Birth Settings in America Outcomes, Quality, Access, and Choice (2020) / Chapter Skim
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6 Maternal and Newborn Outcomes by Birth Setting
6 Maternal and Newborn Outcomes by Birth Setting
Pages 161-258
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From page 161... ...
Aspects of care during the childbearing year are also variable and dependent on such factors as the health of the mother and infant, models of prenatal and intrapartum care, the type of birth attendant, practice standards, and facility policies across and within birth settings and regions. Furthermore, as discussed in Chapter 2, the definition of what constitutes a birth center varies across the literature, both nationally and internationally, and most U.S.
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From page 162... ...
birth settings -- home, birth center, and hospital -- as well as data on outcomes by provider type where available. It then reviews studies of outcomes by birth setting internationally.
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From page 163... ...
In its review of the literature, the committee identified a number of maternal and infant outcomes of interest related to these TMTS and TLTL concepts. These outcomes include maternal and infant mortality and morbidity indicators, which have been the traditional focus of birth settings research, as well as psychosocial outcomes, including several measures of dignity in the childbirth process, such as bodily autonomy, maternal agency, respectful care, and empowerment.
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From page 164... ...
Additionally, the literature on health outcomes by birth setting would benefit from disaggregation of outcomes by race/ethnicity, socioeconomic status, and sexual orientation and gender identity, where possible. While the current literature on outcomes largely does not address differences by race and ethnicity or other subpopulations, as noted in Chapters 3 and 4, traditionally marginalized groups often accrue a disproportionate share of clinical and social risk factors for adverse outcomes during pregnancy and birth.
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From page 165... ...
Hospital births attended by midwives are generally used as the baseline against which these birth settings are compared, and some studies report comparisons by provider type across and within setting as well.
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From page 166... ...
(ResQu: high, GRADE: poor) 8,776 planned birth center births 2,527 planned hospital births
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From page 167... ...
, Planned home births 0.05 -- cephalic, nonanomalous Planned birth center births 0.24 -- Received prenatal Hospital births 0.04 -- care in birth center, Birth center births 0.03 -- singleton, ≥37 weeks, admitted in spontaneous labor continued
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From page 168... ...
71,704 planned home births Cheyney et al., 2014a MANA 2.0 dataset (2004–2009) (ResQu: high, GRADE: poor)
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From page 169... ...
without Freestanding birth center births -- 0.46 congenital with midwife malformations Home midwife -- 0.93 Home other -- 1.65 Planned home Planned home births -- 0.41 births not transferred to another provider prior to labor continued
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From page 170... ...
1,052 TOLAC planned out-of-hospital births 12,092 out-of-hospital births NOTES: AABC = American Association of Birth Centers; CDC = Centers for Disease Control and Prevention; CNM = certified nurse midwife; GRADE = Grading of Recommendations, Assessment, Development, and Evaluation; MANA = Midwives Alliance of North America; ResQu = Birth Place Research Quality; TOLAC = trial of labor after cesarian; VBAC = vaginal birth after cesarean.
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From page 171... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 171 Inclusion/ Mortality Mortality Rate per Exclusion Criteria Birth Setting % 1,000 Live Births Planned out-of- VBAC out-of-hospital births -- 0.95 hospital births Out-of-hospital births -- 0.17 not transferred to another provider prior to labor, multiparous women without a history of cesarean delivery Late neonatal death by days not specified
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From page 172... ...
, vertex, planned 2,069,714 planned hospital births birth center and home births Cheyney et al, 2014a MANA 2.0 dataset (2004–2009) Planned home births (ResQu: high, GRADE: 16,924 planned out-of-hospital births not transferred to poor)
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From page 173... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 173 Morbidity Morbidity Rate per Birth Setting Outcome % 1,000 Live Births Planned home and birth Apgar 5 min <4 0.5 center births Apgar 5 min <7 1.5 Neonatal hospitalization 7.4 first 6 weeks NICU admission first 6 2.8 weeks Hospital births Apgar 5 min <4 Planned home births by Hospital births 0.24 CNM Home births CNM 0.19 Planned home births by Home births other midwife 0.27 other midwives Apgar 5 min <7 Hospital births 1.17 Home births CNM 1.06 Home births other midwife 2.63 Ventilator support >6 h Hospital births 0.27 Home births CNM 0.18 Home births other midwife 0.23 NICU admissions Hospital births 3.03 Home births CNM 0.37 Home births other midwife 0.64 Planned home births Apgar 5 min <7 Planned home births 1.5 NICU admission in the first 6 weeks Planned home births 2.8 continued
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From page 174... ...
