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1 Basic Concepts and
Descriptive Data
Recognizing a need for research on alternative birth settings, the
Office for Maternal and Child Health (OMCB) provided a grant in Sep-
tember 1980 to the National Academy of Sciences (NAS), through its
Institute of Medicine and Commission on Life SCiences, to undertake a
study of methodological approaches for such research. The OMCB sup-
ports projects on alternative birth settings but generally lacks data
on which to make judgments about the strengths and liaitations of
various child-delivery facilities. The absence of adequate evaluation
data has fueled a growing controversy among the various advocates of
particular birth settings regarding a whole range of outco.e measures,
such as safety, cost, and quality of the childbirth experience. The
controversy, OMCB concluded, will abate only with the development of a
sound body of data about various aspects of current birth practices,
including birthplace. The methodological difficulties in conducting
such research, however, are great--thus the request to NAS for guidance
on how best to design research directed at increasing the available
information on alternative birth settings. The presumption is that
good research methods should lead to scientific findings that provide
the basis for informed, rational decision-aaking about various options
for childbirth.
In approaching its task the study comaittee focused on three seta
of isaueaa (1) the provision of background information along with a
range of research designs and approaches appropriate to the study of
various aspects of childbirth practices' (2) the use of risk assessment
and screening criteria and how this affects the choice of a study popu-
lation, and (3) valid outcome measures--including medical, psychologi-
cal, and social variables--and ways to study them. These three sets of
issues are examined in Chapters 2-4 and are supplemented by papers in
Appendixes A-F. The committee did not address econo.ic issues directly,
because they were considered to be outside its range of expertise. How-
ever, recognizing that coat issues will be an important part of any
choice of appropriate maternity care by prospective parents, the comait-
tee commissioned the paper that appears in Appendix B.
The committee recognized that the experiences of such countries as
Britain and Holland are relevant sources of information about various
birth settings and decided that a critical review of this literature
would make a valuable contribution. As a first step the comaittee
10
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11
reviewed the history of maternity practices in the United States and
studied the range of birth settings currently in use, both the physical
sites and the typical maternity care providers and practices. Data on
trends in childbirth settings were reviewed. The committee recognized
that there are many value judgments surrounding childbirth and that
questions and arguments will probably continue regardless of new infor-
mation. This chapter gives an overview of the background and defini-
tions of the birth setting.
BIS'l'ORY OF MATERNITY CARE IN THE UNITED STATES
During the nineteenth century in the United States, obstetrics had not
yet developed as a medical specialty, and the training of birth atten-
dants was •ager. Moat deliveries took place at heme and were attended
by granny (or lay) •idwivea whose knowledge and experience varied
widely. In 1900 fewer than 5 percent of all American babies were born
in a hospital. Midwives with little training attended approximately 50
percent of home birthsr other births were attended by neither physician
nor midwife. COntroversies surrounding the quality of midwife services
helped to bring public and professional attention to the problema
associated with inadequate childbirth practices. In one study, midwives
in New York City in 1906 were found to be •hopelessly dirty, ignorant,
and incompetent• (Edgar, 1911). Laws were passed requiring formal
training, licensing, and supervision of •idwivea, and in 1931 a formal
education program for nurse midwives was established in the United
States (Lubic, 1980). 1
At that time, also, training of physicians in birth practices was
considered poor, and obstetrics was viewed as the weakest of medical
specialties (Flexner, 1910r Williams, 1912).1 Increased attention to
medical intervention in childbirth encouraged the training of more
obstetricians and the delivery of more babies in hospitals. Now the
role of physicians baa eclipsed that of midwives as birth attendants.
By 1979 physicians were attending 97.4 percent of u.s. births, primarily
in hospitals (Devitt, 1977r National Center for Health Statistics,
198lb), while certified nurse •idwivea (CNMs) and lay midwives attended
only 1.6 percent of all births, about 80 percent of the• in hospitals.
Maternity care during the twentieth century baa gone through four
1 Since 1931 a graduate training program baa existed in the united
States for training nurse midwives who are then certified by the
profession. Lay midwives today often must receive training before they
can be licensed by a state.
1 Numeroua articles document the history of obstetric care and the
controversy over the variability of childbirth settings in the United
States and Europe (Baldock, 198lr DeLee, 1920r Devitt, 1977, 1979a,br
Edgar, 19llr Huntington, 1913r Irving, 1937r Kosmak, 1938r Marlette,
1925r Moran, 1915r Williams, 1912r Ziegler, 1922).
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12
periods of shifting emphasis. At first, concern was focused on the
relatively high rates of maternal mortality and on the need to make
labor and delivery safer for the mother. Hospitals were opened in rural
areas, physicians expanded obstetrical training and researchJ and many
developments in other fields, such as the discovery of antibiotics,
benefited maternity care. As a result, the incidence of infection and
the complications of bleeding and toxemia were drastically reduced, and
maternal mortality rates fell (see Figure 1 and Table 1).
A second phase in maternity care emphasized the relief of pain dur-
ing birth. Efforts were made to allay maternal anxiety about the labor
and delivery process. Advances in analgesia, anesthesia, and psychopro-
phylaxis were applied to childbirth. Only later was it recognized that
same types of anesthesia could adversely affect both mother and infant
(Speert, 1980).
