Transfers of Care between Healthcare Professionals in Obstetric Units of Different Sizes across Spain and in a Hospital in Ireland: The MidconBirth Study.

BACKGROUND: In Europe, the majority of healthy women give birth at conventional obstetric units with the assistance of registered midwives. This study examines the relationships between the intrapartum transfer of care (TOC) from midwife to obstetrician-led maternity care, obstetric unit size (OUS) with different degrees of midwifery autonomy, intrapartum interventions and birth outcomes. METHODS: A prospective, multicentre, cross-sectional study promoted by the COST Action IS1405 was carried out at eight public hospitals in Spain and Ireland between 2016-2019. The primary outcome was TOC. The secondary outcomes included type of onset of labour, oxytocin stimulation, epidural analgesia, type of birth, episiotomy/perineal injury, postpartum haemorrhage, early initiation of breastfeeding and early skin-to-skin contact. A logistic regression was performed to ascertain the effects of studied co-variables on the likelihood that participants had a TOC; Results: Out of a total of 2,126 low-risk women, those whose intrapartum care was initiated by a midwife (1772) were selected. There were statistically significant differences between TOC and OUS (S1 = 29.0%, S2 = 44.0%, S3 = 52.9%, S4 = 30.2%, p < 0.001). Statistically differences between OUS and onset of labour, oxytocin stimulation, type of birth and episiotomy or perineal injury were observed (p = 0.009, p < 0.001, p < 0.001, p < 0.001 respectively); Conclusions: Findings suggest that the model of care and OUS have a significant effect on the prevalence of intrapartum TOC and the birth outcomes. Future research should examine how models of care differ as a function of the OUS in a hospital, as well as the cost-effectiveness for the health care system.

Audit of a new model of birth care for women with low risk pregnancies in South Africa: the primary care onsite midwife-led birth unit (OMBU).

BACKGROUND: South Africa's health system is based on the primary care model in which low-risk maternity care is provided at community health centres and clinics, and 'high-risk' care is provided at secondary/tertiary hospitals. This model has the disadvantage of delays in the management of unexpected intrapartum complications in otherwise low-risk pregnancies, therefore, there is a need to re-evaluate the models of birth care in South Africa. To date, two primary care onsite midwife-led birth units (OMBUs) have been established in the Eastern Cape. OMBUs are similar to alongside midwifery units but have been adapted to the South African health system in that they are staffed, administered and funded by the primary care service. They allow women considered to be at 'low risk' to choose between birth in a community health centre and birth in the OMBU. METHODS: The purpose of this audit was to evaluate the impact of establishing an OMBU at Frere Maternity Hospital in East London, South Africa, on maternity services. We conducted an audit of routinely collected data from Frere Maternity Hospital over two 12 month periods, before and after the OMBU opened. Retrospectively retrieved data included the number of births, maternal and perinatal deaths, and mode of delivery. RESULTS: After the OMBU opened at Frere Maternity Hospital, the total number of births on the hospital premises increased by 16%. The total number of births in the hospital obstetric unit (OU) dropped by 9.3%, with 1611 births out of 7375 (22%) occurring in the new OMBU. The number of maternal and perinatal deaths was lower in the post-OMBU period compared with the pre-OMBU period. These improvements cannot be assumed to be the result of the intervention as observational studies are prone to bias. CONCLUSIONS: The mortality data should be interpreted with caution as other factors such as change in risk profile may have contributed to the death reductions. There are many additional advantages for women, hospital staff and primary care staff with this model, which may also be more cost-effective than the standard (freestanding) primary care model.

Structure in Brazilian maternity hospitals: key characteristics for quality of obstetric and neonatal care.

This study aimed to evaluate key characteristics of structure in a sample of maternity hospitals in Brazil. Structure was evaluated according to Ministry of Health criteria and included: geographic location, obstetric volume, presence of ICU, teaching activities, staff qualifications, and availability of equipment and medicines. The results showed differences in staff qualifications and availability of equipment in obstetric and neonatal care according to type of financing, region of the country, and degree of complexity. The North/Northeast and Central-West regions presented the most serious problems with structure. The public and mixed hospitals were better structured in the South/Southeast, reaching satisfactory levels on various items, similar or superior to the private hospitals. The current study contributes to the debate on quality of structure in Brazil's hospital services and emphasizes the need to develop analytical studies considering process and results of obstetric and neonatal care.

