in recent years the percentage of out-of-hospital births has been steadily increasing. COVID-19 was a novel virus imposing a unique birthing situation for millions of women, complicated by lack of integration and varied policies in the U.S.

Methods

To better understand the challenges of birthing people during the pandemic a scoping review was conducted to explore the literature during the first wave of the pandemic related to out-of-hospital births. The approach for this review made use of the methodology manual published by the Joanna Briggs Institute for scoping reviews. All manner of publications (i.e. peer-reviewed published articles, grey articles, conference proceedings, webinars, editorials, and textbook chapters) were included in the review.

Results

Articles retrieved from the database search yielded sixty-three articles, after duplicate removal forty-six records were available for screening. Articles were further excluded using the PRISMA process, yielding thirty-one remaining records. From the thirty-one records twelve themes emerged, which were collapsed into four meta-themes.

Conclusion

These meta-themes focused on (a) advocacy, (b) homebirth infrastructure, (c) support networks, and (d) uncertainty during the pandemic. COVID-19 has accelerated this movement to birthing at home and thought must be given to how the healthcare system is going to support and integrate this mode of birthing.

Examining respect, autonomy, and mistreatment in childbirth in the US: do provider type and place of birth matter?

BACKGROUND

Analyses of factors that determine quality of perinatal care consistently rely on clinical markers, while failing to assess experiential outcomes. Understanding how model of care and birth setting influence experiences of respect, autonomy, and decision making, is essential for comprehensive assessment of quality.

METHODS

We examined responses (n = 1771) to an online cross-sectional national survey capturing experiences of perinatal care in the United States. We used validated patient-oriented measures and scales to assess four domains of experience: (1) decision-making, (2) respect, (3) mistreatment, and (4) time spent during visits. We categorized the provider type and birth setting into three groups: midwife at community birth, midwife at hospital-birth, and physician at hospital-birth. For each group, we used multivariate logistic regression, adjusted for demographic and clinical characteristics, to estimate the odds of experiential outcomes in all the four domains.

RESULTS

Compared to those cared for by physicians in hospitals, individuals cared for by midwives in community settings had more than five times the odds of experiencing higher autonomy (aOR: 5.22, 95% CI: 3.65-7.45), higher respect (aOR: 5.39, 95% CI: 3.72-7.82) and lower odds of mistreatment (aOR: 0.16, 95% CI: 0.10-0.26). We found significant differences across birth settings: participants cared for by midwives in the community settings had significantly better experiential outcomes than those in the hospital settings: high- autonomy (aOR: 2.97, 95% CI: 2.66-4.27), respect (aOR: 4.15, 95% CI: 2.81-6.14), mistreatment (aOR: 0.20, 95% CI: 0.11-0.34), time spent (aOR: 8.06, 95% CI: 4.26-15.28).

CONCLUSION

Participants reported better experiential outcomes when cared for by midwives than by physicians. And for those receiving midwifery care, the quality of experiential outcomes was significantly higher in community settings than in hospital settings. Care settings matter and structures of hospital-based care may impair implementation of the person-centered midwifery care model.

The commitment to a midwifery centre care model in Bangladesh: An interview study with midwives, educators and students

BACKGROUND

Midwifery-led care is a key factor in reducing maternal and new-born mortality globally. In Bangladesh, only a third of births are attended by professionals and almost 70% of births occur outside healthcare facilities. Midwifery is a relatively new profession in Bangladesh and a midwifery centre care model has only recently been introduced. This study aims to explore the willingness within the healthcare system to support a greater role for midwifery centres in maternity services.

METHODS

Data were collected through individual semi-structured interviews with 55 midwives, midwifery educators and final year midwifery students. Two of the midwifery educators were principals of nursing institutes involved in the government's midwifery leadership and considered as experts in the midwifery care system. The data was analysed using qualitative content analysis. The transcribed interviews comprised 150 pages. The study received ethical approval from the Directorate General of Nursing and Midwifery in Bangladesh.

RESULTS

One main category emerged from the study: "The foundations of a midwifery centre care model need to be strengthened for the sustainable implementation of midwifery centres in Bangladesh to continue". Five additional categories were identified: 1) The midwifery centre care model is inaccessible for communities, 2) Striving for acceptable standards of care within a midwifery centre care model is not a priority 3) Respectful, woman-centred care is weak, 4) Community engagement with the midwifery centre care model is insufficient, and 5) The midwifery centre care model is not integrated into the healthcare system. These categories were supported by the identification of 11 sub-categories.

CONCLUSION

The willingness to commit to a midwifery centre care model is not yet in place in Bangladesh. Advocacy, information, and education about the benefits of normal birth assisted by professional midwives is needed at all levels of Bangladeshi society.

The natural pattern of birth timing and gestational age in the U.S. compared to England, and the Netherlands

OBJECTIVE

To examine cross-national differences in gestational age over time in the U.S. and across three wealthy countries in 2020 as well as examine patterns of birth timing by hour of the day in home and spontaneous vaginal hospital births in the three countries.

METHODS

We did a comparative cohort analysis with data on gestational age and the timing of birth from the United States, England and the Netherlands, comparing hospital and home births. For overall gestational age comparisons, we drew on national birth cohorts from the U.S. (1990, 2014 & 2020), the Netherlands (2014 & 2020) and England (2020). Birth timing data was drawn from national data from the U.S. (2014 & 2020), the Netherlands (2014) and from a large representative sample from England (2008-10). We compared timing of births by hour of the day in hospital and home births in all three countries.

