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

Neonatal morbidity and mortality in birth centers in the United States 2018-2021: An observational study of low-risk birthing individuals

BACKGROUND

Many studies reporting neonatal outcomes in birth centers include births with risk factors not acceptable for birth center care using the evidence-based CABC criteria. Accurate comparisons of outcomes by birth setting for low-risk patients are needed.

METHODS

Data from the public Natality Detailed File from 2018 to 2021 were used. Logistic regression, including adjusted and unadjusted odds ratios, compared neonatal outcomes (chorioamnionitis, Apgar scores, resuscitation, intensive care, seizures, and death) between centers and hospitals. Covariates included maternal diabetes, body mass index, age, parity, and demographic characteristics.

RESULTS

The sample included 8,738,711 births (8,698,432 (99.53%) in hospitals and 40,279 (0.46%) in birth centers). There were no significant differences in neonatal deaths (aOR 1.037; 95% CI [0.515, 2.088]; p-value 0.918) or seizures (aOR 0.666; 95% CI [0.315, 1.411]; p-value 0.289). Measures of morbidity either not significantly different or less likely to occur in birth centers compared to hospitals included chorioamnionitis (aOR 0.032; 95% CI [0.020, 0.052]; p-value < 0.001), Apgar score < 4 (aOR 0.814, 95% CI [0.638, 1.039], p-value 0.099), Apgar score < 7 (aOR 1.075, 95% CI [0.979, 1.180], p-value 0.130), ventilation >6 h (aOR 0.349; [0.281,0.433], p-value < 0.001), and intensive care admission (aOR 0.356; 95% CI [0.328, 0.386], p-value < 0.001). Birth centers had higher odds of assisted neonatal ventilation for <6 h as compared to hospitals (aOR 1.373; 95% CI [1.293, 1.457], p-value < 0.001).

CONCLUSION

Neonatal deaths and seizures were not significantly different between freestanding birth centers and hospitals. Chorioamnionitis, Apgar scores < 4, and intensive care admission were less likely to occur in birth centers.

Associations Between State Practice Regulations and Access to Midwifery Care

INTRODUCTION

This study aimed to identify associations between state policies and access to midwifery care. Identifying policies that facilitate increased access to midwives will help policymakers determine the best methods for increasing access to midwives in their states.

METHODS

This cross-sectional study was conducted at the county level as a secondary analysis of National Vital Statistics data from the Natality online database. The unit of analysis was counties with populations of at least 100,000, and the outcome was the proportion of births attended by midwives in 2019. The potential predictors of increased access to midwifery care were independent midwife licensure, independent midwife prescribing, midwife access to hospital medical staff membership, and midwife Medicaid parity. Medicaid provider resources and state statutes verified Medicaid reimbursement rates and eligibility for hospital medical staff privileges. Each state was categorized as an independent or restricted licensure state according to data from the American College of Nurse-Midwives. Data for the control variable, the presence of a midwifery education program, were gathered from the Accreditation Commission for Midwifery Education. The analysis was conducted as a Poisson regression.

RESULTS

There was no association between independent licensing and increased access among all states. Stratifying the analysis by independent licensing law revealed that all but one policy was related to higher rates of midwife attendance at birth. Maximum Medicaid reimbursement correlated with greater access regardless of licensing status. The rate of midwife-attended births in independent licensing states grew as the number of potential predictors in a county increased.

DISCUSSION

Regulatory policies beyond independent licensing are associated with women's access to midwifery services. In independent licensing states, adopting additional policies favorable to midwives may strengthen access to midwifery. Policymakers and regulators can use these findings to identify strategies for accelerating the expansion of midwifery access in their states.

The birth center model of care: Staffing, business characteristics, and core clinical outcomes

OBJECTIVES

Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes.

METHODS

This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission.

RESULTS

The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations.

CONCLUSIONS FOR PRACTICE

Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.

Midwifery Workforce Density Moderates the Association Between Independent Practice and Pregnancy Outcomes

INTRODUCTION

Studies comparing pregnancy outcomes before and after state transition to independent midwifery practice have found little change in primary cesarean birth and preterm birth rates. One reason may be the failure to control for midwife density. The objective was to test if the local midwife density moderates the association between state independent midwifery practice and pregnancy outcomes.