For many years the reduction in maternal mortality was not ace~
panied by comparable improvements in neonatal or infant survival rates
(Table 1). Recognition of this discrepancy led to the third, or peri-
natal, phase of care that has characterized obstetrics for the past 15
years. Technological advances in methods of maternal, fetal, and neo-
natal surveillance, together with changes in clinical practice, have
significantly improved the likelihood that the outcome of pregnancy
will be a healthy infant (Chase, 1972J Committee on Perinatal Health,
1976J Lee et al., 1980J Paneth, 1982J world Health Organization, 1970J
and Williams and Chen, 1982).
In recent years there has been a resurgence of interest in and
emphasis on the effects of psychological factors on the short- and
long-term health of aother and baby. 'l'his fourth phase of change in
obstetrical practice has attempted to provide psychological satisfac-
tion with safe physical outcomes of pregnancy (Ryan, 1981J Stone, 1979).
Because a normal pregnancy does not strictly fit the medical .odel of
disease, doubts have arisen about the necessity for conventional hospi-
tal care, and interest has developed in alternative forms of care that
are believed to provide psychological benefits.
RANGE OF AND TRENDS IN BIRTH SETTING
A wide range of birth settings is available in the United States today.
Tbe birth setting is defined by the particular combination of providers
of aaternity services, the delivery site, the type of equi~nt, the
range of services, and the recipients of care. Birth settings vary
because of the philosophies and practices of those who control the
childbirth environment. 'l'he within-category variation in childbirth
practices, providers, and clientele may be as great as or greater than
differences between sites. Childbirth practices will continue to
evolve, and settings will continue to change, adding to the difficulty
of research. In the sections that follow, five principal types of
physical sites for childbirth are described, and some summary comments
are aade about their perceived advantages and disadvantages. Because
of the issues raised above, these examples should be viewed as
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100
\
\
\
\
\
\ - - - Intent Mon.lity ~te
\ P., 1,000 Live Birth1
80 . \
;. \
- Neonetal Mo!UIIty Rete
IW 1,000 Llw Blrth1
i ·;_ \ · - - - Meternel Mo!UIIty Rete
IW 10,000 Llw Blnhl
i .. \
·. \
!
:
. . '
\.. ' '
!
...\... ··'' ·...
~ ··'
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eo ''·•.,;
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40 ~ \
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--- ...............
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20
' ',,
', ,,
1920 1930 1940 1950 1980 1970 1980
YEAR
PIGURB 1 Neonatal, Infant, and Maternal Mortality Rates, 1915-1980.
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TABLE 1 Neonatal, Infant, and Maternal Mortality Rates by Race, 1915-1980
Neonatal Mortality Rate Infant Mortality Rate Maternal Mortality Rate
per 1,000 Live Births per 1,000 Live Births Per 10,000 Live Births
Black and - Black and Black and
Year Total White Other Total White Other Total White Other
1980 8.4 N/A N/A 12.5 N/A N/A 0.7 N/A N/A
1975 11.6 10.4 16.8 16.1 14.2 24.2 1.3 0.9 2.9
1970 15.1 13.8 21.4 20.0 17.8 30.9 2.2 1.4 5.6
1965 17.7 16.1 25.4 24.7 21.5 40.3 3.2 2.1 8.4
1960
1955
1950
18.7
19.1
20.5
17.2
17.7
19.4
26.9
27.2
27.5
26.0
26.4
29.2
22.9
23.6
26.8
43.2
42.8
44.5
3.7
4.7
8.3
2.6
3.3
6.1
9.8
13.0
22.2
..
....
1945 24.3 23.3 32.0 38.3 35.6 57.0 20.7 17.2 45.5
1940 28.8 27.2 39.7 47.0 43.2 73.8 37.6 32.0 77.4
1935 32.4 31.0 42.7 55.7 51.9 83.2 58.2 53.1 94.6
1930 35.7 34.2 47.4 64.6 60.1 99.9 67.3 60.9 117.4
1925 37.8 36.8 49.5 71.7 68.3 110.8 64.7 60.3 116.2
1920 41.5 40.4 55.0 85.8 82.1 131.7 79.9 76.0 128.1
1915 44.4 N/A N/A 99.9 98.6 181.2 60.8 60.1 105.6
NOTE: Figures for 1980 are estimatesr N/A indicates information not available for that year or
category.
SOURCES: National Center for Health Statistics, 198lar u.s. Department of Commerce, Bureau of the
Census, 1975, 1980.
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15
illustrative rather than definitive and are included only to give some
feeling for differences.
Home Deliveries
Rome births take place in circumstances ranging from no attendant other
than family members to an organized home birth service attended by
licensed professionals. The circumstances of the delivery are as
varied as the home environment. Several reports of existing home birth
services cite both the advantages and disadvantages of home births
(Adamson, 19811 Adamson and Gare, 19801 Burnett et al., 19801 Cameron
et al., 19791 Eischen and Nelson, 198la Mehl et al., 19771 Stillwell,
1979) (see Appendix A). The advantages include psychological benefits
of giving birth in familiar surroundings and supported by family and
friends, and lower costs. Standards for the delivery of care in the
home have been established by the American College of Nurse Midwives
(1980), but many still consider home births unsafe. The lesser ability
of home birth attendants to deal with complications and the relative
lack of emergency backup are considered •ajor disadvantages.
