National BC Study II


Evidence Confirms Birth Centers Provide Top-Notch Care

By Rebekka Dekker, PhD, RN, APRN for the American Association of Birth Centers

We have reached a dramatic cross-road when it comes to maternity care in the U.S. Will we, as a country, continue on our current path of rising C-section rates, excessive costs, and poorer maternal outcomes than 33 other first-world countries?[1] Or will we begin to expand other options for receiving optimal care during our births?

A landmark study published in the Journal of Midwifery and Women’s Health,[2] shows that birth centers provide first-rate care to healthy pregnant women in the U.S. The purpose of this article is to fill you in on what the The National Birth Center Study II found and what it means for moms and families.

First, What is a birth center?

The American Association of Birth Centers defines a birth center as a home-like setting where care providers, usually midwives, provide family-centered care to healthy pregnant women. Most birth centers are located separately from hospitals, while a few are physically inside hospital buildings. In-hospital birth centers must meet certain standards for independence and must be separate from the Labor and Delivery unit in order to be considered true birth centers.[3]

Pregnancy and childbirth are healthy, normal life events for most women and babies. In birth centers, midwives and staff hold to the "wellness" model of birth, which means that they provide continuous, supportive care and interventions are used only when medically necessary.[4]

Birth centers are universally committed to family-centered care. In birth centers, the childbearing woman’s right to be the decision-maker about the circumstances of her birth is fully respected. For example, at birth centers, women are encouraged to eat if they are hungry, move about and spend time in a tub as they wish, and push in whatever positions they find most comfortable. Birth centers recognize that the mother knows what her body needs to give birth. The midwives and staff attend to her needs, while diligently watching for signs that are outside the realm of wellness.[3], [4]

How do birth centers and hospitals work together?

Even though they operate independently, birth centers that meet the standards of the American Association of Birth Centers are integrated within the healthcare system and refer clients to physician care or transfer to a hospital if medical needs arise. Some birth center midwives also have hospital privileges, so in those cases there is no interruption of care in the case of a transfer. In other cases, the midwives will stay with the mother through the transfer and serve in a support capacity for her.

Hospitals that partner with birth centers are known to experience the benefits of increased income and improved public relations. When hospitals partner with a birth center, these hospitals are extending the range of services they offer to the community.

How many women give birth in hospitals and birth centers today?

In the U.S., 98.8% of births take place in hospital labor and delivery units, with physicians attending 86% of these births.[5] In contrast, 0.3% of births take place in birth centers, where nurse-midwives and midwives provide most of the care.[5] Among women who give birth in hospitals, approximately 85% are considered low-risk,[6] while all women who are eligible for care at a birth center are healthy and low-risk.[2]

Since hospitals specialize in treating acute illness and injury, they are an obvious choice for women who have complications that require medical or surgical intervention or who choose to have high-intervention births. However, when normal, healthy pregnant women give birth in hospitals, their care often gets swept up into this same medical way of doing things. The philosophy is often "What if something bad happens?" instead of "What is happening right now?" Standard protocols, meant to prepare for problems that may never arise, can disrupt normal labor for healthy pregnant women.[4]

As a result, many women in hospitals receive interventions, whether or not they need them. Almost all women (87%) who labor in hospitals undergo continuous electronic fetal monitoring, 80% receive intravenous fluids, 47% have labor artificially accelerated with medications, and 43% of first-time moms have labor artificially induced.[7], [8] In addition, 60% of women giving birth in hospitals are not allowed to eat or drink, 76% are restricted to bed, and 92% give birth lying on their backs.[7] There is strong evidence that routine use of these practices, when carried out without medical indications, has few benefits and many potential harms for healthy mothers and babies.[8]-[15]

What is the new birth center study about?

The purpose of Stapleton et al.’s (2013) National Birth Center Study II was to describe the current outcomes of birth centers in the U.S.[2] The researchers enrolled 22,403 women who planned to give birth in a birth center when they registered for prenatal care at 79 birth centers across the U.S. between the years of 2007 and 2010.

The majority of birth centers in the study were accredited by the Commission for the Accreditation of Birth Centers, and women were cared for by certified nurse-midwives (80%), certified professional midwives and licensed midwives (14%), or teams made up of all three types of midwives (6%). Women were enrolled during their first prenatal visit and followed through pregnancy, birth, and for up to 6-weeks post-partum.

