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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. doi: 10.17226/25636.
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Prepublication Copy Uncorrected Proofs BIRTH SETTINGS IN AMERICA: OUTCOMES, QUALITY, ACCESS, AND CHOICE        Committee on Assessing Health Outcomes by Birth Settings Susan Scrimshaw and Emily P. Backes, Editors Board on Children, Youth, and Families Division of Behavioral and Social Sciences and Education Health and Medicine Division A Consensus Study Report of

PREPUBLICATION COPY, UNCORRECTED PROOFS   THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and National Institutes of Health (#HHSN26300013). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25636 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Birth Settings in America: Improving Outcomes, Quality, Access, and Choice. Washington, DC: The National Academies Press. https://doi.org/10.17226/25636.    

PREPUBLICATION COPY, UNCORRECTED PROOFS   The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.    

PREPUBLICATION COPY, UNCORRECTED PROOFS   Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.    

PREPUBLICATION COPY, UNCORRECTED PROOFS   COMMITTEE ON ASSESSING HEALTH OUTCOMES BY BIRTH SETTINGS SUSAN C. SCRIMSHAW, (Chair), Former President, The Sage Colleges JILL ALLIMAN, Frontier Nursing University WANDA BARFIELD, Centers for Disease Control and Prevention (resigned March 2019) MELISSA CHEYNEY, Oregon State University MICHELLE R. COLLINS, Rush University College of Nursing BROWNSYNE TUCKER EDMONDS, Indiana University School of Medicine WENDY GORDON, Bastyr University MARIAN FRANCES MACDORMAN, Maryland Population Research Center M. KATHRYN MENARD, University of North Carolina KAREN MILGATE, Karen Milgate Health Policy Consulting JOCHEN PROFIT, Stanford University CAROL SAKALA, National Partnership for Women & Families NEEL SHAH, Harvard Medical School and Ariadne Labs KATHLEEN RICE SIMPSON, Mercy Hospital Saint Louis RUTH E. ZAMBRANA, University of Maryland EMILY P. BACKES, Study Director ELIZABETH S. HOWE-HUIST, Associate Program Officer DARA SHEFSKA, Associate Program Officer MARY GHITELMAN, Senior Program Assistant LESLEY WEBB, Senior Program Assistant (through October 2019) LORI TREGO, NAM Distinguished Nurse Scholar-in-Residence (through August 2019) BRIDGET B. KELLY, Consultant ERIN HAMMERS FORSTAG, Technical Writer v   

PREPUBLICATION COPY, UNCORRECTED PROOFS   BOARD ON CHILDREN, YOUTH, AND FAMILIES ANGELA DIAZ, (Chair), Department of Pediatrics and Department of Environmental Medicine and Public Health, Mount Sinai Adolescent Health Center, Icahn School of Medicine at Mount Sinai DAVID V. B. BRITT (Co-chair), Sesame Workshop (retired CEO) HAROLYN BELCHER, Kennedy Krieger Institute and Johns Hopkins University School of Medicine RICHARD F. CATALANO, School of Social Work, University of Washington DIMITRI CHRISTAKIS, Seattle Children’s Research Institute, University of Washington JEFFREY W. HUTCHINSON, The Wade Alliance, LLC STEPHANIE J. MONROE, The Wrenwood Group, LLC JAMES M. PERRIN, Harvard Medical School and MassGeneral Hospital for Children NISHA SACHDEV, Bainum Family Foundation DONALD F. SCHWARZ, Robert Wood Johnson Foundation MARTÍN J. SEPÚLVEDA, IBM Corporation (retired) and CLARALUZ LLC MARTIN H. TEICHER, Developmental Biopsychiatry Research Program at McLean Hospital and Harvard Medical School JONATHAN TODRES, Georgia State University College of Law NATACHA BLAIN, Director PAMELLA ATAYI, Program Coordinator     vi   

