The Evidence for Birth Centers
I am happy to announce that on behalf of the American Association of Birth Centers, I have written a blog article about the current evidence for birth centers. (Click here to read the full blog article).
New evidence confirms birth centers are safe. Credit: eyeliam
I was invited to write this article to help explain the results of the National Birth Center Study II, a new, landmark study describing outcomes for more than 15,000 women who planned to give birth in 79 different birth centers in the U.S. The study was published today, January 31st, 2013, in the Journal of Midwifery and Women’s Health (click here for the full-text link to the article).
The results for birth centers?
A C-section rate of 6%, an urgent transfer rate of less than 2%, and infant outcomes similar to what other researchers have reported in low-risk populations. As I wrote:
“If the 15,574 women who planned to give birth in birth centers had instead chosen hospital births, it is estimated that they would have experienced 3,000 additional—and unnecessary— Cesareans. Instead, these C-sections were safely and effectively prevented, along with a potential cost-savings of at least $4.5 million.”
Why are these findings so newsworthy?
“The U.S. Cesarean rate has increased substantially over the past few decades from 21% in 1996 to 32% of all births now. Over half of the increase is among first time moms, and most of these C-sections are done for more subjective reasons such as slow progress in labor. Meanwhile the Cesarean rate has been stable in birth centers for over 20 years at 4.4 to 6%”
To read more about the study and what it means for families, click here to read the article.
Shared this! Thank you for spotlighting this important issue.
It looks like this study reflects only the outcomes of births that occurred in birth centers under very specific criteria. The AABC states there are 248 known freestanding birth centers in the US. Yet this study only collected data from 79 self-selected birth centers. This isn’t even a third of the known birth centers. What would a random sampling of data from the 248 birth centers in the US have told us about the actual safety and cost-effectiveness of OOH birth centers?
That would be a much more useful study. And one I hope is conducted in the near future.
[Edited from original response] This study defines a birth center according to the standards set by the American Association of Birth Centers. The authors wanted to find out the outcomes of the birth center model that is upheld by the American Association of Birth Centers. Most of the birth centers in this study were accredited according to these standards by the Commission for the Accreditation of Birth Centers. So that would be something to look for, if you were wanting to give birth in a birth center. If a birth center is not accredited, families need to do their homework to make sure that the birth center provides care that is in line with the standards of the American Association of Birth Centers. All of the centers in this study did so.
The problems with attempting to conduct a random sample of data from the 248 U.S. birth centers are: 1) there is not a database that has the health records of all those birth centers. While there are birth certificates, the information is very limited and would not provide the answers you seem to be seeking; 2) even if such a database did exist, the quality of the data would be questionable if participation is required rather than voluntary. The strength of this study lies in its prospective design and the high quality standards that the researchers took (audits and so forth) to ensure that the data were reliable and truly reflected what went on in those birth centers. This requires many different resources, but 2 of them are: 1) the birth center and its staff have to agree to participate and be motivated to collect high quality data; and 2) each woman has to provide consent to participate in the study. A random sampling of all of the birth centers in the U.S. would not be feasible until each individual birth center does want to participate (does have the time, resources, and motivation to do so). You would also need at least triple the study resources (money, staff, etc) to carry out a study of that scope. At this point, this is the best data that we have on birth centers in the U.S., and families need to keep in mind the importance of doing their homework if they consider using a birth center– to make sure that the birth center they are using is similar to the ones included in the study.
Hi Rebecca,
Thanks so much for the excellent explanation of the National Birth Center Study II, and for this blog post as well. You have done a really great job of bringing out the important evidence about the quality and safety of birth center care! I am on AABC’s Membership Committee and have been spreading the word since the Study was published on Thursday.
Best,
Susan
According to the study 50 birth centers were CABC accredited. And an additional 29 birth centers participated and agreed to abide by AABC standards. I haven’t found a number on the CABC website, how many US birth centers are currently accredited?
There is a lot of publicity surrounding this study – and it is concerning that it comes with the fine print warning for parents to “do their homework.” That is NOT the message the AABC, the ACNM or other various midwifery organizations are publicizing. The overwhelming message is “Birth Centers are SAFE.”
