Birth Settings in America
Outcomes, Quality, Access, and Choice

INTRODUCTION

Childbirth services play a critical role in the provision of U.S. health care. But, while the U.S. spends more on childbirth than any other country in the world, it has worse outcomes than other high-resource nations, in terms of maternal and infant deaths, illness, and injury. These negative outcomes are more frequent for Black and Native American individuals and their newborns.

Birth Settings in America: Outcomes, Quality, Access, and Choice (2020), a report from the National Academies of Sciences, Engineering, and Medicine, examines one crucial component of U.S. maternity care: the settings in which childbirth occurs. The report identifies ways to improve childbirth services in hospital settings—where the vast majority of pregnant people1 in the U.S. experience childbirth—and in birth centers and for home births. Improving integration across birth settings and investing in the maternity care workforce can also make giving birth safer than it is today.

Read the Report Highlights.

1. Intersex people and people of various gender identities, including transgender, non-binary, and cisgender individuals, give birth and receive maternity care. Thus, we use the terms “pregnant people” or “pregnant individuals” in place of “pregnant women.”

Why Study Birth Settings?

The U.S. has among the highest rates of maternal and neonatal mortality and morbidity of any high-resource country, particularly among Black and Native American individuals. Disparities also exist in maternal and infant mortality rates by geographic location.

There is growing recognition of a mismatch between the collective expectations of the care and support pregnant people deserve and what they actually receive. Structural racism, implicit and explicit bias, and discrimination underlie large and persistent racial and ethnic disparities in the quality of care received by childbearing individuals and infants.

chart
Trends in pregnancy-related mortality ratio: U.S., 2005-2016.
Source: Centers for Disease Control and Prevention, 2019
chart
Infant, neonatal, and postneonatal mortality rates, by race and Hispanic origin: U.S., 2017.
Source: Ely and Driscoll, 2019

Understanding Birth Settings

While the vast majority of pregnant people—98.4%—give birth in a hospital, the percentage of pregnant people choosing to give birth outside of hospitals, either at home or in dedicated birthing facilities called birth centers, is growing. These rates vary substantially by state and region of the country, and individuals who plan to give birth at home or in a birth center are more likely to be White, more highly educated, older, and able to pay for the birth out of pocket.

Pregnant people who give birth in the U.S. can have vastly different experiences depending on the setting in which they give birth, the providers who participate in their care, how the birth is financed, and the state in which they give birth. Hospitals, home births, and birth centers offer different resources, services, and care options. Even among different hospitals, the resources, providers, services, and outcomes can vary widely, depending on factors such as the level of care, geographic location, staffing, and culture.

The report defines a birth center as a freestanding health facility not attached to or inside a hospital. Other “birth centers” that are located within hospitals in the U.S. vary widely in the resources and care model that they offer. Freestanding birth centers are intended for low-risk individuals who desire less medical intervention during birth, a home-like atmosphere, and an emphasis on individually tailored care. Birth center care is typically led by midwives, sometimes with additional care from other maternity care support staff, such as registered nurses, doulas, and birth assistants. Transfer to a higher level of care is available when needed.

A home birth is a birth that occurs at a person’s residence and can be either planned or unplanned. A home birth is typically attended by a midwife but may also be attended by a physician, other attendant, or by no medical attendant at all. Pregnant people desiring a home birth must remain low-risk throughout the pregnancy and must typically reach 37 weeks’ gestation to be eligible for a home birth. If at any point during labor and birth the pregnant person or the newborn develops complications, hospital transport is initiated.

Hospitals are the most common place of birth in the U.S.. Among birth settings, hospitals provide the widest array of medical interventions for pregnant people and newborns. Care providers at hospital maternity care units may include nurses, obstetricians, family physicians, pediatricians, and midwives (although family physicians and midwives do not practice in all maternity care units). Some hospitals may also have specialists, such as anesthesiologists, maternal-fetal medicine specialists, and neonatologists, immediately available or on call.



For more details on birth settings, read Chapter 2.

Maternity Care Providers

Pregnant people are cared for by a number of different health care professionals during pregnancy and birth, and these professionals differ in how they are educated, trained, licensed, and credentialed. Nurses, physicians, and midwives provide the majority of maternal and newborn care across birth settings.

Nurses monitor the pregnant person and fetus/infant during labor and birth; assess the pregnant person’s progress through the stages of labor; identify potential complications; administer medications; monitor the newborn after birth; help new parents learn about infant care; and communicate with the pregnant person, their family, physicians, midwives, and other members of the care team.

Midwives specialize in the management of pregnancy, birth, and newborn care. The U.S. is unique among nations in that it has three types of midwives with nationally recognized credentials: certified nurse midwives (CNMs), certified midwives (CMs), and certified professional midwives (CPMs)

A Certified Nurse Midwife is a registered nurse with a master’s degree in midwifery, while a Certified Midwife has a bachelor’s degree in any field and a master’s degree in midwifery. CNMs and CMs both receive training through a hospital-based educational program. A Certified Professional Midwife has a high school diploma or the equivalent (though some earn a certificate or an associate’s, bachelor’, or master’s degree in midwifery). CPMs gain their credentials by completing an educational program or a two year apprenticeship which primarily occurs in a birth center or home birth setting.