Freestanding Birth Centers
Freestanding birth centers are facilities separate from hospitals that
provide maternity care to those expecting normal childbirths (Bennetts
and Lubic, 19821 Lubic, 19801 Lubic and Ernst, 1978). The facilities
are customarily managed by nurse midwives and are typically equipped to
provide prenatal, peripartua, and neonatal care. Following delivery,
families stay in the center for 12 to 24 hours and receive follow-up
care in their homes, often by public health nurses. Participating
attendants may including obstetricians, certified nurse •idwives, nurse
•idwife assistants, pediatricians, public health nurses, ancillary and
support personnel, and families theaselves. Freestanding birth centers
must meet local health and safety codes and usually have agree•ents with
a laboratory, an ambulance service, and a backup hospital for use as
needed by their patients.
Many families feel that there are advantages to deliveries in places
other than hospitals (Adamson and Gare, 19801 Bennetts and Lubic, 19821
Eischen and Nelson, 19811 Pragmatics, Inc., 19781 Stillwell, 1979).
The advantages of birth in a freestanding center include a recognized
standard of care by professional providers, an environment seen as both
medically safe and psychologically secure, and a coat less than that in
hospitals. Disadvantages include physical separation from e•ergency
personnel and hospital facilities.
Hospital-Based Birth Centers
The hospital-based birth center, an integral part of a hospital's
obstetrical service, is designed to provide low-risk obstetrical
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patients with family-centered care in a homelike setting. The birth
center conforms with the licensing regulations that apply to the hos-
pital itself, but the philosophy of most centers is to provide a more
relaxed setting than is present in the conventional obstetrical facility
(Barton et al., 1980J Faxel and Keiffer, 1980J Nelson, 1979J Pragmatics
Inc., 1978J Schmidt, 1980J Sumner, 1976).
One major advantage claimed for the hospital-based birth center over
the freestanding center is proximity to emergency care facilities. Some
critics, however, feel that noninterventive, personalized care for a
normal birth in such centers is eroded by the proximity of a high-tech-
nology setting.
Conventional Hospital Perinatal Units
Modern conventional hospital perinatal units reflect varying degrees of
integration of conventional and alternative practices. Present-day
practice is moving from the traditional separate labor and delivery
rooms to a single roam. Illllediately after delivery, mother and baby
reaain together for a period of time. In many hospitals, mothers can
opt for •roaming-in• of their babies.
Hospital Maternity Units
The conventional hospital aaternity unit consists of discrete labor,
delivery, postpartum, and nursery areas. In addition, facilities for
dealing with obstetrical co.plications are located close to these unitsa
high-risk labor rooms, operative delivery rooms, intensive care nurser-
ies, and special aaternal recovery rooms. Labor occurs in one room,
and the patient is moved to a second room for the actual birth. '.l'be
infant often is taken immediately to a nursery. Physical facilities
and practices tend to separate faaily members. Advocates of births in
places other than hospitals believe that the use of technology and
intervention in normal births may lead to iatrogenic disease and
co.plications.
Trends in Delivery in Different Sites
Trends in births in the various birth locations described above are
difficult to determine because no reliable nationwide data about birth
sites are available. Tbe National Center for Health Statistics (NCBS)
has derived data on birthplaces from state birth certificates and desig-
nates place of delivery as •in hospital,• •not in hospital,• or •not
specified.• Table 2 shows the number and percent distribution for hos-
pital and nonhospital (including not specified) births for selected
years through 1979. According to these statistics, there was a steady
decrease in the percentage of nonhospital births from 1960 to 1974J the
percentage of nonhospital births increased minimally in 1977 and then
fell again.
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17
TABLE 2 Nwnber and Percent Distribution of Live Births by Place of
Delivery, 1960, 1965-1979
Hospital Not in Hospital
Total Live
Year Births Number Percent Number Percent
1979 3,494,398 3,460,484 99.0 33,914 1.0
1978 3,333,279 3,300,659 99.0 32,620 0.9
1977 3,326,632 3,277,536 98.5 49,096 1.5
1976 3,167,788 3,123,963 98.6 43,825 1.4
1975 3,144,198 3,104,549 98.7 39,649 1.3
1974 3,159,958 3,133,797 99.2 26,161 0.8
1973 3,136,965 3,114,503 99.3 22,462 0.7
1972 3,258,411 3,233,703 99.2 24,708 0.8
1971 3,555,970 3,523,840 99.1 32,130 0.9
1970 3,731,386 3,708,142 99.4 23,244 0.6
1969 3,600,206 3,566,260 99.1 33,946 0.9
1968 3,501,564 3,449,250 98.5 52,314 1.5
1967 3,520,959 3,459,771 98.3 61,188 1.7
1966 3,606,274 3,534,608 98.0 71,664 2.0
1965 3,760,358 3,660,712 97.4 99,646 2.6
1960 4,257,850 4,114,368 96.6 143,482 3.4
NOTE: Pigures for births occurring outside hospitals include cases for
which place of delivery was not specified.
SOURCES: National Center for Health Statistics, 1977, 1980, 1981b, 198lc.