hospital births transferred to another 12,092 out-of-hospital births provider prior to labor, multiparous women without a history of cesarean delivery Grünebaum et al., 2013 CDC birth certificate data Singleton, term (≥37 (ResQu: low)
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From page 175... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 175 Morbidity Morbidity Rate per Birth Setting Outcome % 1,000 Live Births TOLAC out-of-hospital Apgar 5 min <4 births TOLAC out-of-hospital 1.0 births Out-of-hospital births 0.4 NICU admission TOLAC out-of-hospital 4.2 births Out-of-hospital births 2.0 Infant hospitalization in first 6 weeks TOLAC out-of-hospital 17.0 births Out-of-hospital births 7.8 Hospital MD Apgar 5 min = 0 Hospital MD - 0.16 Hospital midwife Hospital midwife - 0.09 Freestanding birth center Freestanding birth center - 0.55 midwife midwife Home midwife Home midwife - 1.63 continued
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From page 176... ...
, vaginal births 1,237,129 hospital CNM births 17,389 hospital other midwife births 13,529 home CNM births 42,375 home other midwife births 25,319 birth center CNM births
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From page 177... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 177 Morbidity Morbidity Rate per Birth Setting Outcome % 1,000 Live Births Hospital births with CNM Apgar 5 min <4 Hospital births CNM - 0.7 Hospital births with other midwife Hospital births other - 0.6 midwife Birth center births with Birth center births CNM - 0.5 CNM Home births CNM - 5.5 Home births with CNM Home births other midwife - 2.3 Injury at birth Home births with other midwife Hospital births CNM - 3.1 Hospital births other - 1.5 midwife Birth center births CNM - 0.9 Home births CNM - 2.4 Home births other midwife - 1.7 Mechanical ventilation <30 min Hospital births CNM - 15.1 Hospital births other - 20.8 midwife Birth center births CNM - 10.2 Home births CNM - 10.8 Home births other midwife - 15.6 Mechanical ventilation >30 min Hospital births CNM - 2.7 Hospital births other - 2.6 midwife Birth center births CNM - 1.4 Home births CNM - 2.0 Home births other midwife - 3.9 continued
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From page 178... ...
Received prenatal (ResQu: high, GRADE: 8,776 planned birth center births care in birth center, poor) 2,527 planned hospital births singleton, ≥37 weeks, admitted in spontaneous labor
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From page 179... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 179 Morbidity Morbidity Rate per Birth Setting Outcome % 1,000 Live Births Hospital birth Apgar 5 min <4 Hospital births 0.4 Planned home birth Planned home births 0.3 Planned birth center birth Planned birth center births 0.6 Apgar 5 min <7 Hospital births 1.9 Planned home births 1.2 Planned birth center births 2.5 NICU admission Hospital births 3.0 Planned home births 0.8 Planned birth center births 1.1 Ventilation Hospital births 3.3 Planned home births 2.5 Planned birth center births 4.5 Hospital birth Apgar 5 min <7 Hospital births 0.51 Birth center birth Birth center births 0.80 Neonatal composite Hospital births 0.44 Birth center births 0.44 Newborn ventilation <10 min Hospital births 2.26 Birth center births 3.05 continued
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From page 180... ...
106,823 hospital births nonanomolous, 3,147 out-of- hospital births delivered by VBAC NOTE: AABC = American Association of Birth Centers; CDC = Centers for Disease Control and Prevention; CNM = certified nurse midwife; GRADE = Grading of Recommendations, Assessment, Development, and Evaluation; MANA = Midwives Alliance of North America; NICU = neonatal intensive care unit; ResQu = Birth Place Research Quality; TOLAC = trial of labor after cesarian; VBAC = vaginal birth after cesarean.
