Neonatal morbidity and mortality in birth centers in the United States 2018-2021: An observational study of low-risk birthing individuals.

BACKGROUND: Many studies reporting neonatal outcomes in birth centers include births with risk factors not acceptable for birth center care using the evidence-based CABC criteria. Accurate comparisons of outcomes by birth setting for low-risk patients are needed. METHODS: Data from the public Natality Detailed File from 2018 to 2021 were used. Logistic regression, including adjusted and unadjusted odds ratios, compared neonatal outcomes (chorioamnionitis, Apgar scores, resuscitation, intensive care, seizures, and death) between centers and hospitals. Covariates included maternal diabetes, body mass index, age, parity, and demographic characteristics. RESULTS: The sample included 8,738,711 births (8,698,432 (99.53%) in hospitals and 40,279 (0.46%) in birth centers). There were no significant differences in neonatal deaths (aOR 1.037; 95% CI [0.515, 2.088]; p-value 0.918) or seizures (aOR 0.666; 95% CI [0.315, 1.411]; p-value 0.289). Measures of morbidity either not significantly different or less likely to occur in birth centers compared to hospitals included chorioamnionitis (aOR 0.032; 95% CI [0.020, 0.052]; p-value < 0.001), Apgar score < 4 (aOR 0.814, 95% CI [0.638, 1.039], p-value 0.099), Apgar score < 7 (aOR 1.075, 95% CI [0.979, 1.180], p-value 0.130), ventilation >6 h (aOR 0.349; [0.281,0.433], p-value < 0.001), and intensive care admission (aOR 0.356; 95% CI [0.328, 0.386], p-value < 0.001). Birth centers had higher odds of assisted neonatal ventilation for <6 h as compared to hospitals (aOR 1.373; 95% CI [1.293, 1.457], p-value < 0.001). CONCLUSION: Neonatal deaths and seizures were not significantly different between freestanding birth centers and hospitals. Chorioamnionitis, Apgar scores < 4, and intensive care admission were less likely to occur in birth centers.

Decolonizing the midwifery curriculum: Jettisoning the Caldwell-Moloy pelvic types.

As faculty in two different midwifery education programs, we have stopped teaching the Caldwell-Moloy classifications of the female pelvis, as have faculty in several other US midwifery programs. In this commentary, we explain the rationale for this change. We review the roots of the Caldwell-Moloy pelvic classification and the lack of contemporary scientific support for either classifying pelvic types or using such a classification for clinical decision-making, and propose an alternative approach to teaching assessment of the bony pelvis.

Adoption of Consensus Guidelines for Safe Prevention of the Primary Cesarean Delivery by Freestanding Birth Centers.

INTRODUCTION: Slow or arrested progress in labor is the most frequent (64%) indication for nonemergent transfer of laboring people from freestanding birth centers to the hospital. After the 2014 publication of the Consensus Statement on Safe Prevention of Primary Cesarean Delivery (Consensus Statement), many freestanding birth centers changed their clinical practice guidelines to allow more time for active labor in the birth center prior to hospital transfer. The result of these changes has not been evaluated in birth centers. Evaluation of adoption of guidelines based on the Consensus Statement in hospitals has shown inconsistent results. METHODS: Birth centers were contacted to determine whether they changed clinical practice guidelines in response to the Consensus Statement. A before-after analysis compared outcomes for the 2 calendar years before and the 2 calendar years after adoption of new guidelines with a retrospective analysis of deidentified client-level data collected in the American Association of Birth Centers Perinatal Data Registry. RESULTS: A third of responding birth centers (11 of 33) changed their clinical practice guidelines, mostly redefining the onset of active labor as beginning at 6 cm cervical dilatation and allowing 4 hours of arrest of dilatation in active labor before transfer to the hospital. These changes were associated with fewer diagnoses of prolonged first stage of labor (13.8% vs 8.0%, P < .01) but not with fewer intrapartum transfers (14.0% vs 14.7%, P = .55) or cesarean births (5.0 vs 4.1%, P = .26.) DISCUSSION: We found no evidence that making these practice changes was associated with better outcomes. Two hours of a lack of documented cervical change in active labor is likely long enough to diagnose arrested progress in labor. Research on proportion of morbidity and mortality associated with prolonged labor could inform practice guidelines for transfers.

Associations between prolonged second stage of labor and maternal and neonatal outcomes in freestanding birth centers: a retrospective analysis.

BACKGROUND: Current guidelines for second stage management do not provide guidance for community birth providers about when best to transfer women to hospital care for prolonged second stage. Our goal was to increase the evidence base for these providers by: 1) describing the lengths of second stage labor in freestanding birth centers, and 2) determining whether proportions of postpartum women and newborns experiencing complications change as length of second stage labor increases. METHODS: This study is a retrospective analysis of de-identified client-level data collected in the American Association of Birth Centers Perinatal Data Registry, including women giving birth in freestanding birth centers January 1, 2007 to December 31, 2016. We plotted proportions of postpartum women and newborns transferred to hospital care against length of the second stage of labor, and assessed significance of these with the Cochran-Armitage test for trend or chi-square test. Secondary maternal and newborn outcomes were compared for dyads with normal and prolonged second stages of labor using Fisher's exact test. RESULTS: Second stage labor exceeded 3 hours for 2.3% of primiparous women and 2 hours for 6.6% of multiparous women. Newborn transfers increased as second stage increased from < 15 minutes to > 2 hours (0.6% to 6.33%, p for trend = 0.0008, for primiparous women, and 1.4% to 10.6%, p for trend < 0.0001, for multiparous women.) Postpartum transfers for multiparous women increased from 1.4% after second stage < 15 minutes to greater than 4% for women after second stage exceeding 2 hours (p for trend < 0.0001.) CONCLUSIONS: Complications requiring hospitalization of postpartum women and newborns become more common as the length of the second stage increases. Birth center guidelines should consider not just presence of progress but also absolute length of time as indications for transfer.