Physicians providing maternal and newborn care evaluate, diagnose, manage, and treat patients; order and evaluate diagnostic tests; prescribe medications; and attend births. Physicians include obstetrician/gynecologists (OB/GYNs), maternal-fetal medicine specialists (MFMSs), family physicians, pediatricians, neonatologists, and anesthesiologists.



Percentage of Births Attended by Physicians, Certified Nurse Midwives (CNMs)/Certified Midwives (CMs), and
Other Midwives by Place of Birth, U.S., 2017

SOURCE: MacDorman and Declercq, 2019.


NOTES:
Home: Does not include planned home births that were transferred to hospitals.
Planned Home: Does not include planned home births that were transferred to hospitals. Excludes data from California, which did not report the planning status of home births.

Read Chapter 2 for more detailed information about the various members of the care team.

Risk in Pregnancy and Childbirth

Risk can be defined as the increased likelihood of an adverse maternal, fetal, or neonatal outcome.

Systems-level factors, such as structural inequalities, racism, and bias (in both the health system and society at large), policy and financing features of the health system, and the social determinants of health, are associated with risk for pregnant people. Systematic risk factors hamper access and contribute to medical, obstetrical, and social risks that manifest in disparities in maternal and neonatal outcomes along lines of race, ethnicity, class, and geography. Understanding the role that non-clinical factors play in determining clinical risk is essential for developing risk-appropriate models of care.

Risk comes from four main sources:



Read Chapter 3 “Epidemiology of Clinical Risks in Pregnancy and Childbirth.”

Read Chapter 4 “Systemic Influences on Outcomes in Pregnancy and Childbirth.”

Maternal and Newborn Outcomes by Birth Setting

In the U.S., home, birth center, and hospital birth settings each offer risks and benefits to the childbearing individual and the newborn. These risks may be modifiable within each setting and across settings.

Finding 6-1: Statistically significant increases in the relative risk of neonatal death in the home compared with the hospital setting have been reported in most U.S. studies of low-risk births using vital statistics data. However, the precise magnitude of the difference is difficult to assess given flaws in the underlying data. Regarding serious neonatal morbidity, studies report a wide range of risk in low-risk home versus hospital birth and by provider type. Given the importance of understanding these severe morbidities, the differing results among studies are of concern and require further study.

Finding 6-2: Vital statistics studies of low-risk births in freestanding birth centers show an increased risk of poor neonatal outcomes, while studies conducted in the U.S. using models indicating intended place of birth have demonstrated that low-risk births in birth centers and hospitals have similar to elevated rates of neonatal mortality. Findings of studies of the comparative risk of neonatal morbidity between low-risk birth center and hospital births are mixed, with variation across studies by outcome and provider type.

Finding 6-3: In the U.S., low-risk women choosing home or birth center birth compared with women choosing hospital birth have lower rates of intervention, including cesarean birth, operative vaginal delivery, induction of labor, augmentation of labor, and episiotomy, and lower rates of intervention-related maternal morbidity, such as infection, postpartum hemorrhage, and genital tract tearing. These findings are consistent across studies. The fact that women choosing home and birth center births tend to select these settings because of their desire for fewer interventions contributes to these lower rates.

Finding 6-4: Some women experience a gap between the care they expect and want and the care they receive. Women want safety, freedom of choice in birth setting and provider, choice among care practices, and respectful treatment. Individual expectations, the amount of support received from caregivers, the quality of the caregiver–patient relationship, and involvement in decision making appear to be the greatest influences on women’s satisfaction with the experience of childbirth.

Finding 6-5: International studies suggest that home and birth center births may be as safe as hospital births for low-risk women and infants when (1) they are part of an integrated, regulated system; (2) multiple provider options across the continuum of care are covered; (3) providers are well qualified and have the knowledge and training to manage first-line complications; (4) transfer is seamless across settings; and (5) appropriate risk assessment and risk selection occur across settings and throughout pregnancy. Such systems are currently not widespread in the U.S..

Finding 6-6: Lack of integration and coordination and unreliable collaboration across birth settings and maternity care providers is associated with poor birth outcomes for women and infants in the U.S..



Read Chapter 5 “Issues in Measuring Outcomes by Birth Settings.”

Read Chapter 6 “Maternal and Newborn Outcomes by Birth Setting.”

Framework for Maternal and Newborn Care in the U.S.

Opportunities exist for improving care, experiences, and outcomes in the U.S. maternity care system. While change will take time, there is an urgent need for all stakeholders—pregnant people, policy makers, payers, health care systems, professional organizations, and providers—to come together to improve maternity care and build a high-functioning, integrated, regulated, and collaborative maternity care system, a system that fosters respect for all pregnant people, newborns, and families, regardless of their circumstances or birth and health choices.