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From page 181... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 181 Morbidity Morbidity Rate per Birth Setting Outcome % 1,000 Live Births Hospital Apgar 5 min <4 Hospital 0.4 Out of hospital Out of hospital 0.73 Apgar 5 min <7 Hospital 2.68 Out of hospital 4.42 Ventilator support Hospital 0.29 Out of hospital 0.38 NICU admission Hospital 3.10 Out of hospital 1.11 Birth injury Hospital 0.10 Out of hospital 0.03
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From page 182... ...
The neonatal mortality rate was nearly twice as high in planned home births as compared with planned hospital births (0.20% vs.
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From page 183... ...
The authors limited analyses to data from Oregon collected over the 2-year period following the change to the birth certificate, yielding a sample of 75,923 hospital births and 3,203 home and birth center births. 3 The study by Cox and colleagues (2015)
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From page 184... ...
The authors compared outcomes of neonates whose mothers had planned home births and those who delivered in hospitals, and found that, compared with hospital births, more planned home births had 5-minute Apgar scores below 4 and a lower rate of NICU admission; they do not report neonatal mortality. 8 In their 2013 study, Grünebaum and colleagues used birth certificate data from the CDC's National Center for Health Statistics to examine deliveries by physicians and midwives in and out of the hospital between 2007 and 2010 for a national sample of nearly 14 million singleton term births.
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From page 185... ...
(Home births attended by others were excluded; only planned home births attended by midwives were included.) Compared with CNM-attended hospital births, all four risk factors were significantly higher among midwife-attended planned home births, and three were significantly higher for planned home births attended by midwives not certified by the American Midwifery Certification Board.
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From page 186... ...
studies show elevated rates of neonatal mortality in home births compared with hospital births; see Tables 6-3 and 6-4. The relative risk to the infant may be two-fold, with absolute risks of about 1.2/1,000 versus 0.6/1,000 for home and hospital, respectively.
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From page 187... ...
Find ings 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. Moreover, giving the interrelationship of midwife credentialing with birth settings, its mediating effect on perinatal outcomes cannot be ascertained with confidence from the current literature.
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From page 188... ...
12,709,881 hospital physician g) without congenital 1,096,555 hospital midwife malformations 39,523 freestanding birth center Neonatal death reported as midwife 0–27 days 61,993 home midwife 28,119 home other Grünebaum et al., CDC linked birth/infant death dataset Singleton, term (≥37 weeks)
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From page 189... ...
1.00 -- Hospital MD 1.69 (1.52–1.88) -- Freestanding birth center midwife 1.81 (1.19–2.75)
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From page 190... ...
≥2,500 g) without congenital malformations Early neonatal death reported as 0–6 days NOTE: CDC = Centers for Disease Control and Prevention; CNM = certified nurse midwife; GRADE = Grading of Recommendations, Assessment, Development, and Evaluation; ResQu = Birth Place Research Quality; VBAC = vaginal birth after cesarean.`
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From page 191... ...
1.00 -- Hospital MD 2.04 (1.73–2.39) -- Freestanding birth center midwife 3.26 (2.01–5.31)
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From page 192... ...
12,039 planned home weeks) , vertex, planned 2,069,714 planned hospital birth center and home Grünebaum et al., CDC birth certificate data Singleton, term (≥37 weeks)
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From page 193... ...
-- 1.00 CNM Home CNM -- 0.69 (0.26–1.83) Planned home by Home other midwife -- 1.62 (1.01–1.83)
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From page 194... ...
, vaginal 1,237,129 hospital CNM 17,389 hospital other midwife 13,529 home CNM 42,375 home other midwife 25,319 birthing center CNM
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From page 195... ...
Birth center CNM -- 0.79 (0.69–0.92 Home CNM -- 0.74 (0.61–0.89) Home other midwife -- 1.08 (0.98–1.18)
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From page 196... ...
Received prenatal care 2017 8,776 planned birth center in birth center, singleton, (ResQu: high, 2,527 planned hospital ≥37 weeks, admitted in GRADE: poor) spontaneous labor
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From page 197... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 197 RR Adj. OR Birth Setting Outcome (95% CI)
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From page 198... ...
NOTE: AABC = American Association of Birth Centers; CDC = Centers for Disease Control and Prevention; CNM = certified nurse midwife; GRADE = Grading of Recommendations, Assessment, Development, and Evaluation; HIE = hypoxic ischemic encephalopathy; NICU = neonatal intensive care unit; ResQu = Birth Place Research Quality.
