An American woman with a low-risk pregnancy who chooses a midwifery-led birth center for her maternity care is four times less likely to have a cesarean than if she chooses a hospital birth, according to a review published today in the Journal of Midwifery & Women’s Health.
The review highlights the findings of the National Birth Center Study II (NBCSII), which followed 15,574 women who planned and were eligible for birth center births at onset of labor.
Among the NBCSII’s findings:
- 84% of women who planned and were eligible for a birth center birth at onset of labor were successful in having one.
- Only 6% of women intending a birth center birth ultimately required a cesarean section, compared with nearly 24% of comparably low-risk women receiving care in hospitals.
- Emergency transfers from birth center to hospital were uncommon.
- Fetal and newborn deaths were rare, and comparable to those in low-risk births in hospital settings.
- There were no maternal deaths.
- Birth center care is economical and in keeping with the fiscal goals of the Patient Protection and Affordable Care Act (aka “Obamacare”).
Some nuts and bolts of the NBCSII, FAQ-style:
What, exactly, is a “birth center”?
- The American Association of Birth Centers defines a birth center as “a homelike facility existing within the health care system with a program of care designed in the wellness model of pregnancy and birth.” The key here is “within the health care system”—the integration between birth center and hospital is critical to the success of any birth center. When emergencies arise, a smooth transfer is vital to keeping mother and baby safe.
Who runs these birth centers?
- The birth centers in the study were all midwifery-led. 80% were staffed by certified nurse midwives (CNMs), 14% by certified professional midwives (CPMs) or licensed midwives (LMs), and the remaining 6% by teams of CNMs, CPMs, and LMs. (The different types of midwives in the U.S. can be a bit confusing for the layperson—the American College of Nurse-Midwives provides a handy comparison chart.)
What is a “low-risk” pregnancy? Who qualifies for a birth center birth?
- Here are the AABC’s eligibility requirements for birth center birth: a single fetus in head-down position, with no medical or obstetrical risk factors that might interfere with normal vaginal birth or require interventions like continuous fetal monitoring or labor induction.
- By those standards, approximately 85% of pregnancies are “low-risk.”
Why did 16% of the women who planned a birth center birth end up giving birth in hospitals anyway?
- Of that 16%, about one-fourth were transferred to hospitals before being admitted to the birth center, due to medical issues. Of the rest, the majority were for non-emergency problems, such as prolonged labor. Only 0.9% of the birth center women required an emergency transfer during labor.
Is birth center birth really as safe as hospital birth?
- Yes, according to the NBCSII’s findings. The rates of fetal death (4.7/10,000 women admitted to a birth center in labor) and neonatal death (4/10,000) in the study were comparable to those in other studies in the U.S. and elsewhere, including those of low-risk birth in hospitals. There were no maternal deaths.
Does birth center care really save money?
- Yes. In this study alone, cost savings–mainly from fewer medical interventions (including cesareans)–were estimated at more than $30 million, and these 15,574 pregnancies represent less than 1% of all U.S. births. Given that expenses for hospital birth in 2008 exceeded $97 billion nationwide, the opportunity for savings in these health-care-dollar-scarce times is enormous.
A few quibbles:
- The women in the study were mainly white (77.4%), well-educated (71.8% had at least some college education, and 51.8% were college graduates), and married (80.1%). They were also relatively slender (only 5.7% were overweight or obese, compared with more than 50% of all pregnant American women), mentally healthy (3.3% were being treated for depression or other psychiatric disease), and largely free of substance use (1.5% smokers, 0.5% users of other substances). Though the study’s findings on safety and cost-savings compare favorably with other studies of low-risk pregnancy outcomes, it isn’t clear that these findings can be extrapolated to the U.S. population as a whole.
- Death rates are crude tools for measuring safety, particularly in low-risk pregnancies. I’d like to know more about morbidity–were the birth center babies more, less, or just as likely as hospital-born babies to suffer birth trauma, for example? I suspect they were less likely to have such complications, given the tendency of birth center staff to perform fewer interventions, but I can’t be certain from this study. Hopefully that will be addressed in a future review.
- What about breastfeeding? Were the birth center mothers more likely to breast feed than those who gave birth in hospitals? Again, I suspect so, and hope that information on breastfeeding will appear in future reviews of NBCSII data.
- The 79 birth centers that participated in the study represent only 32% of American birth centers. All 79 are AABC members and as such support the AABC’s Standards for Birth Centers. Other, non-member birth centers may or may not adhere to such standards, and their safety records may or may not be as good as those in this study. With new birth centers appearing at a remarkable pace (up 27% since 2010), ensuring high quality care in all birth center settings may be challenging.
Withe the publication of this review, the well-entrenched belief that hospitals are the safest place to have a baby takes yet another beating. It’s increasingly clear that most women with low-risk pregnancies can safely give birth at midwifery-led birth centers. A personal/professional note: I’ve taken care of a number of families who’ve had their babies at the Women’s Health and Birth Center here in Santa Rosa, California, run by Rosanne Gephart, CNM. (Rosannne and I go way back). They speak glowingly of their experience at the Birth Center.
One caveat, though. Not all birth centers are alike, and it behooves expectant parents to check out things like staff credentials and birth center accreditation, and to ask pointed questions about how the center handles emergencies and hospital transfers, and how often these occur. Membership in the American Association of Birth Centers is a plus, too. Whether choosing an auto repair shop, a law firm, a pediatrician, or a birth center, it definitely pays to do your homework.
Photo credit: JER_0079