Trends and Characteristics of United States Out-of-Hospital Births 2004-2014: New Information on Risk Status and Access to Care

"I had no choice": A mixed-methods study on access to care for vaginal breech birth

INTRODUCTION

Although current recommendations support vaginal breech birth as a reasonable option, access to breech birth in US hospitals is limited. This study explored the experiences of decision-making and perceptions of access to care in people who transferred out of the hospital system to pursue home breech birth.

METHODS

We conducted a mixed methods study of people with a singleton, term breech fetus who transferred out of the US hospital system to pursue home breech birth. Twenty-five people completed an online demographic and psychosocial survey, and 23 (92%) participated in semi-structured interviews. We used an interpretive description approach informed by situational analysis to analyze qualitative data about participants' experiences and perceived access to care.

RESULTS

Of 25 individuals who left the hospital system to pursue a home breech birth, most felt denied informed choice (64%) and threatened or coerced into cesarean (68%). The majority reported low or very low autonomy in decision-making (n = 20, 80%) and high decisional satisfaction using validated measures. Many participants felt safer in a hospital setting but were not able to access care for planned vaginal breech hospital birth, despite extensive efforts. Participants felt "backed into a corner" and "forced into homebirth," perceiving a lack of access to safe and respectful care in the hospital system.

CONCLUSION

Some service users believe that home birth is their only option when they cannot access hospital-based care for vaginal breech birth. Current barriers to care for breech birth limit birthing people's autonomy and may be placing them and their infants at increased risk.

Challenges and lessons learned birthing during the COVID-19 pandemic: A scoping review

Background and Aims

The impact of the COVID-19 pandemic on the healthcare system facilitated a change in policies to redress the consequences of increased demand and fear of disease transmission. Restrictive measures throughout the healthcare system limiting access to accompanying partners of birthing people in addition to fears of contracting COVID-19, an increasing number of birthing people chose to have an out-of-hospital birth. Out-of-hospital births are not prevalent in the United States. However, in recent years the percentage of out-of-hospital births has been steadily increasing. COVID-19 was a novel virus imposing a unique birthing situation for millions of women, complicated by lack of integration and varied policies in the U.S.

Methods

To better understand the challenges of birthing people during the pandemic a scoping review was conducted to explore the literature during the first wave of the pandemic related to out-of-hospital births. The approach for this review made use of the methodology manual published by the Joanna Briggs Institute for scoping reviews. All manner of publications (i.e. peer-reviewed published articles, grey articles, conference proceedings, webinars, editorials, and textbook chapters) were included in the review.

Results

Articles retrieved from the database search yielded sixty-three articles, after duplicate removal forty-six records were available for screening. Articles were further excluded using the PRISMA process, yielding thirty-one remaining records. From the thirty-one records twelve themes emerged, which were collapsed into four meta-themes.

Conclusion

These meta-themes focused on (a) advocacy, (b) homebirth infrastructure, (c) support networks, and (d) uncertainty during the pandemic. COVID-19 has accelerated this movement to birthing at home and thought must be given to how the healthcare system is going to support and integrate this mode of birthing.

Birth Center Breastfeeding Rates: A Literature Review

INTRODUCTION

Breastfeeding rates in the United States fall short of national targets and are marked by racial and ethnic disparities. Birth centers are associated with high rates of breastfeeding initiation and duration, yet no systematic review has compiled reported birth center breastfeeding data.

METHODS

A PRISMA-guided literature review was conducted in CINAHL, PubMed, and Web of Science to retrieve quantitative studies that reported breastfeeding data in birth centers. Inclusion criteria focused on English language studies published since 2011 with breastfeeding outcomes from birth centers in the United States.

RESULTS

Ten studies were included for analysis. Breastfeeding rates that exceeded actual and target national breastfeeding rates were reported among all 10 studies. Characteristics about breastfeeding outcomes were reported heterogeneously across the studies, which included a range of breastfeeding timepoints (immediately postpartum up to 6 weeks postpartum) and definitions of breastfeeding.

DISCUSSION

Although breastfeeding rates reported in birth centers are higher than national breastfeeding rates and targets, authors of the included studies did not explore or analyze these rates in-depth. Developing standard definitions and data collection may enhance research about breastfeeding outcomes in birth centers.

CLINICAL IMPLICATIONS

Giving birth in a birth center is associated with higher than national breastfeeding rates.

United States community births increased by 20% from 2019 to 2020

BACKGROUND

Anecdotal and emerging evidence suggested that the 2020 COVID-19 pandemic may have influenced women's attitudes toward community birth. Our purpose was to examine trends in community births from 2019 to 2020, and the risk profile of these births.

METHODS

Recently released 2020 birth certificate data were compared with prior years' data to analyze trends in community births by socio-demographic and medical characteristics.

RESULTS

In 2020, there were 71 870 community births in the United States, including 45 646 home births and 21 884 birth center births. Community births increased by 19.5% from 2019 to 2020. Planned home births increased by 23.3%, while birth center births increased by 13.2%. Increases occurred in every US state, and for all racial and ethnic groups, particularly non-Hispanic Black mothers (29.7%), although not all increases were statistically significant. In 2020, 1 of every 50 births in the United States was a community birth (2.0%). Women with planned home and birth center births were less likely than women with hospital births to have several characteristics associated with poor pregnancy outcomes, including teen births, smoking during pregnancy, obesity, and preterm, low birthweight, and multiple births. More than two-thirds of planned home births were self-paid, compared with one-third of birth center and just 3% of hospital births.