PREPUBLICATION COPY, UNCORRECTED PROOFS   PREFACE The United States spends more on childbirth than any other country in the world, with worse outcomes than other high-resource countries, and even worse outcomes for women of color. Our Committee was charged with finding ways to improve these outcomes. We regarded this as an extraordinary opportunity to make recommendations to reverse a trend of increasing negative birth outcomes, do so more economically, and improve the childbirth experience for women and their families. For me, this assignment circled back over three decades to a series of multi-cultural research projects on childbirth, notably with colleagues Christine Dunkel-Schetter and Ruth Zambrana along with many others. Among other things, we did early work associating the experience of racism and low-birthweight for Black women and established the importance of social support. During that time, I lost a newborn daughter to unavoidable complications and this strengthened my determination to prevent such outcomes whenever possible. Chairing this Committee provided an opportunity to continue that work. The Committee composition reflected the range of health professionals who care for pregnant and birthing women and their babies, and those who look at data, policy and wider social contextual factors affecting birth outcomes. Committee members included those with expertise in midwifery, obstetrics, nursing, pediatrics, demography, public health, health services research, health care policy, economics, sociology and anthropology. There was a wide range of experience in different birth settings and with different economic and ethnic groups. This led to rigorous examination of the great variety of evidence, and vigorous debate around what that evidence could and could not support. The range of experience on the Committee also necessitated working to understand settings and experiences of disciplines not well known to each other and a willingness to listen to each other and respect the evidence. Working together across such diverse experience and disciplines underscored for us the vital importance of inter- professional understanding, respect, and cooperation in order to improve birth outcomes within and across settings. Looking through the lens of birth settings and multiple disciplines allowed us to examine childbirth with fresh eyes. The complexity of factors affecting childbirth was an important part of our discussion. In particular, the role of social determinants such as income, educational levels, access to care, financing, transportation, structural racism and geographic variability in birth settings is clear, taking needed improvements far beyond the traditional clinical environments where nearly 98 percent of women in the United States give birth. Possible improvements both within and outside of specific birth settings ranged from easily achieved to extremely difficult, and near-term to long-term. Committee members decided to include all improvements supported by the evidence. While some improvements would take longer and be more difficult to achieve than others, we felt it was important to go on the record with recommendations we believed would benefit all mothers and babies in all settings. As we weighed the competing economic access issues, professional values and mandates, economic and managerial pressures within settings, and professional boundaries, we established that our priority must always be the best possible pregnancy, birth and post-natal experience and outcomes for mothers and babies. It is our expectation and our hope that childbirth in America can be both reframed and reformed to achieve the improved outcomes that we know are possible at less economic cost and at great gain for families and communities, as well as for our nation. vii   

PREPUBLICATION COPY, UNCORRECTED PROOFS   Susan Scrimshaw, Chair Committee on Assessing Health Outcomes by Birth Settings viii   

PREPUBLICATION COPY, UNCORRECTED PROOFS   ACKNOWLEDGMENTS This report would not have been possible without the contributions of many people. First, we thank Congresswoman Lucille Roybal-Allard (D-CA) and Congresswoman Jaime Herrera Beutler (R-WA) for requesting this study and the study’s sponsor the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health for funding the project. Special thanks go to the members of the study committee, who dedicated extensive time, thought, and energy to the project. Thanks are also due to NAM Distinguished Nurse Scholar-in- Residence Lori Trego (University of Colorado, Denver), who contributed her time and expertise throughout the repot process. In addition to its own research and deliberations, the committee received input from several outside sources, whose willingness to share their perspectives and experiences was essential to the committee’s work. We thank Abigail Aiyepola (National Association to Advance Black Birth), Tanya Alteras (MITRE), Melissa Avery (University of Minnesota), Haywood L. Brown (University of South Florida), Steve Calvin (Minnesota Birth Center), Joia Crear-Perry (Black Mamas Matter), Susan Dentzer (Duke-Margolis Center for Health Policy), Jennie Joe (Native American Research and Training Center, University of Arizona), Diana Jolles (Frontier Nursing University), Jennie Joseph (Commonsense Childbirth, Inc), Ebony Marcelle (Community of Hope), Mary Faith Marshall (University of Virginia), Peter Nielsen (Baylor College of Medicine), and Saraswathi Vedam (University of British Columbia, Canada). The committee also gathered information through a commissioned paper. We thank the authors Holly Powell Kennedy (Yale University), Clare Balaam (University of Central Lancashire), Hannah Dahlen (Western Sydney University, Australia), Eugene Declercq (Boston University), Ank de Jong (Amsterdam University Medical Center, The Netherlands), Soo Downe (University of Central Lancashire, UK), David Ellwood (Griffith University School of Medicine, Australia), Caroline S. E. Homer (Burnet Institute, Australia), Jane Sandall (Kings College London, UK), Saraswathi Vedam (University of British Columbia, Canada), and Ingrid Wolfe (King’s College London, UK) for “International Insights for Maternity Care in the United States.” In addition, we thank Kylee Barnes and Leah Houtman for their commissioned analysis. This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: Claire D. Brindis (Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco), Ana Delgado (Zuckerberg San Francisco General, Department of Obstetrics and Gynecology and Inpatient Midwifery Services, University of California, San Francisco), Joyce K. Edmonds (W.F. Connell School of Nursing, Boston College), Alan R. Fleischman (Albert Einstein College of Medicine, New York Academy of Medicine), Sandra D. Lane (Public Health and Anthropology, Syracuse University and Obstetrics and Gynecology, Upstate Medical University), Mary Lawlor (Office of the Executive Director, National Association of Certified Professional Midwives and Monadnock Birth Center, Swanzey, NH), Scott A. Lorch (Perelman School of Medicine, University of Pennsylvania and Neonatal-Perinatal Fellowship Program, The Children’s Hospital ix   

