Two weeks ago the American Association of Birth Centers and the American College of Nurse-Midwives released the findings from a new study. This study looked at a sampling of 15,000 births occurring in 79 different birth centers in 33 states and DC. It’s the repeat of a similar study done in 1989, with this one covering the period from 2007-2010. The report was published in the Journal of Midwifery and Women’s Health, and the findings were publicized in a briefing on Capitol Hill earlier this month.
The big picture finding is this: for low-risk women giving birth, birth centers are an alternative that provides a safe, supportive, and cost-saving environment in which to give birth. Birth centers provide an environment that upholds the safety and wellbeing of the pregnant person and the baby while also improving maternal satisfaction and significantly lowering interventions and costs. This study shows that birth centers are able to keep their maternal and fetal mortality rates extremely low while also lowering c-section rates: “The cesarean birth rate in this cohort was 6% versus the estimated rate of 25% for similarly low-risk women in a hospital setting.” Among the more than 15,000 women included in the study, 84 percent actually delivered at the center. The rest were excluded from birth centers because of prenatal factors like high blood pressure, fetal positioning or going past the due date. For the remaining women who went into labor at the birth center:
“2.4% required transfer postpartum, whereas 2.6% of newborns were transferred after birth. Most transfers were nonemergent, with 1.9% of mothers or newborns requiring emergent transfer during labor or after birth. There were no maternal deaths. The intrapartum fetal mortality rate for women admitted to the birth center in labor was 0.47/1000. The neonatal mortality rate was 0.40/1000 excluding anomalies.”
This study simply reinforces with more current data what other studies have shown previously—birth centers are a reliable and safe option for the vast majority of pregnancies that are low-risk. Approximately 85 percent of pregnant women are considered to have a low-risk pregnancy, according to the CDC, but 98 percent of births happen in hospitals, meaning there is a huge group of pregnant women—83 percent of them—who could be safely giving birth in birth centers but are not.
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But things are changing only slowly. Midwifery care is on the rise but hospitals far outnumber birth centers: 11.6 percent of all vaginal births in the United States in 2010 were attended by Certified Nurse Midwives, but 95.7 percent of those births took place in hospitals. Even if tomorrow hundreds of thousands of pregnant women discovered birth centers there would many barriers in their way. First, there simply aren’t enough birth centers to serve that many women. According to the American Association of Birth Centers, there are currently 248 birth centers in the United States, a significant increase from 1984 when there were just 145, but still nowhere near the number needed to serve the eligible pregnant population. We would need thousands more to begin to meet the need of the potentially eligible population, as most of these centers operate on a model that does not work well with a high volume of patients.
Where home birth gets constantly embattled as a rogue or dangerous practice, birth centers represent a kind of political middle ground for proponents of out-of-hospital birth. They also present an important option for those who might not have a home in which they feel comfortable giving birth—low-income folks with housing instability, or those who simply live with too many people to have the luxurious and private home birth experience. This, of course, would be a monumental shift in our maternity care landscape, and it’s one that is not going to happen quickly. The barriers for birth centers remain high. Simply coming up with the capital to open one can be a challenge. Then there are the political and legislative barriers: professional associations like the American Medical Association and the American College of Obstetrics and Gynecology have a vested interest in keeping childbirth as the domain of physicians—it’s an incredibly lucrative business. “In 2008, hospitalization for pregnancy, birth, and care of the newborn resulted in total hospital charges of $97.4 billion, making it the single largest contributor as a health condition to the national hospital bill,” according to the study and the Healthcare Cost Utilization Project.
Then there is another major concern that isn’t clear if this study, or birth centers as they exist currently, are addressing: the question of race-based maternal health disparities. Over 77 percent of the women included in the survey identified as “Non Hispanic White,” 11.2 percent as Hispanic, 5.5 percent as Black, 2.2 percent as Asian or Pacific Islander and 0.7 percent as Native American. Hispanic women were likely overrepresented because of the higher number of birth centers in Texas (60), the largest in any one single state. Many of those centers are also located in border towns like El Paso, and serve a majority of Hispanic or Latina patients. Latinas also have much lower rates of negative maternal health outcomes, like low-infant birth weight and maternal mortality as compared to other women of color, particularly African-Americans and Native Americans.
The birth center model remains one that serves primarily White women, and it begs the question of whether they are the population that most needs to be served when it comes to maternal health. It’s fantastic that we can prove that this group of women, and possibly others, can get care whose standard matches or even beats the hospital setting. But it remains unclear if this model in its current form is able to address the question of disparities for women of color, particularly Black women who are four times more likely to die in childbirth than White women. Of the 15,000 women in the study, only 800 identified as Black, which may be just another piece of evidence that the birth center model is not reaching them. The data also shows that low-income women are underrepresented in the study, with only 23.8 percent of the births paid for by Medicaid, when the national percentage is closer to 40 percent.
There is a new group trying to address this divide: the National Association of Birth Centers of Color, founded this past fall. It was founded by four Black midwives who themselves either currently run or have run in the past birth centers whose aim is to serve patients of color. Jennie Joseph, one of the founding midwives who runs her own birth center in Florida says the NABCC was founded to provide support to people of color running birth centers that serve at least 30 percent patients of color. It’s a forward thinking concept in a midwifery community that is still dominated by White women. Joseph says she supports the efforts of the groups behind the new study, but thinks there need to be additional initiatives to address the needs of women of color specifically. Birth centers that are run by and/or serve majority women of color may experience different barriers than those centers that serve primarily White populations. Access to capital to open a center could be even more challenging considering the race and gender divides in access to wealth. Then there are the patterns regarding where different communities choose to give birth, and whether they are likely to know about or consider a birth center as an option. Race plays a role in these decisions as well, and outreach to communities of color is likely going to look different from outreach to White families. It will be important to see what impact their work has on expanding the birth center model of care to women of color.