CONCLUSIONS

It is to the great credit of United States midwives working in home and birth center settings that they were able to substantially expand their services during a worldwide pandemic without compromising standards in triaging women to optimal settings for safe birth.

Out-of-hospital births and infant mortality in the United States: Effect measure modification by rural maternal residence

BACKGROUND

Out-of-hospital births have been increasing in the United States, and home births are almost twice as common in rural vs. urban counties. Planned home births and births in rural areas have each been associated with an increased risk of infant mortality.

OBJECTIVES

To estimate the effect of birth setting on infant mortality in the United States and how this is modified by rural-urban county of maternal residence.

METHODS

We conducted a population-based cohort study of infants born in the United States during 2010-2017 using the National Center for Health Statistics' period-linked birth-infant death files. Unadjusted and adjusted Poisson regression models were used to calculate infant mortality rate ratios and 95% confidence intervals for out-of-hospital births vs. hospital births stratified by maternal residence. Relative excess risk due to interaction (RERI) was calculated to assess effect measure modification on the additive scale.

RESULTS

The study included 25,210,263 live births. Of rural births, 97.8% was in hospitals, 0.5% was in birth centres, and 1.5% was planned home births; of urban births, 98.6% was in hospitals, 0.5% was in birth centres, and 0.7% was planned home births. After adjusting for maternal demographics and markers of high-risk pregnancy and stratifying by maternal residence, infant mortality rates were generally higher for out-of-hospital as compared to hospital births (e.g. rural planned home births aRR 1.62, 95% confidence interval [CI] 1.42, 1.85, and rural birth centre aRR 1.33, 95% CI 1.05, 1.68). There were positive additive effects of rural residence on infant mortality for planned home births and birth centre births.

CONCLUSIONS

Within both rural and urban areas, out-of-hospital births generally had higher rates of infant mortality than hospital births after accounting for maternal demographics and markers of high-risk pregnancy. The risks associated with planned home births and birth centre births were more pronounced for women in rural counties.

Characterizing prehospital response to neonatal resuscitation

Objective

To evaluate performance of initial steps of newborn resuscitation according to the American Heart Association and American Academy of Pediatrics' Neonatal Resuscitation Program (NRP) guidelines in the prehospital setting.

Study Design

Observational study of 265 paramedics and Emergency Medical Technicians (EMTs) from 45 EMS teams recruited from public fire and private transport agencies in a major metropolitan area. Participants completed a baseline questionnaire assessing demographics, experience, and comfort in caring for children. Simulations were conducted April 2015 to March 2016. Technical performance was evaluated by blinded video review. NRP actions were assessed using a structured performance tool.

Results

Two hundred sixty-five EMS providers responded to survey questions and participated in simulations. In total, 16% reported feeling very or extremely comfortable caring for children <30 days of age (vs. 71% for children aged 12-18 years). Among 45 EMS teams participating in simulations, 22% (n = 10) dried, 18% (n = 8) stimulated, and 2% (n = 1) warmed within 30 s from arrival and 11% (n = 5) provided BMV within 60 s from arrival, as recommended by NRP. All teams provided BMV. Eighty-eight percent bagged below NRP rate recommendations and 96% bagged with tidal volume exceeding guidelines. Looking over the entire 10-min simulation for ever performing measures, 73% started to dry the baby within a median of 51 (range 0-539) seconds from arrival, 38% started to stimulate the baby within a median of 34 s (range 0-181), and 44% started to warm the baby within a median 291 s (range 27-575 s).

Conclusions

These data from field simulations suggest NRP steps recommended for the first minute after birth are seldom performed in a timely manner and suggests opportunities for improvement.

Exploring Why Birth Center Clients Choose Hospitalization for Labor and Birth

OBJECTIVE

To identify demographic and clinical factors associated with birth center clients electing hospitalization for labor and birth and to explore the timing and rationale for elective hospitalization via health records.

DESIGN

A secondary analysis of multiyear data from a quality assurance project at a single birth center. We compared two subsamples-birth center preference group and hospital preference group-and described the apparent rationale for transfers among clients in the latter group.

SETTING

A single freestanding birth center where all midwives have admitting privileges at a local hospital and can accompany labor transfers.

PARTICIPANTS

All cases included in the analytic sample represent women with low-risk pregnancies who were eligible for birth center birth. The birth center preference group represents clients planning to give birth at the center, and the hospital preference group consists of clients who elected for hospitalization.

MEASUREMENTS

Relevant demographic and clinical information was provided for the entire analytic sample and was matched with available data collected systematically by birth center staff via chart review. The data set also included anonymous responses to an e-mailed questionnaire from clients identified by birth center staff.

RESULTS

Approximately 56.1% (N = 1,155) of the cases in the data set were eligible for comparative analysis. The birth center preference and hospital preference groups included 899 (77.8%) and 256 (22.2%) individuals, respectively. In the hospital preference group, Black clients (n = 23), those who were publicly insured (n = 49), and primiparas (n = 101) were significantly overrepresented. Chart review data and questionnaire responses highlighted insurance restrictions, family preferences, pain relief options, and postpartum care as influential factors among members of the hospital preference subsample.