RESULTS

The U.S. overall mean gestational age distribution, based on last menstrual period, decreased by more than half a week between 1990 (39.1 weeks) and 2020 (38.5 weeks). The 2020 U.S. gestational age distribution (76% births prior to 40 weeks) was distinct from England (60%) and the Netherlands (56%). The gestational age distribution and timing of home births was comparable in the three countries. Home births peaked in early morning between 2:00 am and 5:00 am. In England and the Netherlands, hospital spontaneous vaginal births showed a generally similar timing pattern to home births. In the U.S., the pattern was reversed with a prolonged peak of spontaneous vaginal hospital births between 8:00 am to 5:00 pm.

CONCLUSIONS

The findings suggest organizational priorities can potentially disturb natural patterns of gestation and birth timing with a potential to improve U.S. perinatal outcomes with organizational models that more closely resemble those of England and the Netherlands.

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.

Strengthening Interprofessional Collaboration to Improve Transfers Between a Freestanding Birth Center and an Academic Medical Center

The number of individuals choosing to give birth in a freestanding birth center has doubled since 2004. As many as half of all pregnant persons planning for a birth center birth ultimately develop medical complications and are unable to give birth outside of the hospital. Integrating birth centers into their regional perinatal health care system optimizes outcomes by establishing predetermined pathways for antepartum and intrapartum transfers of care and facilitates ongoing communication and cooperation among clinicians. The Vanderbilt Birth Center is a freestanding birth center that is operated by an academic medical center and partners with a hospital-based midwifery practice that cares for patients transferring from the birth center. Since the inception of the birth center in 2015, the entire perinatal team has worked to improve the process and experience of patient transfer from birth center to hospital care. This article will present strategies implemented through the ongoing collaboration between birth center and hospital health care providers. These include adopting a shared electronic health record, clinical practice guidelines that align across birth sites, preparing birth center patients prenatally for the possibility hospital transfer, the presentation of a united team across birth sites, clear and widely disseminated communication pathways for hospital admission and patient handoff, and ongoing opportunities for interteam communication, collaboration, and education. These strategies may benefit similar midwifery practice models as they seek to partner with larger health care systems and improve the transfer experience for their patients.

Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration

India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.

Adoption of Consensus Guidelines for Safe Prevention of the Primary Cesarean Delivery by Freestanding Birth Centers

INTRODUCTION

Slow or arrested progress in labor is the most frequent (64%) indication for nonemergent transfer of laboring people from freestanding birth centers to the hospital. After the 2014 publication of the Consensus Statement on Safe Prevention of Primary Cesarean Delivery (Consensus Statement), many freestanding birth centers changed their clinical practice guidelines to allow more time for active labor in the birth center prior to hospital transfer. The result of these changes has not been evaluated in birth centers. Evaluation of adoption of guidelines based on the Consensus Statement in hospitals has shown inconsistent results.

METHODS

Birth centers were contacted to determine whether they changed clinical practice guidelines in response to the Consensus Statement. A before-after analysis compared outcomes for the 2 calendar years before and the 2 calendar years after adoption of new guidelines with a retrospective analysis of deidentified client-level data collected in the American Association of Birth Centers Perinatal Data Registry.

RESULTS

A third of responding birth centers (11 of 33) changed their clinical practice guidelines, mostly redefining the onset of active labor as beginning at 6 cm cervical dilatation and allowing 4 hours of arrest of dilatation in active labor before transfer to the hospital. These changes were associated with fewer diagnoses of prolonged first stage of labor (13.8% vs 8.0%, P < .01) but not with fewer intrapartum transfers (14.0% vs 14.7%, P = .55) or cesarean births (5.0 vs 4.1%, P = .26.) DISCUSSION: We found no evidence that making these practice changes was associated with better outcomes. Two hours of a lack of documented cervical change in active labor is likely long enough to diagnose arrested progress in labor. Research on proportion of morbidity and mortality associated with prolonged labor could inform practice guidelines for transfers.

The Impact of Culturally-Centered Care on Peripartum Experiences of Autonomy and Respect in Community Birth Centers: A Comparative Study

OBJECTIVE

National studies report that birth center care is associated with reduced racial and ethnic disparities and reduced experiences of mistreatment. In the US, there are very few BIPOC-owned birth centers. This study examines the impact of culturally-centered care delivered at Roots, a Black-owned birth center, on the experience of client autonomy and respect.

METHODS

To investigate if there was an association between experiences of autonomy and respect for Roots versus the national Giving Voice to Mothers (GVtM) participants, we applied Wilcoxon rank-sum tests for the overall sample and stratified by race.

RESULTS

Among BIPOC clients in the national GVtM sample and the Roots sample, MADM and MORi scores were statistically higher for clients receiving culturally-centered care at Roots (MADM p < 0.001, MORi p = 0.011). No statistical significance was found in scores between BIPOC and white clients at Roots Birth Center, however there was a tighter range among BIPOC individuals receiving care at Roots showing less variance in their experience of care.

CONCLUSIONS FOR PRACTICE

Our study confirms previous findings suggesting that giving birth at a community birth center is protective against experiences of discrimination when compared to care in the dominant, hospital-based system. Culturally-centered care might enhance the experience of perinatal care even further, by decreasing variance in BIPOC experience of autonomy and respect. Policies on maternal health care reimbursement should add focus on making community birth sustainable, especially for BIPOC provider-owners offering culturally-centered care.

