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Summary and Recommendations
CBILDBIRrB TRENDS ARD STATISTICS
Since the turn of the century the birthplace for children in the United
States baa moved from the home to the hospital. Leas than 5 percent of
the babies born in 1900 were delivered in a hospital. By 1940 the pro-
portions bad shifted to about 50 percent in each location, and by 1979
hospital deliveries accounted for 99 percent of all births. Much of
the impetus for the turnaround in selection of birth aitea waa provided
by the application of expanding scientific and medical knowledge in the
field of obstetrics, which led to improvements in techniques and changes
of eapbaaia in maternity care. Beginning with a principal concern that
the progress of labor and delivery be made safer for the mother, the
medical aspects of obstetrics grew in importance. Later the concern for
maternal welfare waa broadened to include better relief of pain during
delivery, often by the administration of analgesic drugs and anesthesia.
More recently, a significant reduction in the neonatal mortality rate
baa resulted from improvements in maternal and pediatric care.
Improvements in obstetrics have resulted in improved physical out-
comes for mothers and babies. From 1955 to 1980 the maternal mortality
rate declined from 47 to 7 deaths per 100,000 live births. Neonatal
deaths in the aae period declined from 19.1 to 8.4 deaths per 1,000
live births.
For a number of reaaona, social aa well aa medical, a new interest
baa developed in the psychological factors surrounding the birth experi-
ence. An increased interest in birth settings other than the conven-
tional hospital one oriented toward treating disease and toward physi-
cian management of patients baa also developed. The changing social
context in which these childbirth interests are expressed includes the
advent of the WOllen's movement, conaumeriam, a desire for a more
natural delivery than that associated with medical intervention, and
concern about rising health care coats. The effect of this baa been a
reexamination of obstetrical practices.
During the 1970a there waa rising concern that births were increas-
ingly occurring in places other than hospitals. Accurate figures are
not available, but it ia estimated that between 36,000 and 158,000
babies were delivered outside hospital settings in 1980. Births at home
(both planned and unplanned) are now estimated to be about 1 percent of
2
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the total number of births per year, a percentage that has not in-
creased, according to the National Center for Health Statistics.
However, the number of freestanding birth centers grew from 3 in 1975
to about 130 now. Birth certificates and related recordkeeping do not
usually contain the information necessary to indicate how many babies
are delivered in each of the various birth locations. However, a few
states (such as Oregon) do have accurate data. In Oregon 4.4 percent
of the babies born in 1981 were not born in a hospital (see Appendix F).
THE BIRTH SE'l"l'ING
Factors contributing to the definition of a birth setting include the
recipients of care, its locale, the providers of maternity care, and
the practices of those providers. The well-being of mother and baby
are the primary concern in any birth setting. Advocates of hospital
births express concern for the availability of advanced technological
care by skilled practitioners in the event of an untoward event during
delivery. Advocates of nonhospital births emphasize the contributions
toward maternal and neonatal well-being made by increased family sup-
port and participation in the birth, minimal medical intervention, and
lower costs.
Maternity Care Providers
Maternity care providers include physicians and a small number of cer-
tified nurse midwives. The role and numbers of these two kinds of pro-
viders have changed dramatically over the years. In 1910, •granny• lay
midwives delivered 50 percent of babies: by 1979, midwives (primarily
certified nurse midwives) delivered 1.6 percent. Physicians attended
more and more births, delivering 98.1 percent of the babies in hospitals
and 34.2 percent of those born elsewhere in 1979. Other health care
personnel, such as naturopath& and chiropractors, deliver a very small
percentage of babies. Some women, either by choice or circuastance,
are not attended at birth by any professionally trained person.
Providers of maternity care agree that identifiable high-risk
pregnancies necessitate the use of specialists and advanced technology.
There is less agreement on how to define and manage a noraal birth.
These disagreements are exacerbated by a lack of adequate data on the
effects of various maternity care practices.
Delivery Sites
The range of delivery sites includes the home, freestanding birth cen-
ters, hospital-based birth centers, and conventional hospital maternity
units. These sites vary as to the primary provider of care, use of
technology, atmosphere, facilities, and proximity to emergency care.