CONCLUSION

The present analysis shows associations between certain individual characteristics and elective hospitalization during labor for birth center clients. Health record data and questionnaire responses indicated a variety of reasons for electing hospitalization, illustrating the complexity of clients' decision-making during pregnancy and birth.

Regional variation in Black infant mortality: The contribution of contextual factors

BACKGROUND

Compared to other racial/ethnic groups, infant mortality rates (IMR) are persistently highestamong Black infants in the United States, yet there is considerable regional variation. We examined state and county-level contextual factors that may explain regional differences in Black IMR and identified potential strategies for improvement.

METHODS AND FINDINGS

Black infant mortality data are from the Linked Birth/Infant Death files for 2009-2011. State and county contextual factors within social, economic, environmental, and health domains were compiled from various Census databases, the Food Environment Atlas, and the Area Health Resource File. Region was defined by the nine Census Divisions. We examined contextual associations with Black IMR using aggregated county-level Poisson regression with standard errors adjusted for clustering by state. Overall, Black IMR varied 1.5-fold across regions, ranging from 8.78 per 1,000 in New England to 13.77 per 1,000 in the Midwest. In adjusted models, the following factors were protective for Black IMR: higher state-level Black-White marriage rate (rate ratio (RR) per standard deviation (SD) increase = 0.81, 95% confidence interval (CI):0.70-0.95), higher state maternal and child health budget per capita (RR per SD = 0.96, 95% CI:0.92-0.99), and higher county-level Black index of concentration at the extremes (RR per SD = 0.85, 95% CI:0.81-0.90). Modeled variables accounted for 35% of the regional variation in Black IMR.

CONCLUSIONS

These findings are broadly supportive of ongoing public policy efforts to enhance social integration across races, support health and social welfare program spending, and improve economic prosperity. Although contextual factors accounted for about a third of regional variation, further research is needed to more fully understand regional variation in Black IMR disparities.

Distance to Hospital-based Intrapartum Care and Planned Home Birth in Minnesota

INTRODUCTION

Loss of hospital-based intrapartum services is associated with increases in out-of-hospital births, but less is known about associations with planned home birth. This study explores the impact of distance to hospital-based intrapartum care on planned home birth.

METHODS

Public-use Minnesota birth certificate data were merged with Minnesota Hospital Annual Report data (2011-2016) to test the relationship of miles from maternal residence to hospital-based intrapartum care with planned home birth in Minnesota. Logistic regression models estimated the odds of a planned home birth versus hospital birth as a function of miles to hospital-based intrapartum care.

RESULTS

The number of hospitals offering birth services in Minnesota declined by 11% from 2011 to 2016. Moderate (>20-50 miles) and great (>50 miles) distances to nearest hospital-based intrapartum care were associated with increased odds of planned home birth compared with short distances (≤20 miles). Adjusted odds ratios were 3.31 (95% CI, 3.04-3.61) and 3.89 (95% CI, 2.37-6.37), respectively, after adjusting for maternal education, age, and race. Planned home birth was the intended birth setting in 4.3% of births among those living great distances from hospital-based intrapartum care, compared with 1.0% among those living a short distance from hospital-based intrapartum care.

DISCUSSION

Better understanding of how geographical barriers affect preferred birth settings can inform efforts to reduce the impact of hospital-based intrapartum service loss on rural women and their birth outcomes.

Key indicators influencing management of prolonged second stage labour by midwives in freestanding birth centres: Results from an ethnographic interview study

PROBLEMS

Complications for newborns and postpartum clients in the hospital are more frequent after a prolonged second stage of labour. Midwives in community settings have little research to guide management in their settings.

AIM

We explored how US birth centre midwives identify onset of second stage of labour and determine when to transfer clients to the hospital for prolonged second stage.

METHODS

Ethnographic interviews of midwives with at least 2 years' experience in birth centres and participant observation of birth centre care.

FINDINGS

We interviewed 21 midwives (18 CNMs, 3 CPMs/equivalent) from 18 birth centres in 11 US states, 45% with hospital practice privileges. Midwives relied on and engaged in embodied practice in evaluating each labour and making decisions concerning management of labour. Midwives considered time a useful but limited measure as a guiding factor in management. Though ideas of time and progress do play an important role in the decision-making process of midwives, their usefulness is limited due to the continual, multifactorial, and multisensory nature of the assessment. Relationship with the transfer hospital structured midwives' decision-making about transfers.

DISCUSSION & CONCLUSION

These findings can inform future robust multivariate evaluation of factors, including but not limited to time, in guidelines for management of second stage of labour. Optimal management may require formal consideration of more than just time and parity. Our findings also suggest the need for evaluation of how structural issues involving hospital privileges for midwives and relationships between birth centre and hospital staff affect the well-being of childbearing families.

Providing Care for Infants Born at Home

The American Academy of Pediatrics (AAP) believes that current data show that hospitals and accredited birth centers are the safest settings for birth in the United States. The AAP does not recommend planned home birth, which has been reported to be associated with a twofold to threefold increase in infant mortality in the United States. The AAP recognizes that women may choose to plan a home birth. This statement is intended to help pediatricians provide constructive, informed counsel to women considering home birth while retaining their role as child advocates and to summarize appropriate care for newborn infants born at home that is consistent with care provided for infants born in a medical care facility. Regardless of the circumstances of his or her birth, including location, every newborn infant deserves health care consistent with that highlighted in this statement, which is more completely described in other publications from the AAP, including Guidelines for Perinatal Care and the Textbook of Neonatal Resuscitation All health care clinicians and institutions should promote communications and understanding on the basis of professional interaction and mutual respect.