A Qualitative Study of US Women's Perspectives on Confidence for Physiologic Birth in the Birth Center Model of Prenatal Care

INTRODUCTION

The purpose of this study was to increase understanding of the components of the US birth center model of prenatal care and how the birth center prenatal care model contributes to birthing people's confidence for physiologic childbirth.

METHODS

This was a qualitative descriptive study using semistructured interviews with individuals who gave birth in freestanding birth centers. Birthing people were recruited from freestanding birth centers in a Midwestern US state and were between the ages of 18 and 42, were English-speaking, and had experienced a birth center birth within the previous 6 months. Interviews were transcribed and analyzed using Glaser's constant comparative method.

RESULTS

Twelve women who gave birth in birth centers, representing urban and rural settings, participated. Four core categories were identified encompassing the components of birth center prenatal care and how the birth center model contributes to women's confidence for physiologic birth: birth center culture and processes, midwifery model of care within the birth center, internal influences, and outside influences.

DISCUSSION

Women who gave birth in birth centers believed that the birth center culture and environment, the midwifery model of care in the birth center, internal influences including the belief that birth is a normal physiologic process, and outside influences including family support and positive birth stories contributed to their confidence for physiologic birth.

Associations between Place of Birth, Type of Attendant, and Small for Gestational Age Births among Pregnant non-Hispanic Black Medicaid Recipients

INTRODUCTION

Although non-Hispanic Black women have increased risks of adverse birth outcomes compared with non-Hispanic white women in the United States, there is a lack of research specifically focusing on non-Hispanic Black women. Thus, this study's purpose was to evaluate whether place of birth and type of attendant used during labor is associated with having a newborn born small for gestational age (SGA) among non-Hispanic Black Medicaid recipients.

METHODS

This study used 2017 Natality data from the National Vital Statistics System for non-Hispanic Black women who used Medicaid as a source of payment (N = 322,604). Type of attendant (ie, the medical professional who assisted during childbirth), place of birth (ie, setting where the woman gave birth), maternal factors, and SGA were obtained from birth certificates. We used multivariate logistic regression to investigate the association between place of birth, type of birth attendant, and newborns born SGA.

RESULTS

After adjustment, women who used a certified nurse-midwife or other midwife as an attendant during labor had statistically significant decreased odds of having a neonate born SGA compared with those who had a physician as an attendant (odds ratio [OR], 0.69; 95% CI, 0.66-0.71 and OR, 0.68; 95% CI, 0.55-0.85, respectively). Those who gave birth in a birthing center or had planned home births also had statistically significant decreased odds of having a neonate born SGA (OR, 0.52; 95% CI, 0.38-0.69 and OR, 0.37; 95% CI, 0.21-0.66, respectively). However, those who had an unplanned home birth had twice the odds of having a neonate born SGA compared with those who gave birth at a hospital or clinic (OR, 2.00; 95% CI, 1.50-2.64).

DISCUSSION

Given the racial disparity in adverse birth outcomes for non-Hispanic Black women, the observed associations provide justification for future research to determine whether birthing location and birth attendant are related to SGA.

Associations between prolonged second stage of labor and maternal and neonatal outcomes in freestanding birth centers: a retrospective analysis

BACKGROUND

Current guidelines for second stage management do not provide guidance for community birth providers about when best to transfer women to hospital care for prolonged second stage. Our goal was to increase the evidence base for these providers by: 1) describing the lengths of second stage labor in freestanding birth centers, and 2) determining whether proportions of postpartum women and newborns experiencing complications change as length of second stage labor increases.

METHODS

This study is a retrospective analysis of de-identified client-level data collected in the American Association of Birth Centers Perinatal Data Registry, including women giving birth in freestanding birth centers January 1, 2007 to December 31, 2016. We plotted proportions of postpartum women and newborns transferred to hospital care against length of the second stage of labor, and assessed significance of these with the Cochran-Armitage test for trend or chi-square test. Secondary maternal and newborn outcomes were compared for dyads with normal and prolonged second stages of labor using Fisher's exact test.

RESULTS

Second stage labor exceeded 3 hours for 2.3% of primiparous women and 2 hours for 6.6% of multiparous women. Newborn transfers increased as second stage increased from < 15 minutes to > 2 hours (0.6% to 6.33%, p for trend = 0.0008, for primiparous women, and 1.4% to 10.6%, p for trend < 0.0001, for multiparous women.) Postpartum transfers for multiparous women increased from 1.4% after second stage < 15 minutes to greater than 4% for women after second stage exceeding 2 hours (p for trend < 0.0001.) CONCLUSIONS: Complications requiring hospitalization of postpartum women and newborns become more common as the length of the second stage increases. Birth center guidelines should consider not just presence of progress but also absolute length of time as indications for transfer.

Neonatal outcomes of births in freestanding birth centers and hospitals in the United States, 2016-2019

BACKGROUND

Births in freestanding birth centers have more than doubled between 2007 and 2019. Although birthing centers, which are defined by the American College of Obstetricians and Gynecologists as ". . . freestanding facilities that are not hospitals," are being promoted as offering women fewer interventions than hospitals, there are limited recent data available on neonatal outcomes in these settings.

OBJECTIVE

To compare several important measures of neonatal safety between 2 United States birth settings and birth attendants: deliveries in freestanding birth centers and hospital deliveries by midwives and physicians.