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From page 199... ...
-- 1.00 Out-of-hospital -- 0.78 (0.58–1.04) Out-of-hospital with HIE HIE Neonates w/o HIE -- 1.00 Planned home with HIE Out-of-hospital w/HIE -- 44 (4.5–424.0)
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From page 200... ...
However, they were able to compare planned home and hospital births for a broad range of general morbidity and intervention-related morbidity indicators. They found that planned home births were associated with fewer maternal interventions, including epidural analgesia (9.0% vs.
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From page 201... ...
. This association between reduced morbidity and home birth settings may be attributable both to home birth models of care and to the fact that healthy women who are highly motivated to avoid interventions are proportionately overrepresented in home birth samples.
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From page 202... ...
(37–42 weeks) , Planned home (ResQu: 12,039 planned home vertex, planned birth moderate)
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From page 203... ...
Cesarean Delivery 5.4 Vaginal only -- -- Any genital tract trauma 53.2 -- -- Postpartum hemorrhage >1000 cc 3.4 -- -- Augmentation of Labor Hospital 22.2 -- 1.00 Planned home 2.1 -- 0.29 (0.27–0.31) Induction of Labor Hospital 25.7 -- 1.00 Planned home 1.4 -- 0.19 (0.18–0.22)
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From page 204... ...
2,527 planned hospital weeks, admitted in spontaneous labor. NOTE: AABC = American Association of Birth Centers; CDC = Centers for Disease Control and Prevention; GRADE = Grading of Recommendations, Assessment, Development, and Evaluation; MANA = Midwives Alliance of North America; ResQu = Birth Place Research Quality.
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From page 205... ...
Cesarean Delivery Hospital (ref) 24.7 -- 1.00 Planned home 0 -- -- Planned birth center 0 -- -- Out-of-hospital -- -- 0.18 (0.16–0.22)
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From page 206... ...
) , using data from a national registry, describe outcomes of planned home births in the United States between 2004 and 2009.
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From page 207... ...
. Summary Maternal outcomes by birth setting are remarkably consistent: low-risk home and birth center births are associated with lower rates of perineal lacera ion; reduced rates of medical intervention, including cesarean deliv t ery; and higher rates of breastfeeding initiation and exclusive breastfeeding at 6–8 weeks postpartum.
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From page 208... ...
PATIENT EXPERIENCE AND SATISFACTION BY U.S. BIRTH SETTING Factors in Maternal Satisfaction and Relationship to Outcomes Maternal satisfaction across birth settings has typically been highest when women are supported in choosing the birth setting and provider type that align most closely with their value systems, individual pregnancy characteristics, and personal preferences.
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From page 209... ...
Bohren and colleagues (2017) found that continuous labor support may contribute to several positive outcomes in childbirth, including increased spontaneous vaginal birth; shorter duration of labor; decreased rates of cesarean birth, instrumental vaginal birth, use of any analgesia, and use of regional analgesia; and decreases in low 5-minute Apgar scores and negative feelings about childbirth experiences.
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From page 210... ...
. Doulas influence the bottom-line costs of birth through their positive effect on, among other outcomes, cesarean birth rates, time in labor, use of analgesia/anesthesia, and breastfeeding rates.
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From page 211... ...
Nurses can view data from the fetal monitor and enter data in the medical record remotely from a central station or in another patient's room; thus nursing documentation does not equate to nursing bedside ttendance, making that an unreliable factor in measuring the effect of a nursing care. The value of nursing care is diminished by historical hospital billing practices not specifying care by registered nurses, which is inconsistent with the reality that patients are admitted to the hospital only if they need nursing care.
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From page 212... ...
suggest a link between continuity of nursing care during labor and risk of cesarean birth. A recent focus on the rate of cesarean birth in the United States and its asso iation with maternal morbidity and mortality has renewed interest in this c topic.
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From page 213... ...
. These aspects of nursing care in the context of labor management guide lines have been shown to be successful in decreasing cesarean births (Bell et al., 2017; Main et al., 2019; Tussey et al., 2015; White VanGompel et al., 2019)
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From page 214... ...