Who were the women in the study?

Women were eligible to give birth at a birth center if they were pregnant with a single baby, if they reached full-term, if the baby was in head-down position, and if there were no other major medical risk factors. In the end, the researchers only looked at outcomes for women who—by the end of pregnancy—were still planning to go to the birth center.

The final study sample was made up of 15,574 women. Three-quarters of the women were white, 11% were Hispanic/Latina, 6% were African American, 2% were Asian, 1% were Native American, and 3% were of other racial status. Most of the women were between the ages of 18 and 34 (85%), while 14% were 35 and older, and 1% was less than 18 years old.

Most of the women were married (80%), and 72% had at least some college education. About half the women were pregnant with their first baby, while the other half were experienced moms. As for payment method, 54% of the women had private insurance, 24% were on Medicaid, 15% used self-payment, 3% had military coverage, and 2% had Medicare. Very few of the moms smoked (1.5%) or abused substances (0.5%).

What were the outcomes for moms?

One of the most important findings of this study was that more than 9 out of 10 women (94%) who entered labor planning a birth center birth achieved a vaginal birth. In other words, the C-section rate for low-risk women who chose to give birth at a birth center was only 6%—compared to the U.S. C-section rate of 27% for low-risk women.[16] This means that the C-section rate for women in birth centers is more than 4 times lower than what is seen among low-risk women in the U.S.

How often did women end up being transferred to hospitals?

Out of the 15,574 women who planned to give birth at the birth center at the start of labor, most women (84%) ended up giving birth at the birth center. Out of the entire sample, 4.5% were referred to a hospital before being admitted to the birth center, 11.9% transferred to the hospital during labor, 2.0% transferred after giving birth, and 2.2% had their babies transferred after birth. Most of the in-labor transfers were first-time moms (82%).

Out of the 1,851 women who transferred to hospitals during labor, 54% ended up with a vaginal birth, 38% had a Cesarean, and 8% had a forceps or vacuum-assisted vaginal birth.

Most of the in-labor transfers were done for non-emergency reasons, such as prolonged labor. Less than 1% of the study sample (0.9% overall, number [n] = 140) transferred to the hospital during labor for emergency reasons. A very small percentage of women (0.4%, n = 67) and infants (0.6%, n = 94) transferred after birth for emergency reasons.

The most common reason for emergency transfer during labor was for non-reassuring fetal heart rate patterns (0.5%, n = 72), while the most common reasons for postpartum and newborn emergency transfers were postpartum hemorrhage (0.2%, n = 36) and newborn respiratory issues (0.4%, n = 66). Most cases of postpartum hemorrhage were handled safely in the birth center without any need for transfer. There were no maternal deaths.

What were the outcomes for babies?

Previously, large research studies have shown that birth centers have excellent outcomes for babies (for example, the 1985-1987 National Birth Center Study I).[17] The National Birth Center Study II describes current outcomes for 2007-2010.

In the National Birth Center Study II, there were 0.47 stillbirths per 1,000 women (.047%) and 0.40 newborn deaths per 1,000 women (.04%). Stillbirths were defined as deaths that occurred after the woman reached term but before giving birth, and newborn deaths were defined as deaths that took place after birth and during the first 28 days of life.

The stillbirth and newborn death rates in the National Birth Center Study II are comparable to what other researchers have reported when they studied low-risk women. The results are strikingly similar to the National Birth Center I Study, which took place about 25 years ago. At that time, researchers found a stillbirth rate of 0.3 per 1,000 and a newborn death rate of 0.3 per 1,000.[17]

The stillbirth and newborn death rates in the new National Birth Center Study II were also similar to what researchers in the United Kingdom found among low-risk women in hospitals, freestanding birth centers, and home births. In the 2011 Birthplace in England study,[18] stillbirth rates ranged from 0.0-0.7 per 1,000 in hospitals, to 0.1-2.2 in freestanding birth centers, and 0.1-1.0 in homes. Newborn death rates ranged from 0.1-0.8 in hospitals, to 0.1-1.3 in freestanding birth centers, and 0.1-1.0 in homes.

