The recent study by Grünebaum et al demonstrated statistically significant, although incremental, increases in the unadjusted rates of total neonatal mortality in midwife-attended birth center births (0.59 per 1000; n = 39,523) compared with midwife-attended hospital births, particularly among nulliparas and gestations longer than 41 weeks.

There are 270 freestanding birth centers in the United States, and of these, only 71 are accredited by the Commission for Accreditation of Birth Centers (CABC). CABC accreditation indicates that a birth center has met a high standard of evidence-based benchmarks for maternity and neonatal care. Accreditation requires that birth center care be limited to women with singleton, cephalic-presenting fetuses between 36 and 42 weeks’ gestation with no medical or obstetric complications precluding a spontaneous labor and vaginal birth.

The birth center must have a transfer arrangement with a hospital; licensed providers trained in risk stratification to determine the need for antepartum, intrapartum, or postpartum transfer; fetal monitoring protocols meeting American College of Obstetricians and Gynecologists standards; skills and equipment to perform neonatal resuscitation meeting Neonatal Resuscitation Program standards; and the ability to manage issues such as postpartum hemorrhage.

In 2013, the American Association of Birth Centers published prospectively collected data on birth centers practicing according to these standards from 2007 to 2010. Among neonates more than 37 weeks and greater than 2500 g without congenital anomalies (n = 13,030), the neonatal mortality rate was 0.23 per 1000, statistically similar to the hospital midwifery birth reference group in the study by Grünebaum et al (0.34 per 1000: P = .55). In an intent-to-treat analysis (n = 15,574), including those women who entered labor in the birth center care but ultimately delivered in hospitals, the overall neonatal mortality rate was 0.38 per 1000 ( P = .68).

The higher neonatal mortality rate of 0.59 per 1000 in all US birth centers over a similar time period reported by Grünebaum et al should be of great concern because the rate is likely even higher among the subset of birth centers not practicing according to widely recognized standards of maternity care as outlined by the American Association of Birth Centers, the CABC, the American College of Nurse-Midwives, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. These other birth centers may attempt deliveries of breech and multiple gestations and may not have appropriate training or equipment for neonatal resuscitation or adequate arrangements for access to hospital obstetrical and neonatal services.

The findings of Grünebaum et al highlight a marked heterogeneity in birth centers in the United States. Many states do not yet require birth center accreditation. In addition to the authors’ recommendation to improve the nature of hospital birth experience, these results should also sound a call to action among collaborating providers, insurers, payers, and birthing families to demand accreditation of birth centers in all states.