Out-of-maternity deliveries in France: A nationwide population-based study

Introduction

In France, many maternity hospitals have been closed as a result of hospital restructuring in an effort to reduce costs through economies of scale. These closures have naturally increased the distance between home and the closest maternity ward for women throughout the country. However, studies have shown a positive correlation between this increase in distance and the incidence of unplanned out-of-maternity deliveries (OMD). This study was conducted to estimate the frequency of OMD in France, to identify the main risk factors and to assess their impact on maternal mortality and neonatal morbidity and mortality.

Materials and methods

We conducted a population-based observational retrospective study using data from 2012 to 2014 obtained from the French hospital discharge database. We included 2,256,797 deliveries and 1,999,453 singleton newborns in mainland France, among which, 6,733 (3.0‰) were OMD. The adverse outcomes were maternal mortality in hospital or during transport, stillbirth, neonatal mortality, neonatal hospitalizations, and newborn hypothermia and polycythemia. The socio-residential environment was also included in the regression analysis. Maternal and newborn adverse outcomes associated with OMD were analyzed with Generalized Estimating Equations regressions.

Results

The distance to the nearest maternity unit was the main factor for OMD. OMD were associated with maternal death (aRR 6.5 [1.6–26.3]) and all of the neonatal adverse outcomes: stillbirth (3.3 [2.8–3.8]), neonatal death (1.9 [1.2–3.1]), neonatal hospitalization (1.2 [1.1–1.3]), newborn hypothermia (5.9 [5.2–6.6]) and newborn polycythemia (4.8 [3.5–6.4]).

Discussion

In France, OMD increased over the study period. OMD were associated with all the adverse outcomes studied for mothers and newborns. Caregivers, including emergency teams, need to be better prepared for the management these at-risk cases. Furthermore, the increase in adverse outcomes, and the additional generated costs, should be considered carefully by the relevant authorities before any decisions are made to close or merge existing maternity units.

Utility of the 5-Minute Apgar Score as a Research Endpoint

Although Apgar scores are commonly used as proxy outcomes, little evidence exists in support of the most common cutpoints (<7, <4). We used 2 data sets to explore this issue: one contained planned community births from across the United States (n = 52,877; 2012-2016), and the other contained hospital births from California (n = 428,877; 2010). We treated 5-minute Apgars as clinical "tests," compared against 18 known outcomes; we calculated sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve for each. We used 3 different criteria to determine optimal cutpoints. Results were very consistent across data sets, outcomes, and all subgroups: The cutpoint that maximizes the trade-off between sensitivity and specificity is universally <9. However, extremely low positive predictive values for all outcomes at <9 indicate more misclassification than is acceptable for research. The areas under the receiver operating characteristic curves (which treat Apgars as quasicontinuous) were generally indicative of adequate discrimination between infants destined to experience poor outcomes and those not; comparing median Apgars between groups might be an analytical alternative to dichotomizing. Nonetheless, because Apgar scores are not clearly on any causal pathway of interest, we discourage researchers from using them unless the motivation for doing so is clear.

Patient and hospital characteristics associated with severe maternal morbidity among postpartum readmissions

OBJECTIVE

To examine the influence of socioeconomic, clinical, and hospital characteristics on the risk of severe maternal morbidity among postpartum readmissions.

STUDY DESIGN

A cross-sectional analysis was conducted using the National Inpatient Sample 2006-2012 to estimate the risk of severe maternal morbidity and identify potential risk factors. Odds ratios were calculated using multivariate logistic regression.

RESULTS

Women aged ≥35 years (ages 35-39: OR 1.12 [CI 1.06, 1.19]; ages 40+: OR 1.27 [CI 1.17, 1.39]), non-Hispanic blacks (OR 1.16 [CI 1.10, 1.22]), and women with pre-existing medical conditions (OR 1.62 [CI 1.56, 1.68]) were at greater risk of severe maternal morbidity during postpartum readmissions. Women hospitalized outside the Northeast region (Midwest: OR 1.20 [CI 1.10, 1.30]; South: OR 1.29 [CI 1.20, 1.38]; West: OR 1.33 [CI 1.22, 1.44]) were also at increased risk.

CONCLUSION

The risk of severe maternal morbidity is heightened beyond delivery hospitalization for a subset of high-risk women.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States

BACKGROUND

Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)-US study.

METHODS

Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables.

RESULTS

Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment.

CONCLUSION

This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States

Background

Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)–US study.

Methods

Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables.

Results

Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years.

Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment.

Conclusion

This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0729-2) contains supplementary material, which is available to authorized users.

Trends and state variations in out-of-hospital births in the United States, 2004-2017

BACKGROUND

Out-of-hospital births have been increasing in the United States, although past studies have found wide variations between states. Our purpose was to examine trends in out-of-hospital births, the risk profile of these births, and state differences in women's access to these births.

METHODS

National birth certificate data from 2004 to 2017 were analyzed. Newly available national data on method of payment for the delivery (private insurance, Medicaid, self-pay) were used to measure access to out-of-hospital birth options.