Women who transferred to a hospital from a planned home or birth center birth or whose opinion on the best course of action differed from their provider's reported even higher rates of mistreatment. Women's experiences also differed significantly by birth setting, with 5.1 percent of women who gave birth at home reporting mistreatment versus 28.1 percent of women who gave birth in a hospital.
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From page 215... ...
. The committee chose Australia, Canada, the Netherlands, and the United Kingdom because they are high-resource countries and have relatively robust data on birth settings and outcomes from their vital statistics systems, as well as a range of wellconducted studies.
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From page 216... ...
2017 % preterm births 2017 % low birthweight 2017 % severe maternal morbidityj 2008–2013 % cesarean births 2017 % births delivered by OB 2017 % births delivered by MW 2017 % births delivered by FP/GP 2017 % births in hospitals 2017 % births in birth centers 2017 % births at home 2017 % privately funded birth care 2017 % publicly funded birth care 2017 GINI Indexc 2013–2017 NOTES: OB = obstetrician; MW = midwife; FP/GP = family physician/general practitioner. The GINI index measures the extent to which the distribution of income or consumption of expenditure among individuals/households within countries deviates from a perfectly equal distribution (Organisation for Economic Co-operation and Development, 2019)
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From page 217... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 217 U.S. Australia Canada Netherlands UK 3385.6a 301.1b 376.3c 165.7d 754.8c 11.8e 12.4e 10.3e 9.9e 11.4e 1.77 1.74 1.5 1.62 1.74 62,853 54,144 48,107 56,326 45,505 5.8 3.3 4.5 3.6 3.9 3.9 2.4 3.5 2.7 2.8 5.9 8.1 5.8 4.8 6.3 -- 7b 7.6f -- 4.2g 16.9 (2016)
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From page 218... ...
International Studies of Home Birth Outcomes When examining international studies of home birth outcomes, it is important to recognize that the context of the maternity care systems in the four countries the committee chose for comparison is very different from that of the current U.S. system, being characterized by universal health coverage and access, standardized high-level midwifery training, regulated risk-based selection of birth setting, and systems for transfer to a higher level of care when needed.
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From page 219... ...
. 22 The study compares low-risk women planning midwife-led care for home versus hospital births (n = 466,112 planned home births and n = 276,958 planned hospital births)
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From page 220... ...
midwife during Freestanding Group, 2011 obstetric unit any phase of labor at midwifery unit (ResQu: high, N = 64,538 ≥37 weeks gestation in Alongside GRADE: good) 16,840 planned home spontaneous labor.
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From page 221... ...
Alongside midwifery unit -- 3.6 0.92 (0.60–1.39) Neonatal Mortality -- 3.3 -- Apgar 5 min <7 0.7 -- -- Respiratory distress 0.4 -- -- Intrapartum and Neonatal Adj.
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From page 222... ...
births factors prior to labor, in Netherlands 276,958 planned midwife-led care at the hospital births onset of labor. A combination of intrapartum or neonatal mortality or NICU admission within 28 days of birth.
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From page 223... ...
Parous hospital (ref) -- 2.41 1 Neonatal Death RR (95%)
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From page 224... ...
Collection, Admitted Australia Patient Data Collection, Register of Congenital Conditions, Registry of Birth Deaths and Marriages, and the Australian Bureau of Statistics (Jul 2000–Jun 2008) 242,936 hospital births 14,483 birth center births 742 home births Samples were restricted to women who were not missing any potential confounder data.
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From page 225... ...
midwifery unit Multiparous-alongside 2.4 -- 1 midwifery unit (ref) Neonatal Mortality Adj.
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From page 226... ...
6,692 planned home outset of labor. Groups planned hospital Canada 6,692 planned hospital matched by parity and previous lower-segment cesarean delivery.
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From page 227... ...
Apgar 5 Min <7 Hospital midwife -- -- 1 Home midwife -- -- 0.92 (0.58–1.47) Hospital MD -- -- 1 Home midwife -- -- 0.99 (0.61–1.61)
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From page 228... ...
born at home moderate, Planned home at GRADE: poor) N = 298,333 hospital Australia Sprague et al., Better Outcomes Birth center births Birth center 2018 Registry & Network matched on 1:4 Hospital (ResQu: (BORN)
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From page 229... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 229 Morbidity/ Morbidity/ Mortality Rate per Outcome Mortality % 1,000 Live Births Risk Perinatal Deaths Adj.