PREPUBLICATION COPY, UNCORRECTED PROOFS   of Philadelphia), Monica R. McLemore (Family Health Care Nursing Department and Advancing New Standards in Reproductive Health, University of California, San Francisco), Jennifer Moore (Office of the Executive Director, Institute for Medicaid Innovation and Department of Obstetrics and Gynecology, University of Michigan Medical School), and Jonathan M. Snowden (School of Public Health, Department of Obstetrics and Gynecology, Oregon Health and Science University). Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by Maxine Hayes (Pediatrics, School of Medicine and Health Services, School of Public Health, University of Washington) and Elena Fuentes-Afflick (Pediatrics, Zuckerberg San Francisco General and Vice Dean for Academic Affairs, University of California, San Francisco). They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. The committee also wishes to extend its gratitude to the staff of the National Academies of Sciences, Engineering, and Medicine, in particular to Elizabeth Howe-Huist and Dara Shefska, who contributed research and writing assistance to the committee’s work and played an important role in editing portions of the report. Lesley Webb provided key administrative and logistical support and made sure that committee meetings ran efficiently and smoothly. Mary Ghitelman also provided administrative support in the final stages of the project and assisted with report production. Thanks are also due to consultant Bridget B. Kelly for her contributions to the formation of the committee and guidance throughout the study process, as well as consulting technical writer Erin Hammers Forstag, who provided invaluable writing assistance. Throughout the project, Natacha Blain, director of the Board on Children, Youth, and Families, provided helpful oversight. The committee is also grateful to Anthony Bryant and Pamella Atayi for their financial and administrative assistance on the project. From the Division of Behavioral and Social Sciences and Education Office of Reports and Communication, we thank Kirsten Sampson-Snyder, Yvonne Wise, and Douglas Sprunger, who shepherded the report through the review and production process and assisted with its communication and dissemination. We also thank Rona Briere for her skillful editing. Susan Scrimshaw, Chair Emily P. Backes, Study Director Committee on Assessing Health Outcomes by Birth Settings x   

PREPUBLICATION COPY, UNCORRECTED PROOFS   CONTENTS Summary S-1 1 Introduction 1-1 Purpose and Scope of This Study The Problem The Opportunity Statistics and Trends in Birth Settings The Committee’s Conceptual Model Key Terms Study Methods Organization of the Report 2 Maternal and Newborn Care in the United States 2-1 Birth Settings Maternal and Newborn Care Team Policy and Financing Conclusion 3 Epidemiology of Clinical Risks in Pregnancy and Childbirth 3-1 Medical Risk Factors Obstetric Risk Factors Medical and Obstetric Risk Factors by Birth Setting in the United States Choice, Risk, and Decision Making Conclusion 4 Systemic Influences on Outcomes in Pregnancy and Childbirth 4-1 Inequities in Maternal and Newborn Outcomes Structural Inequities and Biases Social Determinants of Health Health System: Policy and Financing Conclusion 5 Issues in Measuring Outcomes by Birth Settings: Data and Methods 5-1 Data Sources Study Design and Methodologies Assessing the Quality of Evidence Conclusion 6 Maternal and Newborn Outcomes by Birth Setting 6-1 Understanding Maternal and Infant Outcomes xi   

PREPUBLICATION COPY, UNCORRECTED PROOFS   Fetal and Neonatal Outcomes by U.S. Birth Setting Maternal Outcomes by U.S. Birth Setting Patient Experience and Satisfaction by U.S. Birth Setting International Studies of Outcomes by Birth Setting Interprofessional Collaboration Across the Maternity Care Team and Between Birth Settings Conclusion 7 Framework for Improving Birth Outcomes Across Birth Settings 7-1 Framework for Maternal and Newborn Care in the United States Hospital Settings Home and Birth Center Settings Informed Choice and Risk Selection Access Priority Areas for Future Research Conclusion References R-1 APPENDIX Biosketches of Committee Members and Staff App-1 xii   

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The delivery of high quality and equitable care for both mothers and newborns is complex and requires efforts across many sectors. The United States spends more on childbirth than any other country in the world, yet outcomes are worse than other high-resource countries, and even worse for Black and Native American women. There are a variety of factors that influence childbirth, including social determinants such as income, educational levels, access to care, financing, transportation, structural racism and geographic variability in birth settings. It is important to reevaluate the United States' approach to maternal and newborn care through the lens of these factors across multiple disciplines.

Birth Settings in America: Outcomes, Quality, Access, and Choice reviews and evaluates maternal and newborn care in the United States, the epidemiology of social and clinical risks in pregnancy and childbirth, birth settings research, and access to and choice of birth settings.

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