STUDY DESIGN

This is a retrospective cohort study using the United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, and Division of Vital Statistics natality online database for the years 2016 to 2019. All term, singleton, low-risk births were eligible for inclusion. The study outcomes were several neonatal outcomes including neonatal death, neonatal seizures, 5-minute Apgar scores of <4 and <7, and neonatal death in nulliparous and in multiparous women. Outcomes were compared between the following 3 groups: births in freestanding birth centers, in-hospital births by a physician, and in-hospital births by a midwife. The prevalence of each neonatal outcome among the different groups was compared using Pearson chi-squared test, with the in-hospital midwife births being the reference group. Multivariate logistic regression models were performed to account for several potential confounding factors such as maternal prepregnancy body mass index, maternal weight gain, parity, gestational weeks, and neonatal birthweight and calculated as adjusted odds ratio.

RESULTS

The study population consisted of 9,894,978 births; 8,689,467 births (87.82%) were in-hospital births by MDs and DOs, 1,131,398 (11.43%) were in-hospital births by midwives, and 74,113 (0.75%) were births in freestanding birth centers. Freestanding birth center deliveries were less likely to be to non-Hispanic Black or Hispanic, less likely to women with public insurance, less likely to be women with their first pregnancy, and more likely to be women with advanced education and to have pregnancies at ≥40 weeks' gestation. Births in freestanding birth center had a 4-fold increase in neonatal deaths (3.64 vs 0.95 per 10,000 births: adjusted odds ratio, 4.00; 95% confidence interval, 2.62-6.1), a more than 7-fold increase in neonatal deaths for nulliparous patients (6.8 vs 0.92 per 10,000 births: adjusted odds ratio, 7.7; 95% confidence interval, 4.42-13.76), a more than 2-fold increase in neonatal seizures (3.91 vs 1.94 per 10,000 births: adjusted odds ratio, 2.19; 95% confidence interval, 1.48-3.22), and a more than 7-fold increase of a 5-minute Apgar score of <4 (194.84 vs 28.5 per 10,000 births: adjusted odds ratio, 7.46; 95% confidence interval, 7-7.95). Compared with hospital midwife deliveries, hospital physician deliveries had significantly higher adverse neonatal outcomes (P<0.001).

CONCLUSION

Births in United States freestanding birth centers are associated with an increased risk of adverse neonatal outcomes such as neonatal deaths, seizures, and low 5-minute Apgar scores. Therefore, when counseling women about the location of birth, it should be conveyed that births in freestanding birth centers are not among the safest birth settings for neonates compared with hospital births attended by either midwives or physicians.

Freestanding Birth Centers: An Evidence-Based Option for Birth

Every childbearing person has the right to learn about all options for perinatal care provider and birth setting. To ensure an informed decision about their preferred birth plan, information should be provided either preconceptionally or in early pregnancy. Personal preferences and risk status should be considered in decision-making. Numbers of births in birth centers have doubled over past decade to almost 20,000 births per year. The evidence shows that childbearing people who participate in birth center care, even if they have only birth center prenatal care, experience better outcomes including lower rates of preterm birth, low birth weight births, and cesarean birth, and higher rates of breastfeeding when compared to people with similar risk profiles who receive typical perinatal care.

Maternal and neonatal outcomes following waterbirth: a cohort study of 17 530 waterbirths and 17 530 propensity score-matched land births

OBJECTIVE

Investigate maternal and neonatal outcomes following waterbirth.

DESIGN

Retrospective cohort study, with propensity score matching to address confounding.

SETTING

Community births, United States.

SAMPLE

Medical records-based registry data from low-risk births were used to create waterbirth and land birth groups (n = 17 530 each), propensity score-matched on >80 demographic and pregnancy risk covariables.

METHODS

Logistic regression models compared outcomes between the matched waterbirth and land birth groups.

MAIN OUTCOME MEASURES

Maternal: immediate postpartum transfer to a hospital, any genital tract trauma, severe (3rd/4th degree) trauma, haemorrhage >1000 mL, diagnosed haemorrhage regardless of estimated blood loss, uterine infection, uterine infection requiring hospitalisation, any hospitalisation in the first 6 weeks. Neonatal: umbilical cord avulsion; immediate neonatal transfer to a hospital; respiratory distress syndrome; any hospitalisation, neonatal intensive care unit (NICU) admission, or neonatal infection in the first 6 weeks; and neonatal death.

RESULTS

Waterbirth was associated with improved or no difference in outcomes for most measures, including neonatal death (adjusted odds ratio [aOR] 0.56, 95% CI 0.31-1.0), and maternal or neonatal hospitalisation in the first 6 weeks (aOR 0.87, 95% CI 0.81-0.92 and aOR 0.95, 95% CI 0.90-0.99, respectively). Increased morbidity in the waterbirth group was observed for two outcomes only: uterine infection (aOR 1.25, 95% CI 1.05-1.48) (but not hospitalisation for infection) and umbilical cord avulsion (aOR 1.57, 95% CI 1.37-1.82). Our results are concordant with other studies: waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim.

TWEETABLE ABSTRACT

New study demonstrates #waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim. @TheUpliftLab @BovbjergMarit @31415926abc @NICHD_NIH.

Birth Outcomes for Planned Home and Licensed Freestanding Birth Center Births in Washington State

OBJECTIVE

To describe rates of maternal and perinatal birth outcomes for community births and to compare outcomes by planned place of birth (home vs state-licensed, freestanding birth center) in a Washington State birth cohort, where midwifery practice and integration mirrors international settings.