METHODS

Birth records were abstracted from the State Inpatient Databases for 6 states. The Area Health Resource File provided county variables. Midwife density was operationalized as no midwives, low midwife density (<4.5 per 1000 births), and high midwife density (≥4.5 midwives per 1000 births). Multivariate logistic regression models compared primary cesarean birth and preterm birth, controlling for maternal and county characteristics. Moderation was tested by including an interaction term (independent practice × density) to the regression models. The magnitude of association for the interaction was measured by stratifying the models.

RESULTS

The study included 875,156 women; most (79.7%) resided in a county with low midwife density. Restricted midwifery practice was associated with increased odds of both primary cesarean birth and preterm birth. The interaction term was significant for both preterm birth and primary cesarean, indicating moderation. The largest magnitude of difference was the increased odds of preterm birth in counties with a high midwife density and restricted practice (odds ratio, 3.50; 95% CI, 2.43-5.06) compared with those with high midwife density and independent practice.

DISCUSSION

Midwife density moderates the association between independent midwifery practice and primary cesarean birth and preterm birth. Moderation may explain why prior studies found small or no changes in outcomes when states adopted independent practice. Moderation models can improve testing for associations with independent practice. Both midwife independent practice and increasing midwifery workforce size can be strategies to improve state pregnancy outcomes.

Prenatal care in US birth centers: Midwives' perceptions of contributors to birthing People's confidence in physiologic birth

OBJECTIVE

The purpose of this study was to describe US freestanding birth center models of prenatal care and to examine how the components of this care contribute to birthing people's confidence in their ability to have a physiologic birth.

DESIGN

This was a qualitative descriptive study utilizing semi-structured interviews with birth center midwives. Data were analyzed using thematic analysis, constant comparative method and consensus coding to ensure rigor.

SETTING AND PARTICIPANTS

Midwives from six urban and rural freestanding birth centers in a Midwestern US state were interviewed. Twelve birth center midwives participated.

FINDINGS

Six themes emerged: the birth center physical space and organization of care, dimensions of midwifery care within the birth center, continuity of care and seamless service, the empowered birthing person, physiologic birth as normative, and the hospital paradigm and US cultures of birth.

KEY CONCLUSIONS

We identified significant components of birth center models of prenatal care that midwives believe enhance birthing people's confidence for physiologic childbirth. These components may be considered for application to other settings and may improve perinatal care and outcomes.

Examining respect, autonomy, and mistreatment in childbirth in the US: do provider type and place of birth matter?

BACKGROUND

Analyses of factors that determine quality of perinatal care consistently rely on clinical markers, while failing to assess experiential outcomes. Understanding how model of care and birth setting influence experiences of respect, autonomy, and decision making, is essential for comprehensive assessment of quality.

METHODS

We examined responses (n = 1771) to an online cross-sectional national survey capturing experiences of perinatal care in the United States. We used validated patient-oriented measures and scales to assess four domains of experience: (1) decision-making, (2) respect, (3) mistreatment, and (4) time spent during visits. We categorized the provider type and birth setting into three groups: midwife at community birth, midwife at hospital-birth, and physician at hospital-birth. For each group, we used multivariate logistic regression, adjusted for demographic and clinical characteristics, to estimate the odds of experiential outcomes in all the four domains.

RESULTS

Compared to those cared for by physicians in hospitals, individuals cared for by midwives in community settings had more than five times the odds of experiencing higher autonomy (aOR: 5.22, 95% CI: 3.65-7.45), higher respect (aOR: 5.39, 95% CI: 3.72-7.82) and lower odds of mistreatment (aOR: 0.16, 95% CI: 0.10-0.26). We found significant differences across birth settings: participants cared for by midwives in the community settings had significantly better experiential outcomes than those in the hospital settings: high- autonomy (aOR: 2.97, 95% CI: 2.66-4.27), respect (aOR: 4.15, 95% CI: 2.81-6.14), mistreatment (aOR: 0.20, 95% CI: 0.11-0.34), time spent (aOR: 8.06, 95% CI: 4.26-15.28).

CONCLUSION

Participants reported better experiential outcomes when cared for by midwives than by physicians. And for those receiving midwifery care, the quality of experiential outcomes was significantly higher in community settings than in hospital settings. Care settings matter and structures of hospital-based care may impair implementation of the person-centered midwifery care model.

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.

