129A Profile of Birth Center Use in the United States and the Potential Demand for Birth Center Use in the Future
EUGENE R. DECLERCQ AND ERIKA R. CHENG
Upon completion of this chapter, the reader will be able to:
1. Describe the recent trends in birth center births in the United States
2. Identify the characteristics of mothers who give birth in birth centers in the United States
3. Describe the characteristics of mothers who gave birth in a hospital but express an interest in using birth centers for their future births
This chapter focuses on the “who” and “where” of birth centers in the United States—examining trends in birth center use in the United States over time, the distribution of birth center births by state, the characteristics of mothers who choose a birth center birth, and some unique data from women who recently gave birth in a hospital on their attitudes toward birth center births. Our goal is to provide the most recent data available on birth center births. Given normal delays in the production of a book, we also have a website (www.birthbythenumbers.org) where updates to the figures presented here are posted as new data become available.
THE GROWING DEMAND FOR BIRTH CENTER BIRTHS
130Relatively systematic data on the use of birth centers in the United States only begins to appear after the 1989 revision to the U.S. Standard Certificate of Live Birth (an agreement among states that specifies what variables all states agree to collect data on), which refined an earlier measure that simply defined births as occurring either in or out of a hospital. The 1989 revision added a category of “freestanding birth center” as a possible place of delivery (National Center for Health Statistics [NCHS], 2013). Figure 5.1 is drawn from that birth certificate item and presents the overall trend of nonhospital births from 1989 to 2015 (NCHS, 1991, 2017). The pattern of home births and births in freestanding birth centers roughly parallel each other with a very gradual decline from 1989 to 2004 followed by a more rapid increase to the point where, by 2015, about one in every 70 births (1.4%) in the United States occurred at home or in a birth center.
Figure 5.2 presents the data specifically for birth centers. In 1989, there were 14,273 births recorded as occurring at freestanding birth centers in the United States, representing 0.36% of all U.S. births. That total declined slowly such that by 2004 fewer than one in 400 U.S. births (0.23%) were in birth centers. The total increased slightly in 2005 (from 9,620 in 2004 to 10,217 in 2005), then remained relatively steady until 2008 when another significant increase occurred (12,014 or 0.28% of all births). Since 2008, the number of birth center births has increased rapidly with 18,219 occurring by 2014. Between 2004 and 2014, the proportion of all U.S. births occurring in freestanding birth centers has doubled, from 0.23% to 0.46%. Although starting from a very small base, this represents a notable increase and is consistent with the overall trend toward an increasing reliance on out-of-hospital births.
FIGURE 5.1 Percentage of all births at home or in a birthing center, United States, 1990–2015.
Adapted from CDC (2015) and Hamilton, Martin, Osterman, Curtin, and Matthews (2015).
Where Are Birth Center Births Occurring?
131Figure 5.3 presents the rate of birth center births by state and notable differences that emerge. Although there is a regional pattern to home births (MacDorman & Declercq, 2016; MacDorman, Declercq, & Mathews, 2013), the potential for state differences in birth center births is even more pronounced, since the establishment and operations of birth centers are typically regulated by a state agency, with some states having no birth centers and others having many (see American Association of Birth Centers’ (AABC) website: www.birthcenters.org). As a result, we see both some regional clustering with five states in the Pacific Northwest all having more than 1% of their births occurring in birth centers, and also some adjoining states (North Dakota and Nevada) reporting fewer than 10 mothers in the entire state who gave birth in a birthing center. Birth center births are also more common in the Southwest and less common in the Deep South and, with the exception of New Hampshire, the Northeast.
FIGURE 5.2 Trend in numbers of births at a birthing center in the United States, 1989–2014.
Adapted from CDC (2015) and Hamilton et al. (2015).
FIGURE 5.3 Proportion of birth center births by state, 2014.
Source: Birth By the Numbers, www.birthbythenumbers.org. Data presented in the map were provided by Dr. Eugene Declercq. Map created by Dr. Veronica Vieira, December 2015. Data adapted from CDC (2015) and Hamilton et al. (2015).
Two notes of caution should be mentioned when interpreting birth center data by state. First, state figures are based on residence of the mother, not the location of the delivery. Hence, states with recorded birth center births may not actually have any birth centers located within their borders; rather, resident mothers may have travelled to an adjoining state to utilize a birth center. Second, when the data are broken down by state, we are dealing with relatively small numbers. For example, in 2014, 16 states reported fewer than 40 total birth center births. Therefore, when looking at such data over time a small absolute difference can seem proportionally large.
Table 5.1 presents specific data for the states with the 20 highest rates of birth center births in 2004 and in 2014. Alaska leads all states by a large margin in both years, with a larger proportion of birth center births than the next three highest states combined. The consistency of these trends over time—nine of the top 10 states in 2004 were on the list again in 2014 (the District of Columbia was the only exception)—reflects the long-term potential impact of establishing a sustainable birth center in a state with a favorable policy climate. The rapid growth in birth center use is evidenced by several factors. Although only two states reported more than 1% of their births being in birth centers in 2004, eight did in 2014. Also, states that maintained roughly the same (e.g., Maryland) or even increased (e.g., Idaho) the proportion of birth center births between 2004 and 2014 dropped substantially in the rankings as birth center births increased across U.S. states. Overall, 35 states reported an increase in birth center births between 2004 and 2014, whereas 16 reported decreases or no change.
134Table 5.2 presents data from states with the largest increases in birth center births between 2004 and 2014. Although the increase in birth center births occurred in a majority of states, there was a notable increase in the 10 states listed, which, between them, accounted for three fourths (77%) of the total national increase in the past decade. Texas and Florida alone account for 30% of the national increase in absolute terms. The impact of the movement toward birth centers can also be seen in two states that went from fewer than five recorded birth center births in 2004 to more than 300 in 2014, specifically Minnesota (351 births) and Colorado (337 births).
2004–2014 Increase in Absolute Numbers
2004–2014 % Increase
*Colorado reported zero birth center births in 2004.
Data adapted from CDC (2015) and Hamilton et al. (2015).