Tbe method used by NCBS for classifying hospital and nonhospital
births may obscure small shifts in nonhospital births. Por example,
births in freestanding birth centers are classified by NCHS as hospital
births. Yet the number of freestanding birth centers has increased
from 3 in 1975 to 130 in 1982 (Lubic, 1982). Also, nonhospital births
occur in such diverse locations as doctors' offices, ambulances, public
places, and homes. Therefore, these data are unreliable indices for
demonstrating trends in planned home births.
Because of inadequacies in the NCHS data, it is difficult to esti-
mate the numbers of births that take place outside hospitals. Tbe
Oregon State Health Division reported that 4.4 percent of all registered
births in the state in 1981 were outside hospitals (Oregon Center for
Health Statistics, 1982). Using the Oregon figure as an upper limit
(NCHS indicates Oregon is one of the states with a high percentage of
home births) and the NCBS average figure of approximately 1 percent
(conceding that this underreport& the number of nonhospital births), it
can be determined that, out of 3,598,000 live births in 1980, between
35,980 and 158,422 babies were born outside of hospitals. A second
estimate can be derived from data on births in hospitals during 1980
(Aaerican Hospital Association, 1980). Subtracting 3,408,482 hospital
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births from the total of 3,598,000 live births in 1980 yields an esti-
mated 189,518 nonhospital births. Data from the American Hospital Asso-
ciation produce a higher estimate because of the absence of a 100 per-
cent response rate, exclusion of noncommunity hospitals (i.e., federal
and other public health facilities), and birth estimates based on data
collected for only one-half to three-quarters of the calendar year.
Some states have higher rates of nonhospital births than others
(see Appendix F for information from Oregon). Unpublished data from
NCHS show that 31 states had more than 100 nonhospital births delivered
by physicians and midwives, and 12 states had more than 500 similarly
delivered births (Table 3). Washington, North carolina, Texas,
California, and Oregon are recognized by the NCBS and others as having
a larger percentage of planned home births than other states (Arms,
1975J Burnett et al., 1980J Dingley, 1979r Shy et al., 1980J Stewart,
National Association of Parents and Professionals for Safe Alternatives
in Childbirth, personal communication, 1981). Data available from a
few states may be useful for documenting trends in nonhospital births.
Only 1.5 percent of all births in Oregon in 1974 took place in free-
standing clinics, doctors• offices, homes, and other nonhospital ad-
dresses. By 1981 the percentage had increased to 4.4 percent (Oregon
Center for Health Statistics, 1982).
NCBS is now undertaking a large study that may redress some of the
informational deficiencies about birth location. The studies are termed
•follow-back• surveys, because they trace information on one or more
individuals identified on a vital record, such as a birth or death cer-
tificate. They provide the opportunity to collect more detailed infor-
mation than is available from vital records. Some data on such items
as obstetric care, personnel, and place of birth should be available to
state and local public health agencies by December 1982 and to the gen-
eral public by July 1983 (Placek, 1981).
The committee also reviewed related data on the users of the differ-
ent birth settings, although in general the data on this issue also are
inadequate. Some data, particularly for hospital births, are available
for characterizing the mother by sociodemographic factors. The 1972
National Natality Survey from NCBS provides information on mother's age
and education, child's race, region of residence, family income, and
health insurance coverage of women during legitimate live births in the
hospital in 1972. The 1980 National Natality Survey also will contain
this information (Placek, 1981). Because of the large percentage of
births occurring in hospitals between 1972 and 1980, demographic find-
ings related to users of hospital maternity facilities are deemed repre-
sentative of the u.s. childbearing population as a whole. Bennetts
(1981) found that in a case comparison study using 4,790 mothers from
the 1972 National Natality Survey as controls, women who went to free-
standing birth centers were older (2 percent were 30 years of age or
more), more highly educated (most having completed some college), and
typically were white (63.1 percent) or Mexican American (33.8 percent). 1
1The percentage of Mexican Americans is so high because this study
included one of the largest freestanding birth centers in the country,
and that center primarily serves Mexican Americans.
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19
TABLE 3 States with More than 500 OUt-of-Hospital Births Delivered by
Physicians and Midwives, 1978
Total N\Diber of OUt- Percent Distribution Percent Distribution
of-Hospital Births of Live Births by of Live Births by
Delivered by Physi- Physicians Midwives
State cians and Midwives (Out of HOspital) (Out of HOspital)
New York 721 0.2 0.1
Pennsylvania 549 0.3 0.1
Ohio 868 0.5 o.o (49)
Illinois 960 0.5 0.1 (12)
North Carolina 573 0.6 0.1
Florida 789 0.2 0.5
'l'ennessee 703 0.6 0.4
Alabama 863 0.5 1.0
'l'exas 5052 0.2 1.9
Washington 951 1.0 0.6
Oregon 578 0.7 0.8
california 1978 0.5 0.1
SOURCE: National Center for Health Statistics, 1981, unpublished data.
In her examination of 300 elective ho.e births in the San Francisco
Bay area, Hazell (1975) found that about 90 percent of the families
choosing home birth lived in single-family dwellings, were white, and
the fathers were employed. Usually both members of the couple had
attended some college but neither had graduated. Unfortunately, no
comparison groups were studied.
