BOX 4-1
Birth Settings and Health Outcomes: State of the Science
Key Points Made by Individual Speakers

  • In a comparison of the effects of care in “alternative hospital settings” to care in a conventional labor room, the Hodnett et al. (2012) Cochrane review concluded that women randomized to alternative hospital settings were more likely to have no analgesia or anesthesia, spontaneous vaginal birth, and preference for the same setting next time; and less likely to have intrapartum oxytocin, epidural analgesia, Cesarean delivery, assisted vaginal birth, and episiotomy. They found no difference in postpartum hemorrhage, serious maternal morbidity or mortality, serious perinatal morbidity or mortality, 5-minute Apgar, admission to neonatal intensive care unit, or perinatal death.
  • Jane Sandall reported the Birthplace in England Collaborative Group prospective cohort study showed a low incidence of adverse perinatal outcomes in all birth settings for low-risk women. While there were no differences in perinatal outcomes for nulliparous women between midwifery units and obstetric units or for multiparous women between any settings, there were significantly more adverse outcomes among nulliparous women in births planned at home compared with those planned in obstetric units. The researchers also reported fewer interventions among women planning births at home or in midwifery units compared to women planning births in obstetric units; and a higher percentage of nulliparous women transferred from either home or a midwifery unit to an obstetric unit, compared to multiparous women.
  • Based on a growing collection of reports and studies on intrapartum care principles and processes, the “emerging mosaic” coming into view, in Carol Sakala’s opinion, is that undisturbed, physiologic childbearing confers benefits to women and babies and that common intrapartum practices may have many consequential, sustained, and unintended consequences. Sakala observed that care in birthing centers and home births appears to be associated with fewer interventions and more favorable care practices. Birth center settings do not compromise any measured outcome and, in fact, favor several outcomes. While home births have been associated with lower rates of many maternal and neonatal morbidity measures, they have also been associated with an increased rate of neonatal mortality. Sakala noted that the latter finding is controversial.
  • Esther Sternberg explored the growing body of evidence suggesting that a person’s physical environment can influence health via the body’s stress response system and expressed hope that a greater understanding of the brain-immune connection can help designers build healthier, safer birth environments that support both mental and physical health of the mother, fetus, and child. Sternberg called for more research on physiological outcome measures and suggested some methods that might be useful.
  • Kristi Watterberg described planned home births as “the most emotional and least data-driven issue” that she has encountered in neonatology, with the possible exception of circumcision. In her opinion, data are limited by researchers from different backgrounds having different expectations of what they will find; splintered systems making it difficult to collect reliable and complete data; and the difficulty, or impossibility, of randomizing study participants in clinical trials.

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