METHODS

We conducted a retrospective cohort study including all births attended by members of a statewide midwifery professional association that were within professional association guidelines and met eligibility criteria for planned birth center birth (term gestation, singleton, vertex fetus with no known fluid abnormalities at term, no prior cesarean birth, no hypertensive disorders, no prepregnancy diabetes), from January 1, 2015 through June 30, 2020. Outcome rates were calculated for all planned community births in the cohort. Estimated relative risks were calculated comparing delivery and perinatal outcomes for planned births at home to state-licensed birth centers, adjusted for parity and other confounders.

RESULTS

The study population included 10,609 births: 40.9% planned home and 59.1% planned birth center births. Intrapartum transfers to hospital were more frequent among nulliparous individuals (30.5%; 95% CI 29.2-31.9) than multiparous individuals (4.2%; 95% CI 3.6-4.6). The cesarean delivery rate was 11.4% (95% CI 10.2-12.3) in nulliparous individuals and 0.87% (95% CI 0.7-1.1) in multiparous individuals. The perinatal mortality rate after the onset of labor (intrapartum and neonatal deaths through 7 days) was 0.57 (95% CI 0.19-1.04) per 1,000 births. Rates for other adverse outcomes were also low. Compared with planned birth center births, planned home births had similar risks in crude and adjusted analyses.

CONCLUSION

Rates of adverse outcomes for this cohort in a U.S. state with well-established and integrated community midwifery were low overall. Birth outcomes were similar for births planned at home or at a state-licensed, freestanding birth center.

The Cost of Home Birth in the United States

Policy decisions about the accessibility of home birth hinge on questions of safety and affordability. Families consider safety and cost along with the comfort and familiarity of birthing venues. A substantial literature addresses safety concerns, generally reporting that for low-risk mothers in the care of credentialed midwives, the safety of planned home births is comparable to that in birth centers and hospitals. The lack of notable safety tradeoffs for low-risk mothers elevates the relevance of the economic efficiency of home births. The available cost figures for home births are largely out of date or anecdotal. The purpose of this research is to offer scholars, policymakers, and families improved estimates of both the cost of home births and the potential savings from greater access to home births. On the basis of a nationwide study, we estimate that the average cost of a home birth in the United States is USD 4650, which is significantly below existing cost estimates for an uncomplicated birth center or hospital birth. Further, we find that each shift of one percent of births from hospitals to homes would represent an annual cost savings to society of at least USD 321 million.

Organizational strategies to optimize women's safety during labor and birth: A scoping review

BACKGROUND

Safety is a priority for organizations that provide maternity care, however, preventable harm and errors in maternity care remain. Maternity care is considered a high risk and high litigation area of health care. To mitigate risk and litigation, organizations have implemented strategies to optimize women's safety. Our objectives were to identify the strategies implemented by organizations to optimize women's safety during labor and birth, and to consider how the concept of safety is operationalized to measure and evaluate outcomes of these strategies.

METHOD

This scoping review was conducted using the Joanna Briggs Institute Scoping Review Methodology. Published peer-reviewed literature indexed in CINAHL, Medline, and Embase, databases from 2010 to 2020, were reviewed for inclusion. Fifty studies were included. Data were extracted and thematically analyzed.

RESULTS

Three categories of organizational strategies were identified to optimize women's safety during labor and birth: clinical governance, models of care, and staff education. Clinical governance programs (n = 30 studies), specifically implementing checklists and audits, models of care, such as midwifery led-care (n = 11 studies), and staff training programs (n = 9 studies), were predominately for the management of obstetric emergencies. Outcome measures included morbidity and mortality for woman and newborns. Three studies discussed women's perceptions of safety during labor and birth as an outcome measure.

CONCLUSIONS

Organizations utilize a range of strategies to optimize women's safety during labor and birth. The main outcome measure used to evaluate strategies was focused on clinical outcomes for the mother and newborn.

Pivoting to Childbirth at Home or in Freestanding Birth Centers in the US During COVID-19: Safety, Economics and Logistics

Birth-related decisions principally center on safety; giving birth during a pandemic brings safety challenges to a new level, especially when choosing the birth setting. Amid the COVID-19 crisis, the concurrent work furloughs, business failures, and mounting public and private debt have made prudent expenditures an inescapable second concern. This article examines the intersections of safety, economic efficiency, insurance, liability and birthing persons' needs that have become critical as the pandemic has ravaged bodies and economies around the world. Those interests, and the challenges and solutions discussed in this article, remain important even in less troubled times. Our economic analysis suggests that having an additional 10% of deliveries take place in private homes or freestanding birth centers could save almost $11 billion per year in the United States without compromising safety.

Exploring Why Birth Center Clients Choose Hospitalization for Labor and Birth

OBJECTIVE

To identify demographic and clinical factors associated with birth center clients electing hospitalization for labor and birth and to explore the timing and rationale for elective hospitalization via health records.

DESIGN

A secondary analysis of multiyear data from a quality assurance project at a single birth center. We compared two subsamples-birth center preference group and hospital preference group-and described the apparent rationale for transfers among clients in the latter group.

SETTING

A single freestanding birth center where all midwives have admitting privileges at a local hospital and can accompany labor transfers.