MA'.l'ERNITY CARE PROVIDERS AND TRENDS IN 'l'BEIR USE
Physicians--primarily obstetricians, family practitioners, and general
practioners---constitute by far the largest group of maternity care
providers attending childbirths. In 1979 they delivered 98.1 percent
of in-hospital births and 34.2 percent of nonhospital births (National
Center for Health Statistics, 198lb). According to a recent Manpower
Planning Study (American College of Obstetricians and G¥necologists,
1981), obstetricians attended 81 percent of u.s. births in 1977, family
practitioners 6 percent, and general practitioners 12 percent.
~e training of these physicians varies from 4 years of postgraduate
work for obstetricians to 3 months of training in obstetrics for family
practitioners. In 1981 there were 16,000 board-certified obstetricians,
2,600 physicians eligible for certification, and 4,700 residents in
obstetrical training. An additional 3,000 physicians called themselves
obstetricians but had no special training beyond medical school (Ameri-
can College of Obstetricians and G¥necologists, 1981). Of the 56,200
licensed general practitioners in the United States (U.s. Department of
Commerce, 1980), the number practicing obstetrics is unknown. HOwever,
isolated data are available. For instance, in North carolina approxi-
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mately 50 percent of the general and family practitioners care for preg-
nant women and a slightly smaller percentage do deliveries (Pearse,
American College of Obstetricians and Gynecologists, personal camunica-
tion, 1982).
Certified nurse midwives attend about 1 percent of u.s. births
(American College of Obstetricians and Gynecologists, 1981). CHMs are
registered nurses who have received graduate education for 1 to 2 years
in midwifery and have passed a national certifying examination set by
the profession. ~ey perform deliveries in all types of birth settings,
including freestanding birth centers and conventional hospital units.
Approximately 2,500 CNMs have been certified since the founding of the
American College of Nurse-Midwives in 1955r about 1,800 practiced mid-
wifery in 1980 (American College of Nurse-Midwives, 198lr Rooks et al.,
1978).
Lay midwives, who usually have no formal training, attend home
births almost exclusivelyr there are many practicing lay midwives in
Washington, Oregon, Arizona, Texas, Tennessee, and New Hampshire
(Stewart, National Association of Parents and Professionals for Safe
Alternatives in Childbirth, personal communication, 1982). Lay mid-
wifery practice is illegal in same states and requires licensure in
others. Over the years the number of lay midwives has decreased.
Nurses provide most of the intrapartum and postpartum care iri hos-
pitals, and some do follow-up home visits after discharge of the mother
and child from a freestanding birth center. Nurses often assist pbysi-
ciana at a delivery. There were 1,059,000 registered nurses licensed
to practice in the United States in 1978 (u.s. Department of oa..erce,
1980). It is not known how many are involved in maternity care.
Other providers of maternity care include naturopath& and chiro-
practors. ~eir numbers and training vary substantially. For example,
in Oregon, in 1980, 0.6 percent of all births were attended by naturo-
pathsr moat of these deliveries were nonhospital ones (Oregon Center
for Health Statistics, 1981). Another 0.3 percent of the 1979-1980
births in Oregon were attended by chiropractors (Oregon Center for
Health Statistics, 1981). Twenty-five states have specific legislation
preventing chiropractors from providing maternity care (Duhart,
American Chiropractor Association, personal c:a.unication, 1982).
Trends in the birth-attendant(&) aspects of maternity care cannot
be accurately determined because of discrepancies and aaissions in the
available data. For example, if a birth takes place in a hospital, it
is often classified as a physician-attended birth, although a midwife
or medical student may have delivered the baby. Lay midwives sometiMe
list themselves as •friends• on the birth certificate (see Appendix F).
In some birth settings, physicians routinely sign the birth certificates
of certified nurse midwives who attend the entire birth. Obstacles to
complete andVor accurate reporting and to participation in research
arise froa these practices as well as from the legal ambiguity of some
nontraditional childbirth attendants and the lack of understanding and
trust that may exist among the various maternity care providers.
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'.l'RBRDS IN MATERNITY CARB PRACTICES
In a 1979 report to Congress, the u.s. General Accounting Office (GAO)
defined major obstetrical practices associated with high-risk preg-
nancies that •ust be considered in the evaluation of particular birth
settings. 'l'bese practices included medical and/or surgical induction
of labor, forceps delivery, vacuua extraction, cesarean section
delivery·, intrauterine fetal procedures, and the use of anesthesia in
spontaneous deliveri••·
Other practice• that •hould be con•idered in research on birth
•etting• include the completion of childbirth and/or parenting educa-
tion cla••••• nutritional intake during pregnancy, length of stay,
breast feeding, and parent-infant bonding. Many of these practice•,
de•pite their wide•pread use in both low- and high-ri•k settings, have
received only cur.ary attention by researchers.
Data on trends in the application of various maternity care prac-
tice• often are difficult to obtain and usually are incomplete (see
Table 4 for a preliminary compilation). Data •ources reporting
•pecific practice• are the National Center for Health Statistic•, the
collaborative perinatal •tudy •pon.ared by the National Institute of
Neurological and oo.municative Disorders and Stroke (RINCDS), the
American College of Ob•tetrician• and Gynecologi•t• (ACOG), and the
CC..i••ion on Profe88ional and Bo8pital Activitie• (CPBA) (U.S. General
Accounting Office, 1979). Infomation from the•• studie• shon that
ce•arean •ection rate• have increased, induction rates have remained
approxtaately unchanged, and forcep• delivery and u•e of anesthesia
have declined. 'l'be cc:.aittee believes that the frequency of fetal
monitoring i• incre..ing, although no national data are available to
confir• thi•. Rate• of brea•tfeeding, after a sub•tantial decline,
••• to be increasing <••• Table 4).