Midwifery Autonomy and Employment Changes During the Early COVID-19 Pandemic

INTRODUCTION

The COVID-19 pandemic presented the midwifery workforce with challenges for maintaining access to high-quality care and safety for patients and perinatal care providers. This study analyzed associations between different types of professional autonomy and changes in midwives' employment and compensation during the early months of the pandemic.

METHODS

An online survey distributed to midwifery practices in fall 2020 compared midwives' employment and compensation in February 2020 and September 2020. Chi-square analysis determined associations between those data and measures of midwives' autonomy: state practice environment, midwifery practice ownership, intrapartum practice setting, and midwifery participation in practice decision-making.

RESULTS

Participants included lead midwives from 727 practices, representing 50 states and the District of Columbia. Full-time equivalent (FTE) positions and number of full-time midwives were stable for 77% of practices, part-time employment for 83%, and salaries for 72%. Of the remaining practices, more practices lost FTE positions, full-time positions, part-time positions, and salary (18%, 15%, 9%, and 18%, respectively) than gained (11%, 8%, 8%, and 9%, respectively). Early retirements and furloughs were experienced by 9% of practices, and 18% lost benefits. However, midwifery practice ownership was significantly associated with increased salaries (20.3% vs 7.1%; P < .001) and decreased loss of benefits (7.8% vs 19.9%; P = .002) and furloughs (3.8 vs 10.1%; P = .04). Community-based practice was significantly associated with increased FTE positions (19.0% vs 8.8%; P = .005), part-time positions (17.4% vs 5.1%; P < .001), and salary (19.7% vs 7.0%; P < .001), as well as decreased loss of benefits (11.5% vs 21.1%; P = .02) and early retirement (1.4% vs 6.6%; P = .03). State practice environment and participation in practice decision-making were not directly associated with employment and compensation changes.

DISCUSSION

Policies should facilitate midwifery practice ownership and the expansion and integration of community birth settings for greater perinatal care workforce stability, greater flexibility to respond to disasters, and improved patient access to care and health outcomes.

Place of Birth Preferences and Relationship to Maternal and Newborn Outcomes Within the American Association of Birth Centers Perinatal Data Registry, 2007-2020

PURPOSE

The purpose of this study was to describe sociodemographic variations in client preference for birthplace and relationships to perinatal health outcomes.

METHODS

Descriptive data analysis (raw number, percentages, and means) showed that preference for birthplace varied across racial and ethnic categories as well as sociodemographic categories including educational status, body mass index, payer status, marital status, and gravidity. A subsample of medically low-risk childbearing people, qualified for birth center admission in labor, was analyzed to assess variations in maternal and newborn outcomes by site of first admission in labor.

RESULTS

While overall clinical outcomes exceeded national benchmarks across all places of admission in the sample, disparities were noted including higher cesarean birth rates among Black and Hispanic people. This variation was larger within the population of people who preferred to be admitted to the hospital in labor in the absence of medical indication.

CONCLUSION

This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation.

We Are Not Asking Permission to Save Our Own Lives: Black-Led Birth Centers to Address Health Inequities

PURPOSE

While favorable outcomes of birth centers are documented, Black-led birth centers and maternal health models are rarely highlighted. Such disparities are manifestations of institutional racism. A nascent body of literature suggests that culturally affirming care provided by Black-led birth centers benefit all birthing people-regardless of race. Birth Detroit is one such maternal health model led by Black women that offers a justice response to inequitable care options in Black communities.

METHODS

This article describes a departure from traditional White supremacist research models that privilege quantitative outcomes to the exclusion of iterative processes, lived experiences, and consciousness-raising. A community organizing approach to birth center development led by Black women and rooted in equity values of safety, love, trust, and justice is outlined.

RESULTS

Birth Detroit is a Black-led, community-informed model that includes integration of evidence-based approaches to improving health outcomes and that embraces community midwifery prenatal care and a strategic trajectory to open a birth center in the city of Detroit.

CONCLUSION

Birth Detroit demonstrates the operationalization of a Black feminist standpoint, lifts up the power of communities to lead in their own care, and offers a blueprint for action to improve inequities and maternal-infant health in Black communities.

Associations between Place of Birth, Type of Attendant, and Small for Gestational Age Births among Pregnant non-Hispanic Black Medicaid Recipients

INTRODUCTION

Although non-Hispanic Black women have increased risks of adverse birth outcomes compared with non-Hispanic white women in the United States, there is a lack of research specifically focusing on non-Hispanic Black women. Thus, this study's purpose was to evaluate whether place of birth and type of attendant used during labor is associated with having a newborn born small for gestational age (SGA) among non-Hispanic Black Medicaid recipients.