PARTICIPANTS

All cases included in the analytic sample represent women with low-risk pregnancies who were eligible for birth center birth. The birth center preference group represents clients planning to give birth at the center, and the hospital preference group consists of clients who elected for hospitalization.

MEASUREMENTS

Relevant demographic and clinical information was provided for the entire analytic sample and was matched with available data collected systematically by birth center staff via chart review. The data set also included anonymous responses to an e-mailed questionnaire from clients identified by birth center staff.

RESULTS

Approximately 56.1% (N = 1,155) of the cases in the data set were eligible for comparative analysis. The birth center preference and hospital preference groups included 899 (77.8%) and 256 (22.2%) individuals, respectively. In the hospital preference group, Black clients (n = 23), those who were publicly insured (n = 49), and primiparas (n = 101) were significantly overrepresented. Chart review data and questionnaire responses highlighted insurance restrictions, family preferences, pain relief options, and postpartum care as influential factors among members of the hospital preference subsample.

CONCLUSION

The present analysis shows associations between certain individual characteristics and elective hospitalization during labor for birth center clients. Health record data and questionnaire responses indicated a variety of reasons for electing hospitalization, illustrating the complexity of clients' decision-making during pregnancy and birth.

The Impacts of COVID-19 on US Maternity Care Practices: A Followup Study

This article extends the findings of a rapid response article researched in April 2020 to illustrate how providers' practices and attitudes toward COVID-19 had shifted in response to better evidence, increased experience, and improved guidance on how SARS-CoV-2 and COVID-19 impacted maternity care in the United States. This article is based on a review of current labor and delivery guidelines in relation to SARS-CoV-2 and COVID-19, and on an email survey of 28 community-based and hospital-based maternity care providers in the United State, who discuss their experiences and clients' needs in response to a rapidly shifting landscape of maternity care during the COVID-19 pandemic. One-third of our respondents are obstetricians, while the other two-thirds include midwives, doulas, and labor and delivery nurses. We present these providers' frustrations and coping mechanisms in shifting their practices in relation to COVID-19. The primary lessons learned relate to improved testing and accessing PPE for providers and clients; the need for better integration between community- and hospital-based providers; and changes in restrictive protocols concerning labor support persons, rooming-in with newborns, immediate skin-to-skin contact, and breastfeeding. We conclude by suggesting that the COVID-19 pandemic offers a transformational moment to shift maternity care in the United States toward a more integrated and sustainable model that might improve provider and maternal experiences as well as maternal and newborn outcomes.

The COVID-19 pandemic: A focusing event to promote community midwifery policies in the United States

The COVID-19 pandemic has placed unprecedented stress on health care systems across the globe. This stress has altered prenatal, labor, delivery, and postpartum care in the U.S., motivating many pregnant people to seek maternal health care with community midwives in a home or freestanding birth center setting. Although the dominant maternal health care providers across the globe, community midwives work on the margins of the U.S. health care system, in large part due to policy restrictions. This commentary extends previous research to theorize that the COVID-19-related disrupted health care system and the heightened visibility of community midwives may create a "focusing event," or policy window, which may enable midwives and their advocates to shift policy.

Birth Outcomes of Women with Obesity Enrolled for Care at Freestanding Birth Centers in the United States

Introduction

Current US guidelines for the care of women with obesity generalize obesity‐related risks to all women regardless of overall health status and assume that birth will occur in hospitals. Perinatal outcomes for women with obesity in US freestanding birth centers need documentation.

Methods

Pregnancies recorded in the American Association of Birth Centers Perinatal Data Registry were analyzed (n = 4,455) to form 2 groups of primiparous women (n = 964; 1:1 matching of women with normal body mass indices [BMIs] and women with obese BMIs [>30]), using propensity score matching to address the imbalance of potential confounders. Groups were compared on a range of outcomes. Differences between groups were evaluated using χ² test for categorical variables and Student's t test for continuous variables. Paired t test and McNemar's test evaluated the differences among the matched pairs.

Results

The majority of women with obese BMIs experienced uncomplicated perinatal courses and vaginal births. There were no significant differences in antenatal complications, proportion of prolonged pregnancy, prolonged first and second stage labor, rupture of membranes longer than 24 hours, postpartum hemorrhage, or newborn outcomes between women with obese BMIs and normal BMIs. Among all women with intrapartum referrals or transfers (25.3%), the primary indications were prolonged first stage or second stage (55.4%), inadequate pain relief (14.8%), client choice or psychological issue (7.0%), and meconium (5.3%). Primiparous women with obesity who started labor at a birth center had a 30.7% transfer rate and an 11.1% cesarean birth rate.

Discussion

Women with obese BMIs without medical comorbidity can receive safe and effective midwifery care at freestanding birth centers while anticipating a low risk for cesarean birth. The risks of potential, obesity‐related perinatal complications should be discussed with women when choosing place of birth; however, pregnancy complicated by obesity must be viewed holistically, not simply through the lens of obesity.

Client Experience with the Ontario Birth Center Demonstration Project

INTRODUCTION

In 2014, 2 new freestanding midwifery-led birth centers opened in Ontario, Canada. As one part of a larger mixed-methods evaluation of the first year of operations of the centers, our primary objective was to compare the experiences of women receiving midwifery care who intended to give birth at the new birth centers with those intending to give birth at home or in hospital.