Maternity practice• would be expected to differ across birth ••t-
ting•, e.g., freestanding birth center• are for low-ri•k mothers, and
bo•pital perinatal unit• are equipped for handling complication• in
both aother and child. However, adequate data to docuaent the differ-
ence• are not available <••• Appendix c for practice• in freestanding
birth centers). Purther.ore, there will be a great deal of variation
aero•• and within •etting•, contributing to the complexity of re•earch.
Two examplea--u•e of ane•thesia and breastfeeding--illu•trate differ-
ence• in practice•.
Pro. available •tudie•, avoiding of the use of ane•the•ia in labor
appear• more com.on in nonho•pital •etting•, although hospitals appear
to be u•ing 1••• ane•the•ia in labor than they once did. Table 4 has
only one row providing comparative inforaation on trends in maternity
care practice• aero•• birth settings. fOr freestanding birth center
deliverie• •urveyed by Bennett• (1981), 56 percent of the women received
no ane•th••ia during labor. Thi• figure i• higher than the percentages
in the larger national •aaple• aaking up the re•t of row 5 in Table 4.
However, chronologically, going fro. the top to bottom lines in the row,
a trend toward le•• u•e of ane•the•ia in labor can be dbcerned. Al•o,
the figures from different large studie• •eea to corre•pond (e.g., 7.8
percent and 7.0 percent nonu•e of ane•the•ia frOII CPBA and NCBS data,
OCR for page 22
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TABLE 4 Trends in Maternity Care Practices: Studies, Sample Size (When Given), Years, and Percent of
Sample Receiving Practice
Source& Cited in u.s. General Accounting Office Study, 1979
Bennette, 198lr
NINCDS 1972-79
CPBA (unpubliehed) Niavander and u.s. Senate N • 2,000 deliveries
ACOG, U67r 1970 N • 262,000 NCHS, U72r Gordon, 1972r SubcOIIIIlittee in freestandinCJ
Procedure 1967 N • 2,060,440 1977 N • 1,300,000 1972 N • 2,800,000 NICRD, 1981 1959-65 N • 55,908 Hearin
23
respectively). Data from CPBA in 1977 indicate a jump in the nonuse of
anesthesia to 18.8 percent.
Women who deliver in freestanding birth centers appear to have
higher rates of breastfeeding. National prevalence data on the prac-
tice of breastfeeding is best estimated from the 1965 National Fer-
tility Study (NCBS, 1965) and the 1973 National Survey of Family Growth
(NCBS, 1973). These studies indicated a dramatic decline in breast-
feeding in the United States from 72 percent of women breastfeeding
their first child in 1931-1935 to 29 percent in 1971-1973. This
decrease was especially marked among blacks, the poor, and less-
educated women. A reversal in this trend was noted by the American
Academy of Pediatrics in 1978, when it was found that 46.6 percent of
women from all socioeconomic groups delivering in hospitals breastfed
their infants (Martinez and Nalezineski, 1979). This finding is con-
sistent with preliminary data from the 1980 NCHS National Natality
Survey analysis, which indicates that 45 percent of all childbearing
women in the United States used breastfeeding alone on discharge from
their care providers. In contrast, in a study of 1,938 women who began
labor in freestanding birth centers, Bennetts (1981) found that 79.4
percent used breastfeeding alone on discharge from the freestanding
birth center.
PERINATAL REGIONALIZATION
In addition to reviewing different birth settings and the trends
affecting them, the committee considered how different settings fit
into the current organization of perinatal services and the relevance
of such a system for research on this topic.
In 1971 the American Medical Association House of Delegates adopted
a statement that urged development and operation of centralized c~
munity or regional perinatal programs with physician, government, and
public involvement. Other professional organizations, such as the
American College of Obstetricians and Gynecologists and the American
Academy of Pediatrics, have continued active attempts to improve peri-
natal outcomes through systematic applications of knowledge and tech-
nology, including development of professional standards of care. Since
the original proposal for the regionalization of perinatal health care
delivery, documentation of the benefit of regionalized care has appeared
in the research literature. Debate continues (Sinclair, et al., 1981),
but there are certain gains, such as improved survival of low birth-
weight infants, that can reasonably be attributed to better perinatal
health care delivery (Lee, et al., 19801 Paneth, et al., 1982).
Perinatal regionalization is a systems approach that defines care
in terms of a continuum for a specific geographic and demographic
area. Perinatal care has been subject to some of the most structured
and complete planning in the United States, with much of the country at
least nominally involved in a systems approach. Three levels of care
described in TOward Improving the Outcome of Pregnancy (Committee on
Perinatal Health, National Foundation-March of Dimes, 1976) form the
basis for most perinatal systems currently in existence. Simply stated,
24
Level I care is envisioned as occurring wherever hospital birth occurs.
Care is available for uncomplicated obstetrical events, but hospitals
at this level should be able to detect high-risk patients as early as
possible and to provide emergency care. Level II care should be avail-
able at hospitals able to provide all services of Level I plus care for
most of the complicated obstetrical difficulties and for certain neo-
natal illnesses. Level III care should be able to cover all types of
obstetrical, fetal, and neonatal probleaa in addition to providing
teaching, evaluation, and research services. Level III centers serve
as referral tertiary care centers for 8,000 to 12,000 births annually.