Conclusion 7-1: Quality improvement initiatives—such as the Alliance on Innovation in Maternal Health and the National Network of Perinatal Quality Collaboratives—and adoption of national standards and guidelines—such as the Maternal Levels of Care of the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine; the American Academy of Pediatrics’ Neonatal Levels of Care; and guidelines for care in hospital settings developed by the Association of Women’s Health, Obstetric, and Neonatal Nurses, the Society of Obstetric Anesthesia and Perinatology, and the American College of Nurse-Midwives—have been shown to improve outcomes for pregnant people and newborns in hospital settings

Conclusion 7-2: Providing currently underutilized nonsurgical maternity care services that some women have difficulty obtaining, including vaginal birth after cesarean, external cephalic version, planned vaginal breech, and planned vaginal twin birth, according to the best evidence available, can help hospitals and hospital systems ensure that all pregnant people receive care that is respectful, appropriate for their condition, timely, and responsive to individual choices. Developing in-hospital low-risk midwifery-led units or adopting these practices within existing maternity units, enabling greater collaboration among maternity care providers (including midwives, physicians, and nurses), and ensuring cultivation of skills in obstetric residency and maternal-fetal medicine fellowship programs can help support such care.

Conclusion 7-3: Efforts are needed to pilot and evaluate high value payment models in maternity care and identify and develop effective strategies for value-based care.

Conclusion 7-4: Integrating home and birth center settings into a regulated maternity and newborn care system that provides shared care, and access to safe and timely consultation; written plans for discussion, consultation, and referral that ensure seamless transfer across settings; appropriate risk assessment and risk selection across settings and throughout the episode of care; and well-qualified maternity care providers with the knowledge and training to manage first-line complications may improve maternal and neonatal outcomes in these settings.

Conclusion 7-5: The availability of mechanisms for all freestanding birth centers to access licensure at the state level and requirements for obtaining and maintaining accreditation could improve access to and quality of care in these settings. Additional research is needed to understand variation in outcomes for birth centers that follow accreditation standards and those that do not.

Conclusion 7-6: The inability of all certified nurse midwives, certified midwives, and certified professional midwives whose education meets International Confederation of Midwives (ICM) Global Standards, who have completed an accredited midwifery education program, and who are nationally certified to access licensure and practice to the full extent of their scope and areas of competence in all jurisdictions in the U.S. is an impediment to access across all birth settings.

Conclusion 7-7: Ongoing risk assessment to ensure that a pregnant person is an appropriate candidate for home or birth center birth is integral to safety and optimal outcomes. Mechanisms for monitoring adherence to best-practice guidelines for risk assessment and associated birth outcomes by provider type and settings is needed to improve birth outcomes and inform policy.

Conclusion 7-8: To foster informed decision making in choice of birth settings, high-quality, evidence-based online decision aids and risk-assessment tools that incorporate medical, obstetrical, and social factors that influence birth outcomes are needed. Effective aids and tools incorporate clinical risk assessment as well as a culturally appropriate assessment of risk preferences and tolerance and enable pregnant people, in concert with their providers, to make decisions related to risk, settings, providers, and specific care practices.

Conclusion 7-9: Access to choice in birth settings is curtailed by a pregnant person’s ability to pay. Models for increasing access to birth settings for low-risk women that have been implemented at the state level include expanding Medicaid, Medicare, and commercial payer coverage to cover care provided at home and birth centers within their accreditation and licensure guidelines; cover care provided by certified nurse midwives, certified midwives, and certified professional midwives whose education meets International Confederation of Midwives (ICM) Global Standards, who have completed an accredited midwifery education program, and who are nationally certified; and cover care provided by community-based doulas. Additional research, demonstration, and evaluation to determine the potential impact of these state-level models is needed to inform consideration of nationwide expansion, particularly with regard to effects on reduction of racial/ethnic disparities in access, quality, and outcomes of care.

Conclusion 7-10: Ensuring that levels of payment for maternity and newborn care across birth settings are adequate to support maternity care options across the nation is critical to improving access.

Conclusion 7-11: Research is needed to study and develop sustainable models for safe, effective, and adequately resourced maternity care in underserved rural and urban areas, including establishment of sustainably financed demonstration model birth centers and hospital services. Such research could explore options for using a variety of maternity care professionals—including nurse practitioners, certified nurse midwives, certified professional midwives, certified midwives, public health nurses, home visiting nurses, and community health workers—in underserved communities to increase access to maternal and newborn care, including prenatal and postpartum care. These programs would need to be adequately funded for evaluation, particularly with regard to effects on reduction of racial/ethnic and geographic disparities in access, quality, and outcomes of care.

Conclusion 7-12: To improve access and reduce racial/ethnic disparities in quality of care and treatment, investments are needed to grow the pipeline for the maternity and newborn care workforce—including community health workers, doulas, maternity nurses, nurse practitioners and physicians’ assistants, public health nurses, family medicine physicians, pediatricians, midwives, and obstetricians—with the goal of increasing its diversity, distribution, and size. Greater opportunities for interprofessional education, collaboration, and research across all birth settings are also critical to improving quality of care.



Read Chapter 7 “Framework for Improving Birth Outcomes Across Settings.”

Sponsor


Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)