RESULTS

After a gradual decline from 1990 to 2004, the number of out-of-hospital births increased from 35 578 in 2004 to 62 228 in 2017. In 2017, 1 of every 62 births in the United States was an out-of-hospital birth (1.61%). Home births increased by 77% from 2004 to 2017, whereas birth center births more than doubled. Out-of-hospital births were more common in the Pacific Northwest and less common in the southeastern states such as Alabama, Louisiana, and Mississippi. Women with planned home and birth center births were less likely to have a number of population characteristics associated with poor pregnancy outcomes, including teen births, smoking during pregnancy, obesity, and preterm, low birthweight, and multiple births. More than 2/3 of planned home births were self-paid, compared with 1/3 of birth center and just 3% of hospital births, with large variations by state.

CONCLUSIONS

Lack of insurance or Medicaid coverage is an important limiting factor for women desiring out-of-hospital birth in most states. Recent increases in out-of-hospital births despite important limiting factors highlight the strong motivation of some women to choose out-of-hospital birth.

Association between maternal serious mental illness and adverse birth outcomes

OBJECTIVE

To evaluate the contribution of serious mental illness (SMI) and specific risk factors (comorbidities and substance use) to the risk of adverse birth outcomes.

STUDY DESIGN

This cross-sectional study uses maternal delivery records in the Healthcare Cost and Utilization Project Nationwide/National Inpatient Sample (HCUP-NIS) to estimate risk factor prevalence and relative risk of adverse birth outcomes (e.g., preeclampsia, preterm birth, and fetal distress) in women with SMI.

RESULTS

The relative risk of adverse gestational (1.15, 95% CI: 1.13-1.17), obstetric (1.07, 1.06-1.08), and fetal (1.24, 1.21-1.26) outcomes is increased for women with SMI. After adjusting for risk factors, the risk is significantly reduced but remains elevated for all three adverse outcome categories (gestational: 1.08, 1.06-1.09; obstetric: 1.03, 1.02-1.05; fetal: 1.12, 1.09-1.14).

CONCLUSIONS

Maternal serious mental illness is independently associated with increased risk for adverse birth outcomes. However, approximately half of the excess risk is attributable to comorbidities and substance use.

Planned home deliveries in Finland, 1996-2013

OBJECTIVE

To evaluate trends and perinatal outcomes of planned home deliveries in Finland.

STUDY DESIGN

All infants born in 1996-2013, excluding those born preterm, by operative delivery, and without information on birth mode or gestational age, were studied. The study group included 170 infants born at home as planned, 720,047 infants born at hospital were controls.

RESULT

The rate of planned home deliveries increased from 8.3 to 39.4 per 100,000. In the study group 63%, containing two perinatal deaths, were not low-risk pregnancies according to national guidelines. The rate of hypothermia, asphyxia, and need of invasive ventilation was increased in low-risk home deliveries. One infant had a major congenital malformation. Maternal outcomes were favorable.

CONCLUSION

The rate of planned home deliveries increased. Guidelines for low-risk deliveries were not followed in a majority of cases, including two perinatal deaths. Even in low-risk home deliveries, the neonatal morbidity appeared to be increased.

Placentophagy among women planning community births in the United States: Frequency, rationale, and associated neonatal outcomes

BACKGROUND

Limited systematic research on maternal placentophagy is available to maternity care providers whose clients/patients may be considering this increasingly popular practice. Our purpose was to characterize the practice of placentophagy and its attendant neonatal outcomes among a large sample of women in the United States.

METHODS

We used a medical records-based data set (n = 23 242) containing pregnancy, birth, and postpartum information for women who planned community births. We used logistic regression to determine demographic and clinical predictors of placentophagy. Finally, we compared neonatal outcomes (hospitalization, neonatal intensive unit admission, or neonatal death in the first 6 weeks) between placenta consumers and nonconsumers, and participants who consumed placenta raw vs cooked.

RESULTS

Nearly one-third (30.8%) of women consumed their placenta. Consumers were more likely to have reported pregravid anxiety or depression compared with nonconsumers. Most (85.3%) placentophagic mothers consumed their placentas in encapsulated form, and nearly half (48.4%) consumed capsules containing dehydrated, uncooked placenta. Placentophagy was not associated with any adverse neonatal outcomes. Women with home births were more likely to engage in placentophagy than women with birth center births. The most common reason given (73.1%) for engaging in placentophagy was to prevent postpartum depression. [Corrections added on 16 May 2018, after first online publication: The percentage values in the Results sections were updated.] CONCLUSIONS: The majority of women consumed their placentas in uncooked/encapsulated form and hoping to avoid postpartum depression, although no evidence currently exists to support this strategy. Preparation technique (cooked vs uncooked) did not influence adverse neonatal outcomes. Maternity care providers should discuss the range of options available to prevent/treat postpartum depression, in addition to current evidence with respect to the safety of placentophagy.

Access To Obstetric Services In Rural Counties Still Declining, With 9 Percent Losing Services, 2004-14

Recent closures of rural obstetric units and entire hospitals have exacerbated concerns about access to care for more than twenty-eight million women of reproductive age living in rural America. Yet the extent of recent obstetric unit closures has not yet been measured. Using national data, we found that 9 percent of rural counties experienced the loss of all hospital obstetric services in the period 2004-14. In addition, another 45 percent of rural US counties had no hospital obstetric services at all during the study period. That left more than half of all rural US counties without hospital obstetric services. Counties with fewer obstetricians and family physicians per women of reproductive age and per capita, respectively; a higher percentage of non-Hispanic black women of reproductive age; and lower median household incomes and those in states with more restrictive Medicaid income eligibility thresholds for pregnant women had higher odds of lacking hospital obstetric services. The same types of counties were also more likely to experience the loss of obstetric services, which highlights the challenge of providing adequate geographic access to obstetric care in vulnerable and underserved rural communities.

