Trends and state variations in out‐of‐hospital births in the United States, 2004‐2017

Abstract

Background: Out-of-hospital births have been increasing in the United States, although past studies have found wide variations between states. Our purpose was to examine trends in out-of-hospital births, the risk profile of these births, and state differences in women’s access to these births. Methods: National birth certificate data from 2004–2017 were analyzed. Newly available national data on method of payment for the delivery (private insurance, Medicaid, self-pay) were used to measure access to out-of-hospital birth options. Results: After a gradual decline from 1990–2004, the number of out-of-hospital births increased from 35,578 in 2004 to 62,228 in 2017. In 2017, 1 of every 62 births in the US was an out-of-hospital birth (1.61%). Home births increased by 77% from 2004–2017, while birth center births more than doubled. Out-of-hospital births were more common in the Pacific Northwest, and less common in the southeastern states such as Alabama, Louisiana, and Mississippi. Women with planned home and birth center births were less likely to have a number of population characteristics associated with poor pregnancy outcomes, including teen births, smoking during pregnancy, obesity, and preterm, low birthweight, and multiple births. More than 2/3 of planned home births were self-paid, compared to 1/3 of birth center and just 3% of hospital births, with large variations by state. Conclusions: Lack of insurance or Medicaid coverage is an important limiting factor for women desiring out-of-hospital birth in most states. Recent increases in out-of-hospital births despite important limiting factors highlights the strong motivation of some women to choose out-of-hospital birth.

Pregnancy, Birth and the COVID-19 Pandemic in the United States

“…It remains to be seen whether this revelation that CPMs can be useful in times of trouble will translate to wider legitimation and legalization in the 15 holdout states that have thus far failed to provide them with licensure. CPMS have long been shown to have excellent outcomes when their home births are compared to low risk hospital births (Cheyney et al 2014;Johnson and Daviss 2005), and midwives in other states are pushing their governors to issue similar legislation. An obstetrician from Massachusetts noted that "MA in particular has been very flexible with regulations in recent days to increase workforce capacity and one thing they might do is encourage health systems to hire midwives on staff (particularly since workforce overall is expected to thin).…”

“…Here Romano refers to two large prospective studies (Cheyney et al 2014;Johnson and Daviss 2005) that showed excellent maternal and neonatal outcomes for planned, midwife-attended home births in the US, with cesarean rates (3.7% and 5.2%) that were far lower than the nationwide cesarean rate of 32% at the time (and in the present), and a perinatal mortality rate of 1.7/1000. While Johnson and Daviss (2005) addressed only CPMs, Cheyney et al (2014) focused on primarily on CPMs yet included a small percentage of CNMs. The latter study showed that outcomes for home births were similar to those of broad, population-based studies of home births in the Netherlands and the UK, where home birth is far better integrated into maternity care than in the US (Cheyney and Davis-Floyd 2019;DeVries 2004;DeVries et al 2001;Jordan 1993).…”

Pregnancy health in POWERMOM participants living in rural versus urban zip codes

“…However, there was a significantly higher percentage of women planning to have a homebirth/midwife at their delivery who lived in rural zip codes (2.3%) compared to urban zip codes (0.9%). The percentage of home births in rural zip codes is higher than the average of 1.6% in the USA in 2017 [28]. This larger percentage of home birth may be a reflection of increasing drive times to hospitals with perinatal care in the USA [2].…”

Educating Student Nurses Is a Wise Investment for Midwives

“…Although midwives have been faculty in nursing education programs for decades, this role is worth revisiting in the context of increasing consumer awareness of the profession. More than 98% of US births take place in hospital labor and delivery units where nurses are by far the most visible members of the health care team . The consistent presence of nurses during care of women in labor and birth creates natural interprofessional relationships between nurses and midwives.…”