Estrutura das maternidades: aspectos relevantes para a qualidade da atenção ao parto e nascimento / Estructura de los hospitales de maternidad: aspectos relevantes para la calidad de la atención durante el parto y el nacimiento / Structure in Brazilian maternity hospitals: key characteristics for quality of obstetric and neonatal care

Avaliar aspectos da estrutura de uma amostra de maternidades do Brasil. A estrutura foi avaliada tendo como referências as normas do Ministério da Saúde e englobou: localização geográfica, volume de partos, existência de UTI, atividade de ensino, qualificação de recursos humanos, disponibilidade de equipamentos e medicamentos. Os resultados evidenciam diferenças na qualificação e na disponibilidade de equipamentos e insumos dos serviços de atenção ao parto e nascimento segundo o tipo de financiamento, regiões do país e grau de complexidade. As regiões Norte/Nordeste e Centro-oeste apresentaram os maiores problemas. No Sul/Sudeste, os hospitais estavam melhores estruturados, atingindo proporções satisfatórias em vários dos aspectos estudados, próximas ou mesmo superiores ao patamar da rede privada. O presente estudo traz para o debate a qualidade da estrutura dos serviços hospitalares ofertados no país, e sublinha a necessidade de desenvolvimento de estudos analíticos que considerem o processo e os resultados da assistência.

El presente estudio evalúa aspectos en cuanto a la estructura de una muestra de hospitales de maternidad en Brasil. El marco ha sido evaluado en función de patrones de referencia del Ministerio de Salud y abarca: ubicación geográfica, volumen de nacimientos, presencia de IU, actividades de aprendizaje, formación de recursos humanos, disponibilidad de equipos y medicamentos. Los resultados muestran diferencias en la cualificación y disponibilidad de equipos y servicios de suministros para el parto, según regiones, y su grado de complejidad. El Norte/Nordeste y Centro-oeste mostraron los mayores problemas. En el Sur/Sudeste, los hospitales estaban mejor estructurados, alcanzando proporciones satisfactorias en diversos aspectos del estudio, cercanos o justo por encima del nivel de la red privada. Este estudio aporta al debate la cuestión la calidad estructural de los servicios hospitalarios que se ofrecen en el país, y hace hincapié en la necesidad de desarrollo de estudios de análisis que tengan en cuenta los procesos y resultados de la atención.

This study aimed to evaluate key characteristics of structure in a sample of maternity hospitals in Brazil. Structure was evaluated according to Ministry of Health criteria and included: geographic location, obstetric volume, presence of ICU, teaching activities, staff qualifications, and availability of equipment and medicines. The results showed differences in staff qualifications and availability of equipment in obstetric and neonatal care according to type of financing, region of the country, and degree of complexity. The North/Northeast and Central-West regions presented the most serious problems with structure. The public and mixed hospitals were better structured in the South/Southeast, reaching satisfactory levels on various items, similar or superior to the private hospitals. The current study contributes to the debate on quality of structure in Brazil’s hospital services and emphasizes the need to develop analytical studies considering process and results of obstetric and neonatal care.

Pyelonephritis in pregnancy. How adequate is empirical treatment?

OBJECTIVE: To ascertain the adequacy of empirical antimicrobial treatment in pregnant women with acute pyelonephritis. MATERIAL AND METHODS: We have conducted a retrospective observational study of women admitted to the hospital with acute pyelonephritis between May 2004 and April 2011. Patients were included if the results of urine cultures and susceptibility testing to antibiotics were available. Epidemiological, clinical, therapeutical and outcome variables were collected from chart review. We considered inappropriate empirical antimicrobial treatment (IEAT) as the occurrence of microorganism that were not effectively treated at the time when the causative microorganism and its antibiotic susceptibility were known. RESULTS: Fifty women with appropriate microbiological data from a total of 93 cases of acute pyelonephritis were included in the study. The women's mean age was 26.4 years, and 58% were nulliparous. Pyelonephritis was developed in the 2nd and 3rd trimester in 88% of cases. Previous urinary tract infections were recorded in 34%. Escherichia coli was the most frequent microorganism (70%). The proportion of patients who received IEAT was 10%. Amoxicillin-clavulanate and cephalosporines were the most predominant antibiotics used, with a proportion of IEAT of 10.3% and 5.9%, respectively. CONCLUSIONS: Pregnant women with pyelonephritis received IEAT in a small but significant number of cases. Amoxicillin-clavulante and cephalosporines were adequate in most cases. More studies are needed to define the clinical impact of IEAT on prognosis.