METHODS

This study used 2017 Natality data from the National Vital Statistics System for non-Hispanic Black women who used Medicaid as a source of payment (N = 322,604). Type of attendant (ie, the medical professional who assisted during childbirth), place of birth (ie, setting where the woman gave birth), maternal factors, and SGA were obtained from birth certificates. We used multivariate logistic regression to investigate the association between place of birth, type of birth attendant, and newborns born SGA.

RESULTS

After adjustment, women who used a certified nurse-midwife or other midwife as an attendant during labor had statistically significant decreased odds of having a neonate born SGA compared with those who had a physician as an attendant (odds ratio [OR], 0.69; 95% CI, 0.66-0.71 and OR, 0.68; 95% CI, 0.55-0.85, respectively). Those who gave birth in a birthing center or had planned home births also had statistically significant decreased odds of having a neonate born SGA (OR, 0.52; 95% CI, 0.38-0.69 and OR, 0.37; 95% CI, 0.21-0.66, respectively). However, those who had an unplanned home birth had twice the odds of having a neonate born SGA compared with those who gave birth at a hospital or clinic (OR, 2.00; 95% CI, 1.50-2.64).

DISCUSSION

Given the racial disparity in adverse birth outcomes for non-Hispanic Black women, the observed associations provide justification for future research to determine whether birthing location and birth attendant are related to SGA.

Freestanding Birth Centers: An Evidence-Based Option for Birth

Every childbearing person has the right to learn about all options for perinatal care provider and birth setting. To ensure an informed decision about their preferred birth plan, information should be provided either preconceptionally or in early pregnancy. Personal preferences and risk status should be considered in decision-making. Numbers of births in birth centers have doubled over past decade to almost 20,000 births per year. The evidence shows that childbearing people who participate in birth center care, even if they have only birth center prenatal care, experience better outcomes including lower rates of preterm birth, low birth weight births, and cesarean birth, and higher rates of breastfeeding when compared to people with similar risk profiles who receive typical perinatal care.

Let complete numbers speak for themselves

The authors describe the challenges they encountered, having attempted to retrospectively complete a home birth outcome data set for New York State. In addition, they provide a compelling argument for a midwifery data collective that would bring together health record data for all midwife-attended births nationwide, regardless of setting.

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.

Rural resilience: The role of birth centers in the United States

PURPOSE

To explore the role of the birth center model of care in rural health and maternity care delivery in the United States.

METHODS

All childbearing families enrolled in care at an American Association of Birth Centers Perinatal Data Registry^TM user sites between 2012 and 2020 are included in this descriptive analysis.

FINDINGS

Between 2012 and 2020, 88 574 childbearing families enrolled in care with 82 American Association of Birth Centers Perinatal Data Registry^TM user sites. Quality outcomes exceeded national benchmarks across all geographic regions in both rural and urban settings. A stable and predictable rate of transfer to a higher level of care was demonstrated across geographic regions, with over half of the population remaining appropriate for birth center level of care throughout the perinatal episode of care. Controlling for socio demographic and medical risk factors, outcomes were as favorable for clients in rural areas compared with urban and suburban communities.

CONCLUSIONS

Rural populations cared for within the birth center model of care experienced high-quality outcomes.

HEALTH POLICY IMPLICATIONS

A major focus of the United States maternity care reform should be the expansion of access to birth center models of care, especially in underserved areas such as rural communities.

The Experience of Land and Water Birth Within the American Association of Birth Centers Perinatal Data Registry, 2012-2017

Consumer demand for water birth has grown within an environment of professional controversy. Access to nonpharmacologic pain relief through water immersion is limited within hospital settings across the United States due to concerns over safety. The study is a secondary analysis of prospective observational Perinatal Data Registry (PDR) used by American Association of Birth Center members (AABC PDR). All births occurring between 2012 and 2017 in the community setting (home and birth center) were included in the analysis. Descriptive, correlational, and relative risk statistics were used to compare maternal and neonatal outcomes. Of 26 684 women, those giving birth in water had more favorable outcomes including fewer prolonged first- or second-stage labors, fetal heart rate abnormalities, shoulder dystocias, genital lacerations, episiotomies, hemorrhage, or postpartum transfers. Cord avulsion occurred rarely, but it was more common among water births. Newborns born in water were less likely to require transfer to a higher level of care, be admitted to a neonatal intensive care unit, or experience respiratory complication. Among childbearing women of low medical risk, personal preference should drive utilization of nonpharmacologic care practices including water birth. Both land and water births have similar good outcomes within the community setting.