Perinatal health care planners view the levels and units within a
given region and the regional systems themselves as interdependent or
linked. Risk identification, movement of patients to locations with
appropriate resources, and outcome are important concepts that depend
upon linkage for implementation of solutions. Lowering rates of mortal-
ity and morbidity has been given high priority. This effort has eapha-
sized ready employment of technological advances, many of which have
become available in routine hospital and office practice (Philip et
al., 198lr Wallace, 1978). Although systematic regionalized perinatal
care does manifest concern for interpersonal dimensions of human experi-
ence, it does so in a less uniform fashion than it does for technologi-
cal innovation. For example, in perinatal planning little attention
has been directed to other than hospital-based births. Although most
plans do not summarily exclude alternatives, they do not respond readily
to the needs and desires of individual clients or their families when a
nonhospital birth is proposed. Integration of services has varied
widely in different regions, depending on many factors.
THE BIRTH SETTING CONTROVERSY
Because of the variety of birth sites, personnel, and practices, contro-
versy continues over which arrangements are desirable for childbirth.
At present, opinions about various alternatives tend to cluster in
groups favoring •conventional• or •alternative• obstetrics.
In the •conventional• practice of obstetrics, the health profes-
sional is a physician who has a direct, guiding relationship with the
patient and makes appropriate decisions about her care. Technological
advances such as anesthesia, analgesia, and electronic fetal monitoring
are typical elements of care, and the hospital is usually the preferred
site of birth. Conventional obstetrics tends to emphasize such
practices as:
• procedures to deal with group risks such as infection
• monitoring fetal and neonatal well-being
• hospital atmosphere, with nearness to equipment, use of
technology
In the •alternative• practice of obstetrics, the health provider
may be a certified nurse midwife or physician or other practitioner
with a relationship to the patient that emphasizes choice on such
25
matters as the birth environment and location. Technological advances
are considered important when warranted, but they may be viewed with
skepticism or avoided. Homes, birth rooms in hospitals, and free-
standing birth centers are locations associated with alternative set-
tings. Most alternative locations depend upon hospital back-up systems
when an emergency arises.
Practices more likely to be associated with alternative settings
include:
• homelike atmosphere for birth
• individual choice of activity for the laboring mother, e.g.,
walking, eating, etc.
• family participation and control in the birth process
The •alternative• movement has already caused a reexamination of
conventional obstetrical practice and some resulting changes. Both
factions place high value on such basic issues as the safety of the
mother and child, good prenatal care, childbirth education to increase
a laboring woman's comfort and decrease her use of anesthesia and
analgesia, encouragement of breastfeeding, and education about infant
care.
Unfortunately, the absence of adequate data on a whole range of
issues associated with birth settings makes it unlikely that the con-
troversy will ease in the immediate future or that parents can make
informed choices about the setting best for them.
1be committee commissioned a review to assess the literature on the
safety of nonhospital birth settings (Appendix A). The review makes it
apparent that the literature is insufficient for a conclusive determi-
nation of whether safe, appropriate care can be provided in unconven-
tional settings. Risks are neither clearly identified nor quantified.
There are no good comparative studiesr the number of subjects studied
is small and the studies are poorly controlled. In fact, there is
little, if any, objective evidence about the advantages or disadvan-
tages of any birth setting (Adamson, 1981), or whether low-risk preg-
nancies managed in unconventional settings have outcomes that are
worse, the same, or better than outcomes in traditional hospital
practices. As Adamson and Gare (1980) have stated, the •1ack of data
has been a major factor preventing effective and reasoned dialogue
among health professionals and lay people, especially those holding
widely divergent views.•
In scientific and lay discussions on aspects of childbirth settings,
clear distinctions have not always been made among the various maternity
care practices, personnel, and places. Evidence of beneficial or detri-
mental effects of one compared with another can be statistically unreli-
able or anecdotal. In addition, assertions based on unreliable research
have made their way into discussions and policy statements with seem-
ingly little follow-up evaluation.
The controversy over various types of maternal and child care, the
lack of available data, the interest among recipients of care in alter-
native settings, the declining fertility rates (Pigure 2 and Table 5),
and the competition among providers for this •market• indicate that
26
300
70
z
w
60
2 50
i ~
~
~ ~
w
~
w
%
~
~ ~
m
10
9
8
7
6
5
4
PIGURB 2 Age-specific birth rates:
United States, 1955-78. 3~----~--_.----L----L--~
1955 1960 1965 1970 1975 1980
SOURCBa National Center for Health
Statistics, in press. YEAR
research into the safety, efficacy, psychosocial value, and costs of the
various alternatives is urgently needed. Such research would assist
prospective parents to choose the most suitable birth setting and also
would provide policymakers with information for making decisions about
allocation of resources for maternity care.