The variation within and among the different sites contributes to the
complexity of conducting research in this area and to the difficulty of
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following clients across different locations for purposes of full and
complete data collection.
Birth Practices
Maternity care practices have changed in recent years and appear to dif-
fer in the various birth settings. For example, the frequency of induc-
tion of labor rose from 8.6 percent of births in 1967 to 11.8 percent in
1977, and the rate of cesarean section rose from 7.3 percent in 1972 to
13.4 percent in 1977. Practices that are fairly uniform across the dif-
ferent settings include prenatal care and patient education in child-
birth and the care of infants. Practices more often sean in hospital
settings include protocols and procedures related to the provision of
care for high-risk mothers, fetuses, or infants. Practices more likely
to be found in the nonhospital settings include participation of the
family in prenatal care and at the birth, classes for siblings, and the
decreased use of technology and medication during delivery.
APPROACHES '1'0 RESEARCH AND STUDY DESIGNS
The study committee's major task was to consider research designs for
the evaluation of birth settings. Certain general approaches--
observational and experimental--for designing studies in scientific
research were reviewed. Each would be useful in addressing different
aspects of research of birth settings, depending on the scope of the
investigation and the objectives of the study. The strengths and weak-
nesses of several different designs and methods for data collection
were identified and their use for assessing birth settings reviewed.
Observational Approaches
The committee believes that there is a lack of good descriptive studies
on birth settings, especially alternative settings, and that well-
conducted prospective descriptive and observational studies, even if
without controls, could improve our understanding of the issues and be
useful for generating hypotheses for further study.
Experimental Designs
Randomized Clinical Trials The committee determined that randomized
clinical trials could be used to study many different techniques, or
differences in the birth attendants, in similar birth settings. In the
past such trials have been conducted on birth settings to exaaine the
effects of such variables as the position of the mother during delivery,
the presence of a supportive lay person during delivery, and the use or
nonuse of electronic fetal monitoring. Randomization among sites may
not be generally possible, because women choosing to deliver at one
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s
site, or their care providers, may not be willing to be randomly as-
signed to a different site. However, there may be situations when such
randomization is possible--for example, when a woman is of a divided
mind or open to randomization to a site offering an approach to child-
birth that is similar to that of her original choice.
Prospective Matched Groups Nonrandomized designs are likely to be pro-
posed by researchers studying the impact of alternative birth settings.
Although randomized experiments are most desirable for interpreting
causal relationships, prospective studies using rigorously matched
groups delivering in different settings may provide useful information
about the safety and psychological benefits of alternative settings.
For example, comparisons could be made among women who have selected
particular birth settings, such as a freestanding birth center, a birth
room in a hospital, or a tertiary care hospital. Various types of data
could be collected before and after the birth. Comparisons could be
made of mortality, morbidity, and various psychosocial measures, includ-
ing anxiety, satisfaction with the care received, mother-infant bonding,
and the like. The moat obvious problem with this design is the possi-
bility that any differences among the groups can be attributed to selec-
tion of different sites by mothers with different characteristics.
Regardless of how well the study is planned, this problem may not be
overcome. Despite this limitation, however, the committee believes that
prospective studies would provide much-needed information on the spec-
trum of birth settings.
Cooperative Registries A possible way to collect data with which to
evaluate different birth settings is to organize groups of hospital and
nonhospital birth centers to collect uniform information on each birth
at a central data-collection center. Both hospital and nonhoapital set-
tings could be chosen so as to represent the major points along the
spectrum of birth settings in the United States. The data set should
include important prognostic factors so that subsets within the popula-
tion of mothers and infanta could be properly compared. A cooperative
registry could eventually result in a data base useful for answering
questions on quantitative aspects of birth practices, especially ones
that occur very rarely. This would be a major and very expensive under-
taking similar to the collaborative perinatal project of the National
Institute of Neurological and Comaunicative Disorders and Stroke
(NINCDS) that studied 50,000 pregnancies at 12 different institutions.