Improving the Experience of Care: Results of the American Association of Birth Centers Strong Start Client Experience of Care Registry Pilot Program, 2015-2016

In 2018, the Center for Medicare and Medicaid Innovation in the United States (US) released report demonstrating birth centers as the appropriate level of care for most Medicaid beneficiaries. A pilot project conducted at 34 American Association of Birth Centers (AABC) Strong Start sites included 553 beneficiaries between 2015 and 2016 to explore client perceptions of high impact components of care. Participants used the AABC client experience of care registry to report knowledge, values, and experiences of care. Data were linked to more than 300 process and outcome measures within the AABC Perinatal Data Registry™. Descriptive statistics, t tests, χ analysis, and analysis of variance were conducted. Participants demonstrated high engagement with care and trust in pregnancy, birth, and parenting. Beneficiaries achieved their preference for vaginal birth (89.9%) and breastfeeding at discharge through 6 weeks postpartum (91.7% and 87.6%). Beneficiaries reported having time for questions, felt listened to, spoken to in a way they understood, being involved in decision making, and treated with respect. There were no variations in experience of care, cesarean birth, or breastfeeding by race. Medicaid beneficiaries receiving prenatal care at AABC Strong Start sites demonstrated high levels of desired engagement and reported receiving respectful, accessible care and high-quality outcomes. More investment and research using client-reported data registries are warranted as the US works to improve the experience of perinatal care nationwide.

Strong Start in birth centers: Socio-demographic characteristics, care processes, and outcomes for mothers and newborns

BACKGROUND

A recent Center for Medicare and Medicaid Innovation report evaluated the four-year Strong Start for Mothers and Newborns Initiative, which sought to improve maternal and newborn outcomes through exploration of three enhanced, evidence-based care models. This paper reports the socio-demographic characteristics, care processes, and outcomes for mothers and newborns engaged in care with American Association of Birth Centers (AABC) sites.

METHODS

The authors examined data for 6424 Medicaid or Children's Health Insurance Program (CHIP) beneficiaries in birth center care who gave birth between 2013 and 2017. Using data from the AABC Perinatal Data Registry™, descriptive statistics were used to evaluate socio-behavioral and medical risks, and core perinatal quality outcomes. Comparisons are made between outcomes in the AABC sample and national data during the study period.

RESULTS

Childbearing mothers enrolled at AABC sites had diverse socio-behavioral risk factors similar to the national profile. The AABC sites exceeded national quality benchmarks for low birthweight (3.28%), preterm birth (4.42%), and primary cesarean birth (8.56%). Racial disparities in perinatal indicators were present within the Strong Start sample; however, they were at narrower margins than in national data. The enhanced model of care was notable for use of midwifery-led prenatal, labor, and birth care and decreased hospital admission.

CONCLUSIONS

Birth center care improves population health, patient experience, and value. The model demonstrates the potential to decrease racial disparity and improve population health. Reduction of regulatory barriers and implementation of sustainable reimbursement are warranted to move the model to scale for Medicaid beneficiaries nationwide.

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.

Facility Design: Reimagining Approaches to Childbirth in Hospital and Birth Center Settings

Few maternity care clinicians are aware of the current regulations that guide design standards for childbirth facilities in the United States or the regulatory history. There is considerable variance among state regulations as well as oversight of facility standards for healthcare settings. Understanding evidence-based recommendations on how facility design affects health outcomes is critical to reversing the rise in maternal mortality and morbidity. A variety of measures can be implemented that promise to improve user satisfaction, quality of care, and efficiency for all who engage in the childbirth environment. Recommendations for change include broader assessment to better understand how clinicians and consumers simultaneously maneuver within a complex system. Key metrics include evaluation of workflow within available space, patient acuity and census patterns, integration of evidence-based recommendations, and options that promote physiologic birth. For the changes to succeed, human centered design must be implemented and diverse clinicians and consumers engaged in all phases of planning and implementation. Exploring characteristics and outcomes of low-risk women who receive care in a freestanding birth center or the European alongside maternity unit provides opportunity to reimagine and address improvements for inpatient, hospital birth.

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.