Because the National Birth Center Study II did not include a hospital comparison group, it is impossible for us to tell whether there is a statistical difference in deaths between planned birth center and planned hospital births. However, it is important to note that the rates that the birth center study reported are similar to what other researchers have observed in many different birth settings. The up-to-date statistics from the newly published National Birth Center Study II can better help families make informed decisions about where they choose to give birth.

Why is this finding about the low c-section rate so important?

The U.S. cesarean rate has increased substantially over the past few decades from 21% in 1996 to 32% of all births now.[19] Over half of the increase is among first time moms, and most of these C-sections are done for more subjective reasons such as slow progress in labor and changes in the baby’s heart rate that are sometimes difficult to interpret on continuous electronic fetal monitoring.[20] Meanwhile the cesarean rate has been stable in birth centers for over 20 years at 4.4-6%.[2], [17]

It is well-established that surgical births have short- and long-term health implications for mothers and babies. Although C-sections are obviously necessary in certain medical situations, women and their care providers must weigh potential benefits against the potential harms, including extended hospital stays and longer recovery time for women; breathing and other problems for newborns; and placenta problems in future pregnancies.[21]

Also, it’s important for you to know that having a C-section limits women’s birth choices in future pregnancies. More than half of women who want a vaginal birth after a Cesarean cannot find a supportive care provider[7]—even though vaginal birth after a Cesarean is a safe and appropriate choice for most women.[22] Ultimately, nine out of ten women in the U.S. who give birth by surgery will end up having subsequent babies by surgeries,[5] with the risk of harms rising with each surgery.[23]

Given these issues, it is important that we find a way to safely lower the rate of unnecessary C-sections in first-time moms. The National Birth Center Study II shows that when women receive midwifery-led care in birth centers, preventable C-sections are prevented.

What are the potential cost savings?

The researchers estimated that, in this study, more than $30 million was saved because of the 15,574 women who chose to give birth in birth centers.

Why do birth centers save money?

First of all, vaginal births in birth centers simply cost less. In 2011, the average Medicare/Medicaid facility services reimbursement for an uncomplicated vaginal birth in a hospital was $3,998, compared with $1,907 in birth centers. This factor alone saved $27.2 million in the National Birth Study II. Even if birth center reimbursements were adjusted to make payments fairer and more in line with hospital births, a decreased use of interventions would still translate into a significant cost-savings for insurance companies.

Second, the C-section rate in this study was 6%, compared to 27% for low-risk women who give birth in the U.S. If the 15,574 women who planned to give birth in birth centers had instead chosen hospital births, it is estimated that they would have experienced 3,000 additional—and unnecessary— Cesareans. Instead, these C-sections were safely and effectively prevented, along with a potential cost-savings of at least $4.5 million.

Right now, childbirth is the number one cause of hospitalization in the U.S.—accounting for one-fourth of all hospital discharges.[24] But only 0.3% of American women give birth in birth centers.[5] If even a small portion of hospital births were shifted towards birth centers, our nation would see a significant cost-savings, and more families would be receiving first-rate birth center care.

What is the bottom line for families?

Expecting families who choose the birth center setting in the U.S. can expect high-quality, family-centered care with a Cesarean rate of approximately 6%. Less than 2% of women who choose the birth center setting will require an urgent transfer for either mother or newborn. The stillbirth and newborn death rates are comparable to rates seen in other low-risk populations. The information provided by the new National Birth Center Study II will help women and families make evidence-based, informed decisions about their babies’ births.

What is the bottom line for physicians and hospitals?

For physicians and hospitals, this study confirms the original 1989 Birth Center Study findings that midwifery-led care in birth centers is safe. We now have evidence from two large-scale U.S. studies, along with the added advantage of more than 35 years of birth center experience. These findings should encourage physicians and hospitals to partner with birth centers in their communities. Partnerships will benefit hospitals through increased referral revenue and recognition, and benefit patients by making transitions of care as seamless and patient-centered as possible.

What is the bottom line for policy-makers?

Birth centers are a high-value option for maternity care and complement the existing hospital-based system. Care that is provided by birth centers fully meets the "triple aim" vision of healthcare: improving the experience of care, improving the health of populations, and reducing per capita costs of health.[25] Legislation is needed to align payment methods and regulations so that we can better promote the proliferation of birth centers.

About the Author

Rebecca Dekker, PhD, RN, APRN is a nurse researcher, educator, and founder of Evidence Based Birth. She also serves on the board of

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