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.
Introduction
A birth center is a home-like healthcare facility for childbirth, a maximized home rather than a mini-hospital for low-risk childbirth where care is provided in the midwifery model. Interventions such as epidural anesthesia, labor inductions, or access to operative delivery such as cesarean deliveries are unavailable in most birth centers. Birth centers can be freestanding, or they can be adjacent to or within hospitals. Freestanding birth centers are defined by the American College of Obstetricians and Gynecologists (ACOG) as “. . . freestanding facilities that are not hospitals.” The number of birth centers in the United States has been increasing with 375 such centers in operation as of November 2019.
Why was this study conducted?
This study aimed to compare recent United States data on neonatal outcomes between deliveries in freestanding birth centers and hospitals.
Key findings
Births in freestanding birth centers had a 4-fold increase in neonatal deaths, a more than 7-fold increase in neonatal deaths for nulliparous patients, and a nearly 6-fold increase in neonatal deaths for pregnancies at ≥41 weeks’ gestation.
What does this add to what is known?
This study adds valuable information when counseling women who inquire about the safest location of birth in the United States. Hospital deliveries should be considered the safest birth setting for a neonate in the United States. Further studies are needed to find out whether there are differences in outcome between accredited and nonaccredited birth centers. Although women have several birth location options, it is the professional responsibility of midwives and physicians to recommend a hospital birth
ACOG states that “the American College of Obstetricians and Gynecologists believes that hospitals and accredited birth centers are the safest settings for birth. . . .” Between 2007 and 2019, US freestanding birth center births have more than doubled as a proportion of US vaginal births from 0.37% in 2007 to 0.78% in 2019.
In April 2020, at the height of the COVID-19 pandemic, a COVID-19 Maternity Task Force was established in New York state, and the task force recommended to expand birthing center options without fully addressing the safety of these recommendations. When considering their options of birth location for delivering their babies, women may question where the safest birth setting is in the United States, not only during COVID 19 epidemic but also beyond.
This study aimed to compare several important measures of neonatal safety: the rate of neonatal deaths, neonatal seizures, and 5-minute Apgar scores of <4 and of <7 among United States deliveries between 2016 and 2019 in 2 birth settings and birth attendants—deliveries in freestanding birth centers and deliveries in the hospital by midwives and physicians.
Methods
This was a retrospective cohort study using the United States Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), and Division of Vital Statistics natality online database for the years 2016 to 2019. The database includes data, which are derived from birth certificates, on all live births among United States residents. All term (defined as a birth between 37 0/7 and 42 6/7 weeks’ gestation), singleton, low-risk births were eligible for inclusion. The births were divided based on the location of birth and the obstetrical provider to include the following 3 groups: deliveries in freestanding birth center by midwife, in-hospital birth by physician, and in-hospital birth by midwife. To focus on low-risk births, we did not include preterm births (<37 weeks’ gestation) and excluded patients with previous cesarean delivery and birthweight of <2500 g. In addition, births to women with the following high-risk conditions were excluded: pregestational diabetes, gestational diabetes, chronic hypertension, and hypertensive disorders of pregnancy (including gestational hypertension, mild and severe forms of preeclampsia and eclampsia). Neonatal deaths were defined as infants who, according to the CDC data, were not alive when the birth certificate data were reported.
The study outcomes were the prevalence of 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.
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. Statistical significance was set at P <.05. Multivariate logistic regression models were performed to account for several potential confounding factors such as maternal prepregnancy body mass index (<18.5, 18.5–24.9, 25–29.9, 30–34.9, 35–39.9, and ≥40 kg/m 2 ), maternal weight gain during pregnancy (in kg), parity, neonatal birthweight (2500–2999, 3000–3499, 3500–3999, 4000–4499, and ≥4500 grams), and gestational week at birth. Results were displayed as adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).
Institutional review board approval and informed consent were not required because the deidentified data are publicly available through a data use agreement with the NCHS.
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.