Surveillance Methods The greatest utility of surveillance methods has
been for situations in which the presence of a single adverse event,
for example, the death of a mother during delivery, mandates a chain of
public health activities, including review of the case to determine ita
preventability. Special studies often are added to routine data col-
lection to exaaine the specific circumstances surrounding a maternal
death. Similar types of studies could also be used to evaluate dif-
ferent birth settings.
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The routine recording of births and deaths by all SO states could
serve as a useful starting point for analysis of the risks to mother and
infant as mediated by place of delivery and provider. In most reporting
areas in the United States, docu.entation of low birth weight or preterm
gestation is possible with reasonable accuracy. In some reporting
areas, low Apgar scores and ca.plications of pregnancy and labor are re-
corded. Although not all of these events can be regarded as avoidable,
their presence in a planned nonhospital delivery may reflect a failure
of the risk assessment screening process. Identified adverse events
could be reviewed by a panel of experts to determine the degree of their
preventability. Considerable experience has been accumulated in this
method of assessment by committees established in every state to inves-
tigate the cause of maternal mortality.
The disadvantage of surveillance is that data currently available
fro. vital records do not give specific information on intended place
of delivery, actual place of delivery, and birth attendant(&). The
coaaittee recom.ends that such data be recorded on all birth certifi-
cates.
case-Control Studies If counts of the denominator populations are not
available, and if events to be studied occur infrequently, one recourse
is to match adverse events with control births free of adverse outcomes
and investigate the circuastances of the pregnancy. Por example, if
planned nonhospital deliveries are found more frequently among cases of
adverse events than .-eng oontrols, this can be taken as evidence for a
differential effect of place of delivery on the adverse event. A retro-
spective approach is more likely to have confounding elements than the
preferred prospective approach, however, and questions will always re-
main. Never·theless, a case-control approach may be one of the least
costly ways to gain infor.ation about very rare events.
RISK ASSESSMENT
Any comparisons of birth settings will need to be carried out carefully
because women who deliver in different sites may differ in aany charac-
teristics. Por this reason characteristics of the study population will
need to be carefully described by researchers and any differences con-
trolled for in the study design or analysis. Differences in levels of
risk ..ong the women result fro. the screening process used to increase
the likelihood of a normal delivery in a nonhospital setting. women
delivering in a freestanding birth center will have to be compared with
similar low-risk individuals delivering in the hospital.
WO..n who select different settings are also likely to differ with
respect to demographic and psychological variables. Therefore, the
researcher must direct special attention to assessing psychological
variables to assure similarity ..ong groups.
The screening process for determining the potential for complica-
tions to develop during pregnancy, delivery, or the neonatal period is
called obstetric risk assessment. An understanding of obstetric risk
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assessment ia essential for conducting research on childbirth settings.
Risk status ia aaaeaaed through a scoring ayatea that assigns pregnan-
cies to various levels of probability of outco.eJ tbia measurement of
risk provides a probability statement with an error rate. Attempts to
t.prove the precision of obstetric risk measurement are aimed at reduc-
ing the rate of error.
Moat of the existing risk assessment instruments used for screening
pregnant women are baaed on prediction of perinatal mortality or mor-
bidity. Variables ccaaon to moat instruments are demographic and socio-
economic and variables baaed on past pregnancies, past medical history,
and present pregnancy. In some of the more recent studies, fetal heart
rate and uterine contraction data from electronic monitoring have been
included. Purther development of risk aaaeaaaent aetboda ia needed to
make thea more useful for predicting maternal outcomes and perinatal
morbidity and for research on birth settings. Approximately 20 percent
of women predicted to be at low risk experience co.plicationa that re-
quire transfer to a hospital setting during pregnancy or delivery.
Approximately 14 percent of women aaaeaaed ineligible for delivery in a
low-risk setting experience no complications.
