In Out-of-Hospital Birth

With the Duchess of Cambridge apparently lobbying for a home birth (Be it ever so grandiose, there’s no place like home?) and inspiring U.K. women to follow in her wake, it seems relevant to summarize the newest community birth study, a New Zealand study of freestanding birth centers.

In New Zealand, 9% of women give birth in freestanding birth centers, which are defined as primary care maternity units that provide midwifery care to women anticipating uncomplicated births and where neither epidural analgesia nor instrumental or surgical delivery are available. Investigators compared outcomes in 10,448 women at low risk of complications (≥ 37 wk of pregnancy, one, head-down baby; no prior cesarean; no specific indications for cesarean such as placenta previa; no diabetes, and no lethal congenital anomalies) who labored at birth centers with outcomes in 36,933 similar women who labored in hospitals and began labor spontaneously. Of note, most New Zealand women planning hospital birth would also have been under the care of self-employed midwives, that is, midwives not working for obstetricians or hospitals.

The point of the study was to see if outcomes followed the pattern of other studies of birth centers and home births, notably the Birthplace in England study, these being less use of medical intervention and equivalent or superior outcomes compared with similar women planning hospital birth. Not surprisingly, they did. Specifically, 1st-time mothers were much less likely have cesareans (7% vs. 13%) and less likely to have an instrumental vaginal delivery (14% vs. 17%) or require a blood transfusion (9 vs. 24 per 1000). Indeed, the difference in cesarean rates probably would have been greater had the study not excluded women having labor inductions from the hospital group. Babies of 1st-time mothers in the birth center group were also less likely to be admitted to neonatal intensive care (5% vs. 6%), and perinatal mortality rates (deaths during labor or newborn deaths) were similar. Results were similar for women with prior births, although absolute numbers were lower and absolute differences smaller. Investigators concluded:

These findings indicate that routine hospital birth is not necessarily safer for low-risk pregnancies; with appropriate case selection it is likely that a large proportion of women who currently birth in obstetric units could safely birth in community units.

Interestingly, the Scots have taken up that challenge. The health ministry is launching a pilot program to test reorganizing their maternity care system to funnel healthy women into freestanding birth centers staffed by midwives.

Even more interesting, after many years of opposition, the U.S. obstetricians’ professional organization, the American College of Obstetricians & Gynecologists (ACOG), has come around to endorsing birth in freestanding birth centers. In 2015 it published “Obstetric Care Consensus: Levels of Maternal Care”  in which it defined criteria for appropriate candidates, midwife qualifications, staffing levels, capacity to deal with urgent events, and access to medical consultation and ability to transfer care smoothly and efficiently to a hospital, which, if met, would make birth center care acceptable.

In fact, while ACOG continues to oppose home birth, the needle has moved on that too. Its 2017 Committee Opinion acknowledges that favorable outcomes can be achieved with appropriate selection of candidates, midwives whose education and licensure meet International Confederation of Midwives Global Standards, and access to consultation and timely transport to hospital care. Many home birth midwives meet these criteria—or at least they would if obstetricians and hospitals would cooperate in setting up the means of consulting, collaborating, and transferring care. ACOG, however, despite considering this crucial for home birth safety, goes no further than a mild plea that when transfer occurs, “the receiving health care provider should maintain a nonjudgmental demeanor with regard to the woman and those individuals accompanying her to the hospital” (p. 4).

In short, should the Duchess opt for birth outside of the hospital, it’s a fine decision and ditto for those who want to follow her lead.

The Take-Away: This latest study adds to the pile all concluding that women at low risk of experiencing labor complications would probably be better off at a freestanding birth center than with usual management in a typical hospital, provided the birth center meets certain criteria, or, for that matter, at home provided the same. (See the American Association of Birth Centers for more information on birth center births and the Midwives Alliance of North America for more information on home birth.)

Tip: Don’t be fooled by hospitals calling their labor & delivery units “birth centers.” In most cases, it’s no more than a marketing-friendly name, not a distinctive model of care.

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