Rural community birth: Maternal and neonatal outcomes for planned community births among rural women in the United States, 2004-2009

BACKGROUND

Approximately 22% of women in the United States live in rural areas with limited access to obstetric care. Despite declines in hospital-based obstetric services in many rural communities, midwifery care at home and in free standing birth centers is available in many rural communities. This study examines maternal and neonatal outcomes among planned home and birth center births attended by midwives, comparing outcomes for rural and nonrural women.

METHODS

Using the Midwives Alliance of North America Statistics Project 2.0 dataset of 18 723 low-risk, planned home, and birth center births, rural women (n = 3737) were compared to nonrural women. Maternal outcomes included mode of delivery (cesarean and instrumental delivery), blood transfusions, severe events, perineal lacerations, or transfer to hospital and a composite (any of the above). The primary neonatal outcome was a composite of early neonatal intensive care unit or hospital admissions (longer than 1 day), and intrapartum or neonatal deaths. Analysis involved multivariable logistic regression, controlling for sociodemographics, antepartum, and intrapartum risk factors.

RESULTS

Rural women had different risk profiles relative to nonrural women and reduced risk of adverse maternal and neonatal outcomes in bivariable analyses. However, after adjusting for risk factors and confounders, there were no significant differences for a composite of maternal (adjusted odds ratio [aOR] 1.05 [95% confidence interval {CI} 0.93-1.19]) or neonatal (aOR 1.13 [95% CI 0.87-1.46]) outcomes between rural and nonrural pregnancies.

CONCLUSION

Among this sample of low-risk women who planned midwife-led community births, no increased risk was detected by rural vs nonrural status.

Mapping integration of midwives across the United States: Impact on access, equity, and outcomes

METHODS

Our multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and interprofessional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the 'on the ground' relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race.

RESULTS

MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state.

CONCLUSION

The MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.

Out-of-hospital births in California 1991-2011

OBJECTIVE

We investigated the frequencies and characteristics of out-of-hospital births in a 20-year period in California, where 1 of every 7 births in the United States occurs.

STUDY DESIGN

Birth certificate records of deliveries in California between 1991 and 2011 were analyzed. Out-of-hospital births were assessed by year, parity, gestational age and maternal race/ethnicity.

RESULTS

In the 20-year period there were 10 593,904 deliveries, of which 46 243 occurred out of hospital (0.44%). Out-of-hospital births decreased from 0.54 to 0.38% per year between 1991 and 2004, and increased from 0.41% in 2005 to 0.61% in 2011. In contrast, preterm out-of-hospital births declined from 7.2% in 2006 to 5.0% in 2011. The frequency of vaginal birth after cesarean in the out-of-hospital birth cohort increased from 1.2% (n=19) in 1996 to 4.2% (n=82) in 2011.

CONCLUSION

California birth records from a 20-year period show an increase in out-of-hospital births from years 2005 to 2011, following a period of decline from 1991 to 2004.

Outcomes of childbearing Medicaid beneficiaries engaged in care at Strong Start birth center sites between 2012 and 2014

BACKGROUND

Variations in care for pregnant women have been reported to affect pregnancy outcomes.

METHODS

This study examined data for all 3136 Medicaid beneficiaries enrolled at American Association of Birth Centers (AABC) Center for Medicare and Medicaid Innovation Strong Start sites who gave birth between 2012 and 2014. Using the AABC Perinatal Data Registry, descriptive statistics were used to evaluate socio-behavioral and medical risks, and core perinatal quality outcomes. Next, the 2082 patients coded as low medical risk on admission in labor were analyzed for effective care and preference sensitive care variations. Finally, using binary logistic regression, the associations between selected care processes and cesarean delivery were explored.

RESULTS

Medicaid beneficiaries enrolled at AABC sites had diverse socio-behavioral and medical risk profiles and exceeded quality benchmarks for induction, episiotomy, cesarean, and breastfeeding. Among medically low-risk women, the model demonstrated effective care variations including 82% attendance at prenatal education classes, 99% receiving midwifery-led prenatal care, and 84% with midwifery- attended birth. Patient preferences were adhered to with 83% of women achieving birth at their preferred site of birth, and 95% of women using their preferred infant feeding method. Elective hospitalization in labor was associated with a 4-times greater risk of cesarean birth among medically low-risk childbearing Medicaid beneficiaries.

CONCLUSIONS

The birth center model demonstrates the capability to achieve the triple aims of improved population health, patient experience, and value.

Maternity care access, quality, and outcomes: A systems-level perspective on research, clinical, and policy needs

The quality of maternity care in the United States is variable, and access to care is tenuous for rural residents, low-income individuals, and people of color. Without accessible, timely, and high-quality care, certain clinical and sociodemographic characteristics of individuals may render them more vulnerable to poor birth outcomes. However, risk factors for poor birth outcomes do not occur in a vaccum; rather, health care financing, delivery, and organization as well as the policy environment shape the context in which patients seek and receive maternity care. This paper describes the relationship between access and quality in maternity care and offers a systems-level perspective on the innovations and strategies needed in research, clinical care, and policy to improve equity in maternal and infant health.

Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States

BACKGROUND

There is little agreement on who is a good candidate for community (home or birth center) birth in the United States.

METHODS

Data on n=47 394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gestational diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, history of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education.

RESULTS

The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6). Cesarean births were most common in the breech (44.7%), preeclampsia (30.6%), history of cesarean without vaginal birth (22.1%), and primipara (11.0%) groups.

DISCUSSION

The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting.

Comparison of Births by Provider, Place, and Payer in New Hampshire

This study examines maternity care in a rural state by birth attendant, place of birth, and payer of birth. It is a secondary analysis of birth certificate data in New Hampshire between the years 2005 and 2012. Results revealed that in New Hampshire, the majority of births occurred in the hospital setting (98.6%). Physicians attended 75.8% of births, certified nurse midwives attended 17%, and certified professional midwives attended 1%. Medicaid coverage was the payer source for 28% of all births, compared with 44.9% nationally. Women with a private payer source were more likely than women with Medicaid or other payer sources to have a cesarean section. The findings demonstrate quality of care outcomes among a range of clinicians and settings, providing a policy argument for expanding maternity care options.

Planned home compared with planned hospital births: mode of delivery and Perinatal mortality rates, an observational study

Background

To compare the mode of delivery between planned home versus planned hospital births and to determine if differences in intervention rates could be interpreted as over- or undertreatment.

Methods

Intervention and perinatal mortality rates were obtained for 679,952 low-risk women from the Dutch Perinatal Registry (2000–2007). Intervention was defined as operative vaginal delivery and/or caesarean section. Perinatal mortality was defined as the intrapartum and early neonatal mortality rate up to 7 days postpartum.

Besides adjustment for maternal and care factors, we included for additional casemix adjustment: presence of congenital abnormality, small for gestational age, preterm birth, or low Apgar score. The techniques used were nested multiple stepwise logistic regression, and stratified analysis for separate risk groups. An intention-to-treat like analysis was performed.

Results

The intervention rate was lower in planned home compared to planned hospital births (10.9% 95% CI 10.8–11.0 vs. 13.8% 95% CI 13.6–13.9). Intended place of birth had significant impact on the likelihood to intervene after adjustment (planned homebirth (OR 0.77 95% CI. 0.75–0.78)).

The mortality rate was lower in planned home births (0.15% vs. 0.18%). After adjustment, the interaction term home- intervention was significant (OR1.51 95% CI 1.25–1.84). In risk groups, a higher perinatal mortality rate was observed in planned home births.

Conclusions

The potential presence of over- or under treatment as expressed by adjusted perinatal mortality differs per risk group. In planned home births especially multiparous women showed universally lower intervention rates. However, the benefit of substantially fewer interventions in the planned home group seems to be counterbalanced by substantially increased mortality if intervention occurs.

Birth outcomes among US women with intellectual and developmental disabilities

BACKGROUND

Women with intellectual and developmental disabilities (IDD) are bearing children at increasing rates. However, there is very little research about pregnancy experiences and birth outcomes among women with IDD. No studies to date have examined birth outcomes with a US population-based sample.

OBJECTIVE

The main objective was to estimate the national occurrence of deliveries in women with IDD and to compare their birth outcomes to women without IDD.

METHODS

We examined the 2007-2011 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project to compare birth outcomes in women with and without IDD. Birth outcomes included preterm birth, low birth weight, and stillbirth. Multivariable regression analyses compared birth outcomes between women with and without IDD controlling for race/ethnicity, maternal age, household income, health insurance status and type, comorbidity, region and hospital location, teaching status, ownership, and year.

RESULTS

Of an estimated 20.6 million deliveries identified through the HCUP 2007-2011 data 10,275 occurred in women with IDD. In adjusted regression analyses, women with IDD compared to those without IDD were significantly more likely to have preterm birth (OR = 1.46; 95%CI: 1.26-1.69, p < 0.001), low birth weight (OR = 1.61, 95%CI: 1.27-2.05, p < 0.001), and stillbirth (OR = 2.40, 95% CI: 1.70-3.40, p < 0.001).

CONCLUSION

This study provides a first examination of the birth outcomes among women with IDD in the United States using a largest population-based sample. There are significant differences in birth outcomes between women with and without IDD. Understanding the causes of these differences and addressing these causes are critical to improving pregnancy outcomes among women with IDD.

Vaginal birth after cesarean: neonatal outcomes and United States birth setting

BACKGROUND

Women who seek vaginal birth after cesarean delivery may find limited in-hospital options. Increasing numbers of women in the United States are delivering by vaginal birth after cesarean delivery out-of-hospital. Little is known about neonatal outcomes among those who deliver by vaginal birth after cesarean delivery in- vs out-of-hospital.

OBJECTIVE

The purpose of this study was to compare neonatal outcomes between women who deliver via vaginal birth after cesarean delivery in-hospital vs out-of-hospital (home and freestanding birth center).