Factors affecting the use of emergency obstetric care among pregnant women with antenatal bleeding.

OBJECTIVE: to investigate the factors that affect the use of emergency obstetric care services among pregnant women in Turkey with antenatal bleeding. DESIGN: descriptive, cross-sectional study. SETTING: Mersin Maternity and Child Hospital, Mersin, Turkey. PARTICIPANTS: 125 pregnant women who had been admitted to the emergency department for antenatal bleeding. FINDINGS: advanced age, high level of education, lack of health insurance, receiving antenatal care, nuclear family structure and knowledge of the danger signs during pregnancy were found to affect the use of emergency obstetric care services among pregnant women with antenatal bleeding. KEY CONCLUSIONS: delays in seeking emergency obstetric care among pregnant women with antenatal bleeding are due to the difficulties faced by women when deciding whether or not to seek health care. Access to health services and health institutions themselves do not cause any delay in terms of provision of emergency obstetric care to pregnant women with antenatal bleeding. IMPLICATIONS FOR PRACTICE: pregnant women should be informed about the causes of antenatal bleeding, what to do in the case of bleeding, and the need to seek health care as soon as possible. In addition, midwives should inform families and pregnant women about the use of emergency medical services and the relevant procedures.

Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, north west of Ethiopia: a community-based cross sectional study.

BACKGROUND: Reduction of maternal mortality is a global priority particularly in developing countries including Ethiopia where maternal mortality ratio is one of the highest in the world. The key to reducing maternal mortality ratio and improving maternal health is increasing attendance by skilled health personnel throughout pregnancy and delivery. However, delivery service is significantly lower in Amhara Regional State, Ethiopia. Therefore, this study aimed to assess factors affecting institutional delivery service utilization among mothers who gave birth in the last 12 months in Sekela District, Amhara Region, Ethiopia. METHODS: Community-based cross-sectional study was conducted among mothers with birth in the last 12 months during August, 2010. Multistage sampling technique was used to select 371 participants. A pre tested and structured questionnaire was used to collect data. Bivariate and multivariate data analysis was performed using SPSS version 16.0 software. RESULTS: The study indicated that 12.1% of the mothers delivered in health facilities. Of 87.9% mothers who gave birth at home, 80.0% of them were assisted by family members and relatives. The common reasons for home delivery were closer attention from family members and relatives (60.9%), home delivery is usual practice (57.7%), unexpected labour (33.4%), not being sick or no problem at the time of delivery (21.6%) and family influence (14.4%). Being urban resident (AOR [95% CI] = 4.6 [1.91, 10.9]), ANC visit during last pregnancy (AOR [95% CI] = 4.26 [1.1, 16.4]), maternal education level (AOR [95%CI] =11.98 [3.36, 41.4]) and knowledge of mothers on pregnancy and delivery services (AOR [95% CI] = 2.97[1.1, 8.6]) had significant associations with institutional delivery service utilization. CONCLUSIONS: Very low institutional delivery service utilization was observed in the study area. Majority of the births at home were assisted by family members and relatives. ANC visit and lack of knowledge on pregnancy and delivery services were found to be associated with delivery service utilization. Strategies with focus on increasing ANC uptake and building knowledge of the mothers and their partners would help to increase utilization of the service. Training and assigning skilled attendants at Health Posta level to provide skilled home delivery would improve utilization of the service.

Freestanding midwifery units versus obstetric units: does the effect of place of birth differ with level of social disadvantage?