The comparison of characteristics between the 3 groups is presented in Table 1 . Patients delivering in freestanding birth centers were less likely to be non-Hispanic Black or Hispanic, women with public insurance, or nulliparous, whereas they were more likely to be women with advanced education or be at ≥40 weeks’ gestation (59.9% of birth center deliveries were at >40 weeks’ gestation compared with 40.1% of hospital physician and 47.1% of hospital midwife deliveries).
| Characteristics | Birth center | Hospital MD/DO | Hospital Midwife | All births | P value |
|---|---|---|---|---|---|
| Race and ethnicity | <.001 | ||||
| Non-Hispanic White | 54,618 (73.7) | 4,539,195 (52.2) | 608,570 (53.8) | 5,202,383 (53.9) | |
| Non-Hispanic Black | 3916 (5.3) | 1,113,898 (12.8) | 134,768 (11.9) | 1,252,582 (13) | |
| NH AIAN | 259 (0.3) | 54,034 (0.6) | 18,307 (1.6) | 72,600 (.8) | |
| NH Asian | 1333 (1.8) | 614,249 (7.1) | 60,952 (5.4) | 676,534 (7) | |
| Hispanic | 11,192 (15.1) | 2,091,346 (24.1) | 265,565 (23.5) | 2,368,103 (24.5) | |
| Others and unknown | 968 (1.3) | 73,928 (0.9) | 11,626 (1.0) | 86,522 (0.9) | |
| Age, y | <.001 | ||||
| <20 | 910 (1.2) | 494,804 (5.7) | 62,257 (5.5) | 557,971 (5.6) | |
| 20–34 | 60,048 (81.0) | 6,841,916 (78.7) | 906,360 (80.1) | 7,808,324 (78.9) | |
| >35 | 13,155 (17.7) | 1,352,747 (15.6) | 162,781 (14.4) | 1,528,683 (15.4) | |
| Educational attainment | <.001 | ||||
| Below HS | 9214 (12.4) | 1,058,275 (12.2) | 141,985 (12.5) | 1,209,474 (12.4) | |
| HS diploma | 8795 (11.9) | 2,163,251 (24.9) | 286,331 (25.3) | 2,458,377 (25.2) | |
| Some college | 20,250 (27.3) | 2,406,558 (27.7) | 317,886 (28.1) | 2,744,694 (28.1) | |
| Baccalaureate degree | 23,448 (31.6) | 1,845,342 (21.2) | 234,779 (20.8) | 2,103,569 (21.5) | |
| Graduate or postbaccalaureate | 11,580 (15.6) | 1,107,173 (12.7) | 133,349 (11.8) | 1,252,102 (12.8) | |
| Insurance coverage | <.001 | ||||
| Public | 11,984 (16.2) | 3,570,006 (41.1) | 454,121 (40.1) | 4,036,111 (40.8) | |
| Private | 33,324 (45.0) | 4,445,296 (51.2) | 572,939 (50.6) | 5,051,559 (51.1) | |
| Self-pay or other | 28,805 (38.9) | 674,165 (7.8) | 104,338 (9.2) | 807,308 (8.2) | |
| Birth order | <.001 | ||||
| 1 | 24,997 (33.7) | 3,968,354 (45.7) | 436,783 (38.6) | 4,430,134 (44.9) | |
| 2 | 24,099 (32.5) | 2,509,516 (28.9) | 368,174 (32.5) | 2,901,789 (29.4) | |
| >3 | 24,755 (33.4) | 2,188,532 (25.2) | 324,262 (28.7) | 2,537,549 (25.7) | |
| Prenatal visits | |||||
| >5 | 71,615 (96.6) | 8,314,224 (95.7) | 1,089,083 (96.3) | 9,474,922 (95.8) | |
| <5 | 6028 (3.4) | 375,243 (4.3) | 42,315 (3.7) | 420,056 (4.2) | |
| Gestation, wk | <.001 | ||||
| 37 | 2656 (3.6) | 696,944 (8) | 75,370 (6.7) | 774,970 (7.8) | |
| 38 | 8257 (11.1) | 1,497,569 (17.2) | 175,095 (15.5) | 1,680,921 (17) | |
| 39 | 18,751 (25.3) | 3,012,367 (34.7) | 348,309 (30.8) | 3,379,427 (34.2) | |
| 40 | 23,652 (31.9) | 2,106,570 (24.2) | 307,210 (27.2) | 2,437,432 (24.6) | |
| 41 | 14,555 (19.6) | 865,851 (10) | 148,595 (13.1) | 1,029,001 (10.4) | |
| >42 | 6242 (8.4) | 510,166 (5.9) | 76,819 (6.8) | 593,227 (6) | |
| Gestational groups | <.001 | ||||
| 37–40 | 53,316 (71.8) | 7,313,450 (84.2) | 905,984 (80.1) | 8,272,750 (83.6) | |
| >41 | 20,797 (28.1) | 1,376,017 (15.8) | 225,414 (19.9) | 1,622,228 (16.4) |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