STUDY DESIGN

We conducted a retrospective cohort study using 2007-2010 linked United States birth and death records to compare singleton, term, vertex, nonanomolous, and liveborn neonates who delivered by vaginal birth after cesarean delivery in- or out-of-hospital. Descriptive statistics and multivariate regression analyses were conducted to estimate unadjusted, absolute, and relative birth-setting risk differences. Analyses were stratified by parity and history of vaginal birth. Sensitivity analyses that involved 3 transfer status scenarios were conducted.

RESULTS

Of women in the United States with a history of cesarean delivery (n=1,138,813), only a small proportion delivered by vaginal birth after cesarean delivery with the subsequent pregnancy (n=109,970; 9.65%). The proportion of home vaginal birth after cesarean delivery births increased from 1.78-2.45%. A pattern of increased neonatal morbidity was noted in unadjusted analysis (neonatal seizures, Apgar score <7 or <4, neonatal seizures), with higher morbidity noted in the out-of-hospital setting (neonatal seizures, 23 [0.02%] vs 6 [0.19%; P<.001]; Apgar score <7, 2859 [2.68%] vs 139 [4.42%; P<.001; Apgar score <4, 431 [0.4%] vs 23 [0.73; P=.01]). A similar, but nonsignificant, pattern of increased risk was observed for neonatal death and ventilator support among those neonates who were born in the out-of-hospital setting. Multivariate regression estimated that neonates who were born in an out-of-hospital setting had higher odds of poor outcomes (neonatal seizures [adjusted odds ratio, 8.53; 95% confidence interval, 2.87-25.4); Apgar score <7 [adjusted odds ratio, 1.62; 95% confidence interval, 1.35-1.96]; Apgar score <4 [adjusted odds ratio, 1.77; 95% confidence interval, 1.12-2.79]). Although the odds of neonatal death (adjusted odds ratio, 2.1; 95% confidence interval, 0.73-6.05; P=.18) and ventilator support (adjusted odds ratio, 1.36; 95% confidence interval, 0.75-2.46) appeared to be increased in out-of-hospital settings, findings did not reach statistical significance. Women birthing their second child by vaginal birth after cesarean delivery in out-of-hospital settings had higher odds of neonatal morbidity and death compared with women of higher parity. Women who had not birthed vaginally prior to out-of-hospital vaginal birth after cesarean delivery had higher odds of neonatal morbidity and mortality compared with women who had birthed vaginally prior to out-of-hospital vaginal birth after cesarean delivery. Sensitivity analyses generated distributions of plausible alternative estimates by outcome.

CONCLUSION

Fewer than 1 in 10 women in the United States with a previous cesarean delivery delivered by vaginal birth after cesarean delivery in any setting, and increasing proportions of these women delivered in an out-of-hospital setting. Adverse outcomes were more frequent for neonates who were born in an out-of-hospital setting, with risk concentrated among women birthing their second child and women without a history of vaginal birth. This information urgently signals the need to increase availability of in-hospital vaginal birth after cesarean delivery and suggests that there may be benefit associated with increasing options that support physiologic birth and may prevent primary cesarean delivery safely. Results may inform evidence-based recommendations for birthplace among women who seek vaginal birth after cesarean delivery.

Birth Outcomes Among U.S. Women With Hearing Loss

INTRODUCTION

The purpose of this study is to estimate the national occurrence of deliveries in women with hearing loss and to compare their birth outcomes to women without hearing loss.

METHODS

This study examined the 2008-2011 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project in 2015 to compare birth outcomes in women with hearing loss and without. Birth outcomes included preterm birth and low birth weight. Multivariate regression analyses compared birth outcomes between women with and without hearing loss, controlling for maternal age, racial and ethnic identity, type of health insurance, comorbidity, region of hospital, location and teaching status of the hospital, ownership of the hospital, and median household income for mother's ZIP code.

RESULTS

Of an estimated 17.9 million deliveries, 10,462 occurred in women with hearing loss. In adjusted regression analyses controlling for demographic characteristics, women with hearing loss were significantly more likely than those without hearing loss to have preterm birth (OR=1.28, 95% CI=1.08, 1.52, p<0.001) and low birth weight (OR=1.43, 95% CI=1.09, 1.90, p<0.05).

CONCLUSIONS

This study provides a first examination of the pregnancy outcomes among women with hearing loss in the U.S. This analysis demonstrates significant disparities in birth outcomes between women with and without hearing loss. Understanding and addressing the causes of these disparities is critical to improving pregnancy outcomes among women with hearing loss.

On the same page: a novel interprofessional model of patient-centered perinatal consultation visits

OBJECTIVE

To plan and implement an interprofessional collaborative care clinic for women in midwifery care needing a consultation with a maternal-fetal medicine specialist.

STUDY DESIGN

A community-engaged design was used to develop a new model of collaborative perinatal consultation, which was tested with 50 women. Participant perinatal outcomes and semistructured interviews with 15 women (analyzed using qualitative descriptive analysis) and clinic providers were used to evaluate the model.

RESULTS

Participant perinatal outcomes following a simultaneous consultation visit involving a nurse-midwife and maternal-fetal medicine specialist were similar to practice and hospital averages. Women's comments on their experience were positive and had the theme 'on the same page' with six subcategories: clarity, communication, collaboration, planning, validation and 'above and beyond'. Providers also were pleased with the model.

CONCLUSION

A simultaneous consultation involving the woman, a nurse-midwife and a maternal-fetal medicine specialist improved communication and satisfaction among women and providers.