BACKGROUND: Social inequity in perinatal and maternal health is a well-documented health problem even in countries with a high level of social equality. We aimed to study whether the effect of birthplace on perinatal and maternal morbidity, birth interventions and use of pain relief among low risk women intending to give birth in two freestanding midwifery units (FMU) versus two obstetric units in Denmark differed by level of social disadvantage. METHODS: The study was designed as a cohort study with a matched control group. It included 839 low-risk women intending to give birth in an FMU, who were prospectively and individually matched on nine selected obstetric/socio-economic factors to 839 low-risk women intending OU birth. Educational level was chosen as a proxy for social position. Analysis was by intention-to-treat. RESULTS: Women intending to give birth in an FMU had a significantly higher likelihood of uncomplicated, spontaneous birth with good outcomes for mother and infant compared to women intending to give birth in an OU. The likelihood of intact perineum, use of upright position for birth and water birth was also higher. No difference was found in perinatal morbidity or third/fourth degree tears, while birth interventions including caesarean section and epidural analgesia were significantly less frequent among women intending to give birth in an FMU. In our sample of healthy low-risk women with spontaneous onset of labour at term after an uncomplicated pregnancy, the positive results of intending to give birth in an FMU as compared to an OU were found to hold for both women with post-secondary education and the potentially vulnerable group of FMU women without post-secondary education. In all cases, women without post-secondary education intending to give birth in an FMU had comparable and, in some respects, more favourable outcomes when compared to women with the same level of education intending to give birth in an OU. In this sample of low-risk women, we found that the effect of intended place on birth outcomes did not differ with women's level of education. CONCLUSION: FMU care appears to offer important benefits for birthing women with no additional risk to the infant. Both for women with and without post-secondary education, intending to give birth in an FMU significantly increased the likelihood of a spontaneous, uncomplicated birth with good outcomes for mother and infant compared to women intending to give birth in an OU. All women should be provided with adequate information about different care models and supported in making an informed decision about the place of birth.

Transfers of women planning birth in midwifery units: data from the birthplace prospective cohort study.

OBJECTIVE: To examine the percentage of women transferred, reasons for transfer and factors associated with the transfer of women planning birth in midwifery units (MUs). DESIGN: Prospective cohort study. SETTING: All freestanding midwifery units (FMUs) and alongside midwifery units (AMUs) in England. PARTICIPANTS: Twenty-nine thousand, two hundred and forty-eight eligible women with a singleton, term and 'booked' pregnancy, planning birth in an MU between April 2008 and April 2010. METHODS: Multivariable logistic regression was used to explore the sociodemographic and clinical characteristics associated with transfer. MAIN OUTCOME MEASURES: Transfer during labour or within 24 hours of birth. RESULTS: Over one in four women were transferred from AMUs and over one in five from FMUs. In both types of MU, compared with multiparous women aged 25-29 years, nulliparous women aged <20 years had higher odds of transfer (FMU-adjusted odds ratio [OR], 4.5; 95% confidence interval [CI], 3.10-6.57; AMU-adjusted OR, 2.6; 95% CI, 2.18-2.06), and the odds of transfer increased with increasing age. Nulliparous women aged ≥ 35 years in FMUs had 7.4 times the odds of transfer (95% CI, 5.43-10.10) and, in AMUs, 6.0 times the odds of transfer (95% CI, 4.81-7.41). Starting labour care after 40 weeks of gestation and the presence of complicating conditions at the start of labour care were also independently associated with a higher risk of transfer. CONCLUSIONS: Transfer from MUs is common, especially for first-time mothers. This study provides evidence on the maternal characteristics associated with an increased risk of transfer, which can be used to inform women's choices about place of birth.

Is the operative delivery rate in low-risk women dependent on the level of birth care? A randomised controlled trial.

OBJECTIVE: To investigate possible differences in operative delivery rate among low-risk women, randomised to an alongside midwifery-led unit or to standard obstetric units within the same hospital. DESIGN: Randomised controlled trial. SETTING: Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Tromsø, Norway. POPULATION: A total of 1111 women assessed to be at low risk at onset of spontaneous labour. METHODS: Randomisation into one of three birth units: the special unit; the normal unit; or the midwife-led unit. MAIN OUTCOME MEASURES: Total operative delivery rate, augmentation, pain relief, postpartum haemorrhage, sphincter injuries and intrapartum transfer, Apgar score <7 at 5 minutes, metabolic acidosis and transfer to neonatal intensive care unit. RESULTS: There were no significant differences in total operative deliveries between the three units: 16.3% in the midwife-led unit; 18.0% in the normal unit; and 18.8% in the special unit. There were no significant differences in postpartum haemorrhage, sphincter injuries or in neonatal outcomes. There were statistically significant differences in augmentation (midwife-led unit versus normal unit RR 0.73, 95% CI 0.59-0.89; midwife-led unit versus special unit RR 0.69, 95% CI 0.56-0.86), in epidural analgesia (midwife-led unit versus normal unit RR 0.68, 95% CI 0.52-0.90; midwife-led unit versus special unit RR 0.64, 95% CI 0.47-0.86) and in acupuncture (midwife-led unit versus normal unit RR 1.45, 95% CI 1.25-1.69; midwife-led unit versus special unit RR 1.45, 95% CI 1.22-1.73). CONCLUSIONS: The level of birth care does not significantly affect the rate of operative deliveries in low-risk women without any expressed preference for level of birth care.