The committee recognizes the difficulties of doing good research in
this area. Issues of psychological health and satisfaction will be hard
to quantify in persuasive ways. Furtheraore, the large number of birth
setting combinations of providers, locations, and practices add to the
difficulties of generalizing any results to other settings. The con-
founding influence of the regional perinatal system, in which patients
are transferred from one setting to another, means investigators will
have to keep track of clients across settings. They will have to deter-
27
TABLE 5 Live Births, Crude Birth Rates, and Births per 1,000
Women by Age of Mother, According to Race: United States,
Selected Years 1950-1978 (data are based on the national vital
registration system)
Live Births per 1,000 wc.en by Age of Mother
Crude
Race and Live Birth- 10-14 lS-19 2G-24 2S-29 3G-34 35-39 4G-44 45-49
Year Births Rate! Years Years Years Year• Years Years Years Years
'l'otal
1950 3,632,000 24.1 1.0 81.6 196.6 166.1 103.7 S2.9 lS.l 1.2
19SS 4,097,000 2S.O 0.9 90.3 241.6 190.2 116.0 S8.6 16.1 1.0
1960 4,2S7,8SO 23.7 o.8 89.1 258.1 197.4 112.7 S6.2 15.S 0.9
196S 3,760,3S8 19.4 o.8 70.S 195.3 161.6 94.4 46.7 12.8 o.8
1970 3,731,386 18.4 1.2 68.3 167.8 US.l 73.3 31.7 8.1 o.s
197S 3,144,198 14.8 1.3 S6.3 114.7 110.3 53.1 19.4 4.6 0.3
1977 3,326,632 15.4 1.2 S3.7 115.2 114.2 57.S 19.2 4.2 0.2
1978 3,333,279 1S.3 1.2 S2.4 112.3 112.0 S9.1 18.9 3.9 0.2
1979 3,473,000 15.8 n/a n/a n/a n/a n/a n/a n/a n/a
1980 3,S98,000 16.2 n/a n/a n/a n/a n/a n/a n/a n/a
White
1950 3,108,000 23.0 0.4 70.0 190.4 16S.l 102.6 Sl.4 u.s 1.0
19S5 3,485.000 23.8 0.3 79.1 23S.8 186.6 114.0 56.7 15.4 0.9
1960 3,600,744 22.7 0.4 79.4 2S2.8 194.9 109.6 54.0 14.7 o.8
196S 3,123,860 18.3 0.3 60.6 189.0 158.4 91.6 44.0 12.0 0.7
1970 3,091,264 17.4 o.s S7.4 163.4 145.9 71.9 30.0 7.5 0.4
197S 2,5Sl,996 13.8 0.6 46.8 109.7 110.0 S2.1 18.1 4.1 0.2
1977 2,691,070 14.4 0.6 44.6 109.8 113.8 S6.3 17.8 3.8 0.2
1978 2,681,116 14.2 0.6 43.6 106.3 111.1 57.9 17., 3.5 0.2
1979 n/a
1980 n/a
All Other
1950 S24,000 33.3 S.l 163.S 242.6 173.8 112.6 64.3 21.2 2.6
1955 613,000 34.5 4.8 167.2 281.6 218.2 132.6 74.9 22.0 2.1
1960 657,106 32.1 4.0 1S8.2 294.2 214.6 135.6 74.2 22.0 1.7
196S 636,498 27.6 4.0 138.4 239.2 183.5 113.0 62.7 19.3 1.5
1970 640,122 2S.l 4.8 133.4 196.8 140.1 82.S 42.2 12.6 0.9
197S S92,202 21.2 4.7 108.6 143.S 112.1' S9.7 27.6 7.6 o.s
1977 63S,S62 21.9 4.3 102.4 145.7 116.5 64.8 27.5 6.9 0.5
1978 6S2,163 22.1 4 ..1 99.1 145.7 117.3 66.7 27.0 6.5 0.4
1979 n/a
1980 n/a
Black&
1960 602,264 31.9 4.3 156.1 295.4 218.6 137.1 73.9 21.9 1.1
1965 S81,126 27.S 4.3 144.6 243.1 180.4 111.3 61.9 18.7 1.4
1970 S72,362 2S.3 5.2 147.7 202.7 136.3 79.6 41.9 12.5 1.0
197S S11.581 20.9 S.l 113.8 145.1 10S.4 54.1 25.4 7.5 0.5
1977 S44,221 21.7 4.7 107.3 147.7 111.1 58.8 25.1 6.6 0.5
1978 S51,540 21.6 4.4 103.7 147.S 110.6 S9.6 24.0 6.0 0.4
1979 n/a
1980 n/a
Data are based on births adjusted for underregistration for 1950 and 1955 and on
IIIO'fB I
registered births for all other years. Fi9ures for 1960, 1965, and 1970 are based on a
SO percent sa.ple of births, for 197S-1978, they are based on 100 percent of births in
..lected states and on a SO percent sa.ple of births in all other states. Beg innift9 in
1970, births to nonresidents of the United States are excluded.
!Live births per 1,000 population.
IIOURCBt Rational Center for Health Statistics, 198la.
28
mine bow to handle births in which labor is conducted in a nontradi-
tional setting andVor is managed by someone other than a physician until
a complication occurs, after which the .other is transferred to a hos-
pital and the delivery is cmapleted by a physician. It will be very
difficult to auater a powerful, well-controlled study to deteraine con-
clusively if one birth setting is incr...ntally more or leas safe than
another. Nevertheless, the cOIIIIIlittee believes research can illuainate
some of the issues and provide inforaation to aake better decisions
about aaternal and child care.
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