A Program Evaluation of Behavioral Health Integration in a Freestanding Birth Center.

The objective of this evaluation was to evaluate the integration of behavioral health services at a freestanding birth center. Program evaluation included (1) retrospective health record reviews and (2) provider and client evaluation of satisfaction. In May 2017, an urban freestanding birth center initiated grant-funded integrated behavioral health services. Participants included women receiving perinatal care from May 2016 to April 2018 (n = 831). Clients (n = 414) and providers (n = 9) were surveyed through e-mail, with 166 (40%) and 7 (78%) responses, respectively. Depressive symptoms were measured with the Edinburgh Postnatal Depression Scale. Screening and treatment of depression were identified from health records. The on-site therapist saw 21% of women who birthed during the program's first year. Compared with the year before the program began, in the program's first year, more women were screened for depression at least once (401/415 (96.6%) vs 413/415 (99.5%), P = .002) and more women with an indication received treatment (62.5% [105/168] vs 34.5% [38/110], P < .001). Provider and client satisfaction was high. The on-site therapist provided services easily integrated into the freestanding birth center practice, resulting in increased depression screening and treatment, with overwhelming client and provider satisfaction.

Exploring Why Birth Center Clients Choose Hospitalization for Labor and Birth.

OBJECTIVE: To identify demographic and clinical factors associated with birth center clients electing hospitalization for labor and birth and to explore the timing and rationale for elective hospitalization via health records. DESIGN: A secondary analysis of multiyear data from a quality assurance project at a single birth center. We compared two subsamples-birth center preference group and hospital preference group-and described the apparent rationale for transfers among clients in the latter group. SETTING: A single freestanding birth center where all midwives have admitting privileges at a local hospital and can accompany labor transfers. PARTICIPANTS: All cases included in the analytic sample represent women with low-risk pregnancies who were eligible for birth center birth. The birth center preference group represents clients planning to give birth at the center, and the hospital preference group consists of clients who elected for hospitalization. MEASUREMENTS: Relevant demographic and clinical information was provided for the entire analytic sample and was matched with available data collected systematically by birth center staff via chart review. The data set also included anonymous responses to an e-mailed questionnaire from clients identified by birth center staff. RESULTS: Approximately 56.1% (N = 1,155) of the cases in the data set were eligible for comparative analysis. The birth center preference and hospital preference groups included 899 (77.8%) and 256 (22.2%) individuals, respectively. In the hospital preference group, Black clients (n = 23), those who were publicly insured (n = 49), and primiparas (n = 101) were significantly overrepresented. Chart review data and questionnaire responses highlighted insurance restrictions, family preferences, pain relief options, and postpartum care as influential factors among members of the hospital preference subsample. CONCLUSION: The present analysis shows associations between certain individual characteristics and elective hospitalization during labor for birth center clients. Health record data and questionnaire responses indicated a variety of reasons for electing hospitalization, illustrating the complexity of clients' decision-making during pregnancy and birth.

Key indicators influencing management of prolonged second stage labour by midwives in freestanding birth centres: Results from an ethnographic interview study.

PROBLEMS: Complications for newborns and postpartum clients in the hospital are more frequent after a prolonged second stage of labour. Midwives in community settings have little research to guide management in their settings. AIM: We explored how US birth centre midwives identify onset of second stage of labour and determine when to transfer clients to the hospital for prolonged second stage. METHODS: Ethnographic interviews of midwives with at least 2 years' experience in birth centres and participant observation of birth centre care. FINDINGS: We interviewed 21 midwives (18 CNMs, 3 CPMs/equivalent) from 18 birth centres in 11 US states, 45% with hospital practice privileges. Midwives relied on and engaged in embodied practice in evaluating each labour and making decisions concerning management of labour. Midwives considered time a useful but limited measure as a guiding factor in management. Though ideas of time and progress do play an important role in the decision-making process of midwives, their usefulness is limited due to the continual, multifactorial, and multisensory nature of the assessment. Relationship with the transfer hospital structured midwives' decision-making about transfers. DISCUSSION & CONCLUSION: These findings can inform future robust multivariate evaluation of factors, including but not limited to time, in guidelines for management of second stage of labour. Optimal management may require formal consideration of more than just time and parity. Our findings also suggest the need for evaluation of how structural issues involving hospital privileges for midwives and relationships between birth centre and hospital staff affect the well-being of childbearing families.

The Experience of Land and Water Birth Within the American Association of Birth Centers Perinatal Data Registry, 2012-2017.

Consumer demand for water birth has grown within an environment of professional controversy. Access to nonpharmacologic pain relief through water immersion is limited within hospital settings across the United States due to concerns over safety. The study is a secondary analysis of prospective observational Perinatal Data Registry (PDR) used by American Association of Birth Center members (AABC PDR). All births occurring between 2012 and 2017 in the community setting (home and birth center) were included in the analysis. Descriptive, correlational, and relative risk statistics were used to compare maternal and neonatal outcomes. Of 26 684 women, those giving birth in water had more favorable outcomes including fewer prolonged first- or second-stage labors, fetal heart rate abnormalities, shoulder dystocias, genital lacerations, episiotomies, hemorrhage, or postpartum transfers. Cord avulsion occurred rarely, but it was more common among water births. Newborns born in water were less likely to require transfer to a higher level of care, be admitted to a neonatal intensive care unit, or experience respiratory complication. Among childbearing women of low medical risk, personal preference should drive utilization of nonpharmacologic care practices including water birth. Both land and water births have similar good outcomes within the community setting.