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From page 230... ...
10,632 obstetrician-led obstetrician-led Netherlands care care NOTE: CI = confidence interval; GRADE = Grading of Recommendations, Assessment, Devel opment, and Evaluation; NICU = neonatal intensive care unit; NPA = natural prospective approach; OR = odds ratio; PGA = perfect guideline approach; ResQu = Birth Place Research Quality; RR = relative risk.
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From page 231... ...
OR (95%) CI Home-NPA 0.42 -- -- Home-PGA 0.41 -- -- Hospital-NPA 0.54 -- -- Hospital-PGA 0.50 -- -- Planned place unknown-PGA 0.50 -- -- Planned place unknown-NPA 0.47 -- -- Intrapartum and Neonatal Death 0–7 Days Home-NPA 0.15 -- 1.05 (0.91–1.21)
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From page 232... ...
midwife during Freestanding Group, 2011 16,840 planned home any phase of labor at midwifery unit (ResQu: high, 11,282 planned ≥37 weeks gestation in Alongside GRADE: good) freestanding midwifery spontaneous labor.
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From page 233... ...
Alongside midwifery unit -- 10.3 0.37 (0.30–0.46) Cesarean Section 5.4 -- -- 1st- or 2nd-degree tear 34.2 -- -- 3rd-degree or more tear 1.1 -- -- Postpartum hemorrhage 1.8 -- -- (>500 mL)
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From page 234... ...
We included cases in the hospital Netherlands 92,333 planned home LEMMoN study only Parous-home 54,419 planned hospital if severe acute maternal Parous-hospital morbidity occurred after the onset of labor. Hermus et al., Netherlands Perinatal Data were collected for Birth center 2017 Registry and case report all term (≥37 weeks Midwife-led Netherlands form (Jul 2013–Dec gestational hospital 2013)
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From page 235... ...
25.8 -- -- Nulli-hospital midwife-led 26.0 -- -- Nulli-home 26.3 -- -- continued
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From page 236... ...
MultiparousEngland 11,265 planned A composite defined freestanding freestanding midwifery as any of: stillbirth midwifery unit unit births after the start of care Nulliparous 16,673 alongside in labor, early neonatal alongside midwifery unit births death, neonatal midwifery unit encephalopathy, Multiparous meconium aspiration alongside syndrome, brachial midwifery unit plexus injury, fractured humerus or clavicle.
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From page 237... ...
OR (99%) CI Nulliparous-freestanding -- 6.7 -- midwifery unit Nulliparous-alongside -- 7.7 -- midwifery unit Multiparous-freestanding -- 0.7 -- midwifery unit Multiparous-alongside -- 1.0 -- midwifery unit 3rd- or 4th-Degree Perineal Trauma Nulliparous-freestanding -- 4.0 -- midwifery unit Nulliparous-alongside -- 4.9 -- midwifery unit Multiparous-freestanding -- 0.9 -- midwifery unit Multiparous-alongside -- 1.6 -- midwifery unit Cesarean Section Nulliparous-freestanding -- -- 0.84 (0.63–1.14)
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From page 238... ...
Homer et al., Linked data from Singleton, cephalic, Hospital 2014 the New South spontaneous, >37 weeks Birth center (ResQu: high, Wales Perinatal Data Home GRADE: fair) Collection, Admitted Australia Patient Data Collection, Register of Congenital Conditions, Registry of Birth Deaths and Marriages, and Australian Bureau of Statistics (Jul 2000–Jun 2008)
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From page 239... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 239 Morbidity/ Morbidity/ Mortality Rate per Outcome Mortality % 1,000 Live Births Risk 3rd- or 4th-Degree Perineal Trauma Multiparous-freestanding -- -- 0.60 (0.36–1.00) midwifery unit Multiparous-alongside -- -- 1 midwifery unit Caesarean Section Adj.
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From page 240... ...
6,692 planned home outset of labor. Canada 6,692 planned hospital Groups matched by parity and previous lower-segment cesarean delivery.
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From page 241... ...
MATERNAL AND NEWBORN OUTCOMES BY BIRTH SETTING 241 Morbidity/ Morbidity/ Mortality Rate per Outcome Mortality % 1,000 Live Births Risk Cesarean Section RR (95%)
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From page 242... ...