Selection of Variables
Investigators should provide detailed atateaenta of bow variables are
defined and used in their studies. Fetal, neonatal, and maternal deaths
occur now with leas frequency than in previous decades and can no longer
be taken aa the sole measure of quality of care. Morbidity ia becoming
a more frequent aeaaure of pregnancy outcome. Interest baa shifted to
studying the effects of maternal and perinatal care on such morbidity
indices aa neurological deficits, developmental problema, and satisfac-
tion with the birth experience. T.berefore, outcome measures must be
defined for these indices, including the quality of bonding established
between parents and infantJ •parenting• abilityJ and the eiDOtional,
intellectual, and physical development of the infant. T.be comaittee
concluded that more research ia needed to define outcome measures other
than mortality that can be accurately aeaaured for studying birth
practices.
RECOMMENDATIONS
T.be comaittee concludes that reliable information about the safety and
efficacy of different birth settings (see Appendix A), the psychologi-
cal benefits of different practices (see Appendix D), and the differ-
ences in economic costa of the alternatives (see Appendix B) ia lack-
ing. Rigorous data will proaote informed debate and policy development
by advocates of the various settings. Honetheleaa, the c~ittee recog-
nizes that many values surround childbirth and that iaauea and arguments
will continue regardless of research and new information.
Although it realized the difficulty of doing research on this topic,
the committee identified several approaches that could begin to generate
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information. The comaittee'a observations and recom.endations are as
follows a
• Research into the safety and efficacy of the various birth set-
tings has high priority. Recomaended research designs or methods for
collecting data (described in detail in Chapter 2) include randa.ized
clinical trials wherever possible to study different techniques or
methods used in aiailar birth aettingaJ prospective aatched group or
cohort studies of low-risk women delivering in different settings, in-
tensive surveillance methods--for example, surveillance of live births
and their complications--together with special data collection and
methods of evaluating adverse event&J and a registry to collect data
useful for evaluating maternity care in a number of different institu-
tions and in different settings. Specific recoaaendations or caveats
about research on birth settings are given in Chapters 2 1 3 1 and 4 of
this volume.
• Lack of data has been a aajor i~iment to research in the
evaluation of birth settings. Government agencies responsible for de-
signing birth and fetal death certificates should include space for
routine recording of the intended and actual site of delivery (e.g.,
conventional hospital delivery rooa or alternative birth roo., free-
standing birth center, planned hoae delivery, accidental nonhoapital
delivery) and the precise type of provider (board-certified or certifi-
cate-eligible obstetrician, general or faaily practitioner, certified
nurse midwife, midwife with no special training, other individual).
Births in freestanding birth centers should not be described as occur-
ring in a hospital. These data will enable investigators to deteraine
the numbers of births planned in different settings, to analyze trends
in the choice of birthplaces, and to identify the health care provider.
Linked to mortality and morbidity data, this inforaation will be especi-
ally valuable for studying birth settings.
• Risk assessment of patients is crucial in deteraining research
population eligibility for delivery in an alternative setting. Moat
existing risk assessment inatru.enta can predict that a low-risk preg-
nancy will not result in a perinatal death. More than 98 percent of
pregnant women labeled as low risk will have live infants at the end of
the neonatal period. These instruments are leas accurate for predicting
neonatal morbidity. Therefore, a number of women and their infanta
will need to be transferred to a hospital during labor and delivery.
Research to perfect and extend the reliability of risk aaaea...nt
methods is desirable because accurate screening will ainiaize the need
to transfer .other and child before, during, or after delivery (see
Appendix E).
• The lack of sound empirical data about the psychological bene-
fits of one or another birth setting makes it difficult for potential
parents and physicians to choose the one moat appropriate. Appendix D
of this report reviews the literature on aoae of the psychological as-
pects of birth and raises methodological issues for consideration by
researchers. Priorities in this area are studies of differences in
developmental outco.ea of the child and parent-child relationships ac-
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cording to birth settings. Does one setting foster a closer relation-
ship between parent and child than another?
• Because of the range of settings and the breadth of questions
to be answered, the ca.aittee urges a aultidiaciplinary approach and
the for.ation of multidisciplinary teams for research on birth settings.
A good research prograa will require a variety of investigators to as-
sure valid screening and selection of a study population and ca.petent
handling of the range of settings and the flow of patients across a aya-
tea of care. Experts in research design should be a part of such an
effort.