I would love nothing more than to make that proclamation. But that would require a more thorough evaluation of all birth center practices and outcomes in the US. Parents deserve this information to make informed decisions. And midwives deserve this information in order to guide their practices.
Hi, again, Liz. [edited from original response]
The information that people are seeking is readily available to parents and practitioners through the AABC (http://birthcenters.org) and CABC (http://birthcenteraccreditation.org). If you want further information, it is important for you to contact those organizations directly.
I always find it to be good advice to “do your own homework.” On the other hand, it raises alarms for me when any study, website, brochure, or journal says, “Just take our word for it. Don’t worry about our sources or methodology. Don’t ask questions.” So it’s good that people like you are asking questions!
As I said earlier, it’s simply not possible to carry out a study that would include every single birth center–just like there has never been a study done on every single hospital, college, church, or bowling alley. Scientific studies are generally done on either cross-sections or portions of whole populations and are carefully built to represent the whole as best as possible.
There are now 2 studies (first study was published in 1989 in the New England Journal of Medicine) that show that the birth center model, which is upheld by the AABC and CABC is safe, produces optimum outcomes for moms and babies, and saves on healthcare costs for the nation. Most researchers agree that the first study answered the question of safety and this study confirms it.
I’ve given my opinion on this study as a researcher and someone who analyzes data for a living, and so my perspective on it (and other studies) comes from a unique background where I may have a different comfort level about its methods. That’s simply because I see so many other studies and have that context to compare the quality of the data. Compared to other studies I’ve seen, the size and methodology of this one passes muster. Many, many studies are done and practices put into place based on sample sizes that are far smaller than this. That is my opinion. You are certainly entitled to your own opinion.
One last note: I appreciate your interest in this topic; however, I am concerned about your tone. You may not mean to come across this way (it’s so hard to distinguish tone across the internet, perhaps you mean well and think you are writing in a pleasant tone), but please be certain to abide by the comment standards here. If future comments do not meet these standards 100%, I reserve the right to not publish them. I moderate comments in order to keep the discussion civil and evidence-based. http://evidencebasedbirth.com/sample-page/blog/comments/
Best wishes,
Rebecca
Rebecca, how was it determined that the centers contributing data were providing care in line with AABC standards?
Also, you advise parents to “do their home work” when considering a non-accredited birth center. Do you have specific questions they should ask, the answers that would indicate the birth centers adhere to AABC standards, and how to verify the information the birth centers provide?
Hi Kocia,
These are good questions. I can refer you to the full-text article for some of this info. http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full
The researchers state: “This report examines intrapartum care and perinatal outcomes of women who received care in birth centers that contributed to the UDS, entered labor eligible for and planning a birth center birth, and had estimated dates of birth during 2007 through 2010. Eligibility criteria for birth center birth were established by the AABC and CABC and included singleton, full-term gestation in vertex presentation with no medical or obstetric risk factors precluding a normal vaginal birth or necessitating interventions such as continuous electronic fetal monitoring or induction of labor.”
All of the participating birth centers in this study were members of the American Association of Birth Centers, and as such they “have access to continuing education activities and support the organization’s model and Standards for Birth Centers.” You can read the AABC’s standards here: http://www.birthcenters.org/sites/default/files/aabc/AABC%20STANDARDS-2007REV.pdf
So what questions should you ask of a birth center? The American Association of Birth Centers has a great list of questions to ask. http://www.birthcenters.org/for-parents/how-to-choose-a-birth-center
Are the birth attendants licensed?
Is the birth center accredited? A member of the AABC? Licensed? (not all states offer licensure)
What are the arrangments of care for when someone needs to transfer?
You can find many more questions on the link I posted above.
If the birth center is not accredited, I would ask particular questions about what kind of clients they accept for labor. Do they take any high risk clients at all? (Breech, twins, pre-term, post-term). What medical conditions do you accept care for? If they are taking high risk clients or someone with major medical complications, that is a sign that this birth center is not practicing under the standards of the AABC and thus these study results do not apply to that situation.
You can also visit this website to see the list of criteria that facilities must meet in order to be accredited, this would give you an idea of questions to ask. http://www.birthcenteraccreditation.org/find-accredited-birth-centers/accreditation-is-the-mark-of-quality/
Hope this helps!
Rebecca
Yes, very helpful. Thank you.