METHODS

We conducted a cross-sectional survey of women cared for by midwives with admitting privileges at one of the 2 birth centers. Consenting women received the survey 3 to 6 weeks after their due date. We stratified the analysis by intended place of birth at the beginning of labor, regardless of where the actual birth occurred. One composite indicator was created (Composite Satisfaction Score, out of 20), and statistical significance (P < .05) was assessed using one-way analysis of variance. Responses to the open-ended questions were reviewed and grouped into broader categories.

RESULTS

In total, 382 women completed the survey (response rate 54.6%). Half intended to give birth at a birth center (n = 191). There was a significant difference on the Composite Satisfaction Scores between the birth center (19.4), home (19.5), and hospital (18.9) groups (P < .001). Among women who intended to give birth in a birth center, scores were higher in the women admitted to the birth center compared with those who were not (P = .037). Overall, women giving birth at a birth center were satisfied with the learners present at their birth, the accessibility of the centers, and the physical amenities, and they had suggestions for minor improvements.

DISCUSSION

We found positive experiences and high satisfaction among women receiving midwifery care, regardless of intended place of birth. Women admitted to the birth centers had positive experiences with these new centers; however, future research should be planned to reassess and further understand women's experiences.

Midwifery and Birth Centers Under State Medicaid Programs: Current Limits to Beneficiary Access to a High-Value Model of Care

Policy Points Birth center services must be covered under Medicaid per federal mandate, but reimbursement and other policy barriers prevent birth centers from serving more Medicaid patients. Midwifery care provided through birth centers improves maternal and infant outcomes and lowers costs for Medicaid beneficiaries. Birth centers offer an array of birth options and have resources to care for patients with medical and psychosocial risks. Addressing the barriers identified in this study would promote birth centers' participation in Medicaid, leading to better outcomes for Medicaid-covered mothers and newborns and significant savings for the Medicaid program.

CONTEXT

Midwifery care, particularly when offered through birth centers, has shown promise in both improving pregnancy outcomes and containing costs. The national evaluation of Strong Start for Mothers and Newborns II, an initiative that tested enhanced prenatal care models for Medicaid beneficiaries, found that women receiving prenatal care at Strong Start birth centers experienced superior birth outcomes compared to matched and adjusted counterparts in typical Medicaid care. We use qualitative evaluation data to investigate birth centers' experiences participating in Medicaid, and identify policies that influence Medicaid beneficiaries' access to midwives and birth centers.

METHODS

We analyzed data from more than 200 key informant interviews and 40 focus groups conducted during four case study rounds; a phone-based survey of Medicaid officials in Strong Start states; and an Internet-based survey of birth center sites. We identified themes related to access to midwives and birth centers, focusing on influential Medicaid policies.

FINDINGS

Medicaid beneficiaries chose birth center care because they preferred midwife providers, wanted a more natural birth experience, or in some cases sought certain pain relief methods or birth procedures not available at hospitals. However, Medicaid enrollees currently have less access to birth centers than privately insured women. Many birth centers have difficulty contracting with managed care organizations and participating in Medicaid value-based delivery system reforms, and birth center reimbursement rates are sometimes too low to cover the actual cost of care. Some birth centers significantly limit Medicaid business because of low reimbursement rates and threats to facility sustainability.

CONCLUSIONS

Medicaid beneficiaries do not have the same access to maternity care providers and birth settings as their privately insured counterparts. Medicaid policy barriers prevent some birth centers from serving more Medicaid patients, or threaten the financial sustainability of centers. By addressing these barriers, more Medicaid beneficiaries could access care that is associated with positive birth outcomes for mothers and newborns, and the Medicaid program could reap significant savings.

Rural resilience: The role of birth centers in the United States

PURPOSE

To explore the role of the birth center model of care in rural health and maternity care delivery in the United States.

METHODS

All childbearing families enrolled in care at an American Association of Birth Centers Perinatal Data Registry^TM user sites between 2012 and 2020 are included in this descriptive analysis.

FINDINGS

Between 2012 and 2020, 88 574 childbearing families enrolled in care with 82 American Association of Birth Centers Perinatal Data Registry^TM user sites. Quality outcomes exceeded national benchmarks across all geographic regions in both rural and urban settings. A stable and predictable rate of transfer to a higher level of care was demonstrated across geographic regions, with over half of the population remaining appropriate for birth center level of care throughout the perinatal episode of care. Controlling for socio demographic and medical risk factors, outcomes were as favorable for clients in rural areas compared with urban and suburban communities.

CONCLUSIONS

Rural populations cared for within the birth center model of care experienced high-quality outcomes.

HEALTH POLICY IMPLICATIONS

A major focus of the United States maternity care reform should be the expansion of access to birth center models of care, especially in underserved areas such as rural communities.

Birth and the Big Bad Wolf: Biocultural Evolution and Human Childbirth, Part 2

In Part 2 of this two-part article, we further employ the lens of evolutionary medicine to explore similarities in premodern biocultural features of birth, arguing that these were an outgrowth of our common evolutionary heritage as bipedal primates. These practices grew out of the empiricism of millennia of trial and error and supported humans to give birth in closer alignment with our evolved biology. We argue that many common obstetric procedures today work against this evolved biology. In seeking to manage birth, we sometimes generate an obstetric paradox wherein we (over)intervene in human childbirth to try to keep it safe, yet thereby cause harm. We describe premodern birthing patterns in three sections: (a) eating and drinking at will and unrestrained movement in labor with upright pushing; (b) obligate midwifery and continuous labor support; and (c) the low-intervention birth/long-term breastfeeding/co-sleeping adaptive complex, and discuss how these are still relevant today. We conclude with a set of suggestions for improving the global technocratic treatment of birth and with a futuristic epilogue about a 7th, cyborgian pig that asks: What will become of birth as humans continue to coevolve with our technologies?

Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey

BACKGROUND

In many countries, cesarean section has become the most common major surgical procedure. Most nations have high cesarean birth rates, suggesting overuse. Due to the excess harm and expense associated with unneeded cesareans, many health systems are seeking approaches to safe reduction of cesarean rates. Surveys of childbearing women are a distinctive and underutilized source of data for examining factors that may contribute to cesarean reduction.

METHODS

To identify factors associated with unplanned primary cesarean birth, we carried out a secondary analysis of the Listening to Mothers in California Survey, limited to the subgroup who had not had a previous cesarean birth and did not have a planned primary cesarean (n = 1,964). Participants were identified through birth certificate sampling and contacted initially by mail and then by telephone, text message and email, as available. Sampled women could participate in English or Spanish, on any device or with a telephone interviewer. Following bivariate demographic, knowledge and attitude, and labor management analyses, we carried out multivariable analyses to adjust with covariates and identify factors associated with unplanned primary cesarean birth.

RESULTS

Whereas knowledge, attitudes, preferences and behaviors of the survey participants were not associated with having an unplanned primary cesarean birth, their experience of pressure from a health professional to have a cesarean and a series of labor management practices were strongly associated with how they gave birth. These practices included attempted induction of labor, early hospital admission, and labor augmentation. Women's reports of pressure from a health professional to have a primary cesarean were strongly related to the likelihood of cesarean birth.

CONCLUSIONS

While women largely wish to avoid unneeded childbirth interventions, their knowledge, preferences and care arrangement practices did not appear to impact their likelihood of an unplanned primary cesarean birth. By contrast, a series of labor management practices and perceived health professional pressure to have a cesarean were associated with unplanned primary cesarean birth. Improving ways to engage childbearing women and implementing changes in labor management and communication practices may be needed to reduce unwarranted cesarean birth.

Key indicators influencing management of prolonged second stage labour by midwives in freestanding birth centres: Results from an ethnographic interview study

PROBLEMS

Complications for newborns and postpartum clients in the hospital are more frequent after a prolonged second stage of labour. Midwives in community settings have little research to guide management in their settings.

AIM

We explored how US birth centre midwives identify onset of second stage of labour and determine when to transfer clients to the hospital for prolonged second stage.

METHODS

Ethnographic interviews of midwives with at least 2 years' experience in birth centres and participant observation of birth centre care.

FINDINGS

We interviewed 21 midwives (18 CNMs, 3 CPMs/equivalent) from 18 birth centres in 11 US states, 45% with hospital practice privileges. Midwives relied on and engaged in embodied practice in evaluating each labour and making decisions concerning management of labour. Midwives considered time a useful but limited measure as a guiding factor in management. Though ideas of time and progress do play an important role in the decision-making process of midwives, their usefulness is limited due to the continual, multifactorial, and multisensory nature of the assessment. Relationship with the transfer hospital structured midwives' decision-making about transfers.

DISCUSSION & CONCLUSION

These findings can inform future robust multivariate evaluation of factors, including but not limited to time, in guidelines for management of second stage of labour. Optimal management may require formal consideration of more than just time and parity. Our findings also suggest the need for evaluation of how structural issues involving hospital privileges for midwives and relationships between birth centre and hospital staff affect the well-being of childbearing families.

The Use of Tranexamic Acid to Prevent Postpartum Hemorrhage

Tranexamic acid (TXA) is an antifibrinolytic pharmacologic agent with demonstrated effectiveness for reducing the incidence of death from blood loss following trauma and major surgery. In intrapartum care, TXA is being used in in conjunction with uterotonic agents to treat postpartum hemorrhage (PPH). Based on the findings of the WOMAN trial that found TXA reduced maternal death due to PPH, the World Health Organization recommends that TXA be part of the standard comprehensive PPH treatment package, and US professional organizations recognize its use as adjunctive treatment for PPH. Evidence suggests that TXA used prophylactically in the setting of cesarean birth may decrease blood loss and the incidence of PPH. There is limited evidence for prophylactic use of TXA in women of all risk categories following vaginal birth but prophylactic use in women who have an a priori risk for PPH is being investigated. This article presents a case in which a midwife identifies a woman in active labor who has significant risk factors for PPH. In consultation with the collaborating obstetrician, TXA is given early during the third stage of labor in addition to the recommended components of active management for the purpose of preventing PPH.

Midwife Led Units: Transforming Maternity Care Globally

Background

Midwifery-led care is a high-certainty, evidence-based strategy to improve maternity care. Midwife-led units (MLUs) are one example of how the midwifery model of care is being integrated into existing health systems to transform maternal health around the world.

Purpose

To promote global investment in MLUs by describing the benefits, current advances and future directions of this model of care.

Method

A viewpoint based on prevalent notions of midwifery, research findings, guidance from professional organizations and authors' professional experience.

Conclusion

Renewed commitment to research and the implementation of MLUs across a variety of settings is needed to address the practice, education and policy issues associated with this evidence-based strategy. The World Health Organization "Year of the Nurse and Midwife-2020" is an opportune time to invest in midwifery models of care that are fundamental to achieving core global health initiatives such as Universal Healthcare 2030.