Obstetric near-miss and maternal mortality in maternity university hospital, Damascus, Syria: a retrospective study.

BACKGROUND: Investigating severe maternal morbidity (near-miss) is a newly recognised tool that identifies women at highest risk of maternal death and helps allocate resources especially in low income countries. This study aims to i. document the frequency and nature of maternal near-miss at hospital level in Damascus, Capital of Syria, ii. evaluate the level of care at maternal life-saving emergency services by comparatively analysing near-misses and maternal mortalities. METHODS: Retrospective facility-based review of cases of near-miss and maternal mortality that took place in the years 2006-2007 at Damascus Maternity University Hospital, Syria. Near-miss cases were defined based on disease-specific criteria (Filippi 2005) including: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anaemia. Main outcomes included maternal mortality ratio (MMR), maternal near miss ratio (MNMR), mortality indices and proportion of near-miss cases and mortality cases to hospital admissions. RESULTS: There were 28,025 deliveries, 15 maternal deaths and 901 near-miss cases. The study showed a MNMR of 32.9/1000 live births, a MMR of 54.8/100,000 live births and a relatively low mortality index of 1.7%. Hypertensive disorders (52%) and haemorrhage (34%) were the top causes of near-misses. Late pregnancy haemorrhage was the leading cause of maternal mortality (60%) while sepsis had the highest mortality index (7.4%). Most cases (93%) were referred in critical conditions from other facilities; namely traditional birth attendants homes (67%), primary (5%) and secondary (10%) healthcare unites and private practices (11%). 26% of near-miss cases were admitted to Intensive Care Unit (ICU). CONCLUSION: Near-miss analyses provide valuable information on obstetric care. The study highlights the need to improve antenatal care which would help early identification of high risk pregnancies. It also emphasises the importance of both: developing protocols to prevent/manage post-partum haemorrhage and training health care professionals to manage infrequent but fatal conditions like sepsis. An urgent review of the referral system and the emergency obstetric care in Syria is highly recommended.

Use of complementary and alternative medicine in departments of obstetrics in croatia and a comparison to Germany.

BACKGROUND: This nationwide study assessed the use of complementary and alternative medicine (CAM) methods in departments of obstetrics in Croatia and compared it with an identical assessment carried out in Germany. METHODS: All Croatian obstetrics departments were sent a questionnaire already tested in Germany which assessed the use of CAM methods: whether any were used during childbirth and if so how frequently, and the reasons behind their application. RESULTS: Questionnaires were returned by 100% (36/36) of departments identified. The only used CAM therapy was acupuncture, which was available in 5.6% (2/36) of the departments. All other methods (homeopathy, aromatherapy, massage etc.) were not used at all. Furthermore, acupuncture was only administered by physicians. These findings were found to strongly contrast with the findings from Germany. CONCLUSIONS: Among the main CAM methods only acupuncture is used to a small extent in the field of obstetrics in Croatia. Thus, the impression from the literature that shows a considerable use of CAM in this area definitely does not apply for all parts of the world. Future studies should seek to identify the reasons behind the intensive use of CAM in Germany and its virtual non-use in Croatia. This also means that analyses of CAM use are required with respect to perinatal outcome, the results of which could finally help decide about the reasonability of CAM.

Use of complementary and alternative medicine in departments of obstetrics in Germany.

BACKGROUND: This nationwide study aimed to assess the use of complementary and alternative medicine (CAM) methods in German departments of obstetrics. METHODS: All German departments of obstetrics were identified and were sent a questionnaire designed to assess which CAM methods, if any, they used during childbirth, how frequently, and why. SPSS software was used for statistical analyses (Spearman's bivariate correlation, cross-tabulation, and Pearson's chi-square test). RESULTS: The questionnaires were returned by 40.3% (381/946) of the identified departments. The most commonly used CAM therapy was acupuncture (available in 97.3% (366/376) of departments) followed by homeopathy (offered in 93.4%) and aromatherapy (available in 76.6%). Most decisions regarding CAM use were made by midwives; only decisions on acupuncture were taken by obstetricians and midwives. Reasons given for using CAM were patient demand and perceived efficacy of CAM, particularly by midwives. Obstetricians were only partly convinced of the efficacy of CAM methods and their conviction varied with the type of unit they worked in. CONCLUSIONS: CAM methods are widely used in German departments of obstetrics despite lacking evidence of effectiveness. Efficacy, side effects and consequences of CAM use should be assessed using the mandatory German quality assurance measures and birth surveys. CAM use elsewhere also merits further study.