1 previous cesarean Canada 2,899 planned home delivery, spontaneous with midwife or induced labor on 4,752 planned hospital an outpatient basis, with midwife absence of significant 5,331 planned hospital preexisting disease, not with physician transferred to hospital. Hospital midwife planned hospital birth eligible for home birth.
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From page 243... ...
Hospital MD 11.0 -- 1 Home midwife -- -- 0.65 (0.56–0.76) Postpartum Hemorrhage Hospital midwife 6.0 -- 1 Home midwife 3.8 -- 0.62 (0.45–0.70)
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From page 244... ...
born at home moderate, 1,136 planned home Planned home, GRADE: poor) (790 occurred at home, at hospital Australia 346 transferred to hospital)
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From page 245... ...
Home-hospital 7.5 -- 0.84 (0.42–1.69) Cesarean Section (emergency)
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From page 246... ...
(gestational diabetes 495 birth center and hypertension) admissions 50 cases of birth 1,980 matched center births received a midwifery hospital birth secondary review cohort Wiegerinck et al., National Perinatal Term (>37 to <42 Matched 2018 Register (2005–2008)
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From page 247... ...
12.5 -- 1 Hospital 24.5 -- 2.0 (1.6–2.5) Cesarean Birth center (ref)
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From page 248... ...
) with a retrospective cohort design (N = 6,692 planned home births matched to 6,692 planned hospital births for comparable low-risk women)
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From page 249... ...
. In the United Kingdom, women have the option of choosing from multiple birth settings, including home, freestanding midwifery unit (FMU)
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From page 250... ...
. Appropriate maternity care in the Netherlands is determined based on risk level within an integrated system in which women have a choice of birth setting (Hermus et al., 2017; Schuit et al., 2016)
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From page 251... ...
Taken together, U.S. and international studies suggest that for infants, home births for low-risk individuals may be as safe as hospital or birth center births when certain system-level features are in place, including collaboration and integration across birth settings, eligibility criteria for community birth, well-trained providers, appropriate risk selection, ability to manage first-line complications, interdisciplinary collaboration, choice among multiple birth settings that are covered through universal coverage policies, and low barriers to transfer.
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From page 252... ...
In all international settings, where home and free tanding birth center births are better integrated into s the maternity care system, these strategies have been widely implemented, and as a result, outcomes for both women and newborns tend to be etter b in these settings than in the United States, where health systems do not employ these strategies. Finding 6-6: Lack of integration and coordination and unreliable collab oration across birth settings and maternity care providers are associated with poor birth outcomes for women and infants in the United States.
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From page 253... ...
Collaboration among health professionals can also greatly improve safety when care must be transferred across birth settings as inter rofessional p teamwork has been shown to be central to providing safe, effective, and efficient obstetric care (Guise and Segel, 2008)
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From page 254... ...
These solutions can assist in creating an integrated maternity system premised on mutual accommodation and smooth articulations across birth settings and provider types (Cheyney et al., 2014c)
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From page 255... ...
Several additional studies on the experiences of transfer have also been published as part of the Australian Birthplace Study (see Fox et al., 2018a, 2018b) , as well as in other highresource countries that are currently experiencing a rise in planned home births (Rowe et al., 2012; Ball et al., 2016; Blix et al., 2016; Patterson et al., 2017)
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From page 256... ...
. Conversely, poor coordination of care across providers and birth settings has been associated with adverse maternal–newborn outcomes.
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From page 257... ...
CONCLUSION There has yet to be a national, prospective, cohort study in the United States that utilizes an intention-to-treat model to compare outcomes by planned birth location and provider type, pays adequate attention to statistical power for rare outcomes, and controls for maternal risk factors and other confounders. Certainly, a better understanding of the true effect size of choice of birth setting with respect to fetal and neonatal outcomes would be achievable with a nationally validated, granular data registry (Caughey and Cheyney, 2019)
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From page 258... ...
The committee's review of the relevant literature on health outcomes by birth setting revealed a dearth of evidence related to the possible connection between maternal mortality and severe maternal morbidity and birth settings, likely because these events are so rare. Indeed, only one case of either of these outcomes following a planned home or birth center birth (see Cheyney et al., 2014a)
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