Certified nurse midwife-attended births: trends in Washington State, 1995-2004.

Nationwide, the proportion of certified nurse-midwife (CNM)-attended births has increased steadily. We examined trends in CNM-attended singleton spontaneous vaginal births between 1995 and 2004 in Washington State by site of birth, payer source, and hospital birth volume. CNMs were more likely than other providers to care for women at risk for adverse outcomes based on several sociodemographic indicators. The increased rate of CNM-attended births occurred primarily in hospitals and among both Medicaid- and privately-funded births. The rate of CNM-attended births doubled in hospitals with high birth volumes. We recommend future research designed to understand these trends.

Choosing childbirth provider location--rural women's perspective.

INTRODUCTION: The delivery of obstetric services in rural communities is under threat. Decreased choice in services can result in women being forced to seek obstetric care outside their own local community, possibly contrary to their preference. Other women willingly make the decision to travel away to deliver. We investigated factors that influenced rural women's choice of childbirth provider location. METHODS: Roma, a provincial centre approximately 490 km west of Brisbane, Queensland, Australia has a population of approximately 15 000 living in the town or surrounding areas. It has a public hospital with maternity unit, supported by a paediatrician and flying obstetrician. We did an exploratory study, conducting semi-structured interviews with 20 women who lived in Roma (or surrounds) and had delivered a baby between January 2001 and August 2004, or were pregnant when interviewed. Themes were extracted from transcripts of audiotapes and field notes and analysed using an appropriate framework. A subset of interviews were reviewed by both authors and themes compared. RESULTS: Fourteen women (70%) delivered locally and six (30%) travelled away, comparable with Queensland perinatal data for 1995 to 2003. The women reported a range of reasons that influenced their choice of childbirth provider location. All participants stated that concerns about the safety of themselves and, more importantly, their baby influenced their choice. The availability of family support and familiarity with the doctor and maternity service influenced choice, as did financial considerations. All participants agreed that delivering in town was logistically much easier, however some choose to deliver away. Different women were influenced by a different set of factors; however, safety (actual and perceived) appeared to be the overriding concern of all participants. CONCLUSION: This study highlights the pivotal importance of perceived safety on women's decision-making about where to deliver their babies. Measures to increase the number of deliveries in rural towns to prevent further withdrawal of obstetric services must address actual and perceived safety issues to be successful.

[Abuse of caesarean delivery in Brazil: geographic dimensions of a medical aberration]. / L'abus du recours à la césarienne au Brésil: dimensions géographiques d'une aberration médicale.

"Brazil is the world champion of caesareans." This prowess points out a serious public health problem. While the increase in the percentage of caesareans among all deliveries is an international phenomenon, it is highest by far in Brazil, where caesareans account for nearly 40% of births, that is, three times the maximum recommended by WHO. This abusive practice appears pandemic and has spread in recent years throughout the entire country, although at divergent rates. It weighs heavily on Brazil's national health insurance fund. After a critical examination of the information sources related to births, we analyze successively the principal factors likely to explain this abuse: level of development, emergence of family planning and the association of caesarean delivery with tubal ligation for sterilization purposes, and tension within the healthcare system, especially the role of private physicians in urban areas. By studying these aspects of the problem in their geographic dimensions, we find important regional differences that must be considered in defining policies to limit this excess.

Vaginal births after C-section are not necessarily riskier in a birth center than in the hospital.

Recent research concluded that VBACs are riskier in a birth center than in the hospital. This conclusion is only true if the woman is sure she will not have any more pregnancies and if she does not suffer from "Fear of Hospitals." Since childbirth centers offered a VBAC rate of 87%, whereas US hospitals currently offer a VBAC rate of less than 10%, the woman has a much higher risk of a repeat cesarean if she delivers in hospital, which increases her risk on subsequent pregnancies.