The birth center model of care: Staffing, business characteristics, and core clinical outcomes.

OBJECTIVES: Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes. METHODS: This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission. RESULTS: The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations. CONCLUSIONS FOR PRACTICE: Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.

Strong Start Innovation: Equitable Outcomes Across Public and Privately Insured Clients Receiving Birth Center Care.

INTRODUCTION: The Birth Center model of care is a health care delivery innovation in its fourth decade of demonstration across the United States. The purpose of this research was to evaluate the model's potential for decreasing poverty-related health disparities among childbearing families. METHODS: Between 2013 and 2017, 26,259 childbearing people received care within the 45 Center for Medicare and Medicaid Innovation Strong Start birth center sites. Secondary analysis of the prospective American Association of Birth Centers Perinatal Data Registry was conducted. Descriptive statistics described sociobehavioral, medical risk factors, and core clinical outcomes to inform the logistic regression model. Privately insured consumers were independently compared with 2 subgroups of Medicaid beneficiaries: Strong Start enrollees (midwifery-led care with peer counselors) and non-Strong Start Medicaid beneficiaries (midwifery-led care without peer counselors). RESULTS: After controlling for medical risk factors, Strong Start Medicaid beneficiaries achieved similar outcomes to privately insured consumers with no significant differences in maternal or newborn outcomes between groups. Perinatal outcomes included induction of labor (adjusted odds ratio [aOR], 0.86; 95% CI 0.61-1.13), epidural analgesia use (aOR, 1.00; 95% CI, 0.68-1.48), cesarean birth (aOR, 1.16; 95% CI, 0.87-1.53), exclusive breastfeeding on discharge (aOR, 1.11; 95% CI, 0.48-2.56), low Apgar score at 5 minutes (aOR, 1.23; 95% CI, 0.86-1.83), low birth weight (aOR, 1.12; 95% CI, 0.77-1.64), and antepartum transfer of care after the first prenatal appointment (aOR, 1.53; 95% CI, 0.97-2.40). Medicaid beneficiaries who were not enrolled in the Strong Start midwifery-led, peer counselor program demonstrated similar results except for having higher epidural analgesia use (aOR, 1.30; 95% CI, 1.10-1.53) and significantly lower exclusive breastfeeding on discharge (aOR, 0.57; 95% CI, 0.40-0.81) than their privately insured counterparts. DISCUSSION: The midwifery-led birth center model of care complemented by peer counselors demonstrated a pathway to achieve health equity.

Place of Birth Preferences and Relationship to Maternal and Newborn Outcomes Within the American Association of Birth Centers Perinatal Data Registry, 2007-2020.

PURPOSE: The purpose of this study was to describe sociodemographic variations in client preference for birthplace and relationships to perinatal health outcomes. METHODS: Descriptive data analysis (raw number, percentages, and means) showed that preference for birthplace varied across racial and ethnic categories as well as sociodemographic categories including educational status, body mass index, payer status, marital status, and gravidity. A subsample of medically low-risk childbearing people, qualified for birth center admission in labor, was analyzed to assess variations in maternal and newborn outcomes by site of first admission in labor. RESULTS: While overall clinical outcomes exceeded national benchmarks across all places of admission in the sample, disparities were noted including higher cesarean birth rates among Black and Hispanic people. This variation was larger within the population of people who preferred to be admitted to the hospital in labor in the absence of medical indication. CONCLUSION: This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation.

Freestanding Birth Centers: An Evidence-Based Option for Birth.

Every childbearing person has the right to learn about all options for perinatal care provider and birth setting. To ensure an informed decision about their preferred birth plan, information should be provided either preconceptionally or in early pregnancy. Personal preferences and risk status should be considered in decision-making. Numbers of births in birth centers have doubled over past decade to almost 20,000 births per year. The evidence shows that childbearing people who participate in birth center care, even if they have only birth center prenatal care, experience better outcomes including lower rates of preterm birth, low birth weight births, and cesarean birth, and higher rates of breastfeeding when compared to people with similar risk profiles who receive typical perinatal care.

Salary and Workload of Midwives Across Birth Center Practice Types and State Regulatory Structures.

INTRODUCTION: Expansion of the midwifery-led birth center model of care is one pathway to improving maternal and newborn health. There are a variety of practice types among birth centers and a range of state regulatory structures of midwifery practice across the United States. This study investigated how those variations relate to pay and workload for midwives at birth centers. METHODS: Data from the American Association of Birth Centers Practice Survey and the Bureau of Labor Statistics' report on occupational employment and wage statistics were analyzed to explore how midwife salaries and workload at birth centers compare within and beyond the birth center model. RESULTS: Survey results from 161 birth centers across the United States demonstrate wide variation in nurse-midwife salaries and are inconsistent with nurse-midwife salaries across all settings as reported by the Bureau of Labor Statistics. The reported number of hours worked by midwives within the birth center model is high. Salaries of midwives who work in birth center-only practices were consistently lower than salaries of midwives who worked in blended birth center and hospital practices, independent of the midwife's level of experience, geographic region of the country, and state regulatory structure. DISCUSSION: Further research is needed to understand how to bring salaries and workload for midwives at birth centers into alignment with national averages.

Rural resilience: The role of birth centers in the United States.

PURPOSE: To explore the role of the birth center model of care in rural health and maternity care delivery in the United States. METHODS: All childbearing families enrolled in care at an American Association of Birth Centers Perinatal Data RegistryTM user sites between 2012 and 2020 are included in this descriptive analysis. FINDINGS: Between 2012 and 2020, 88 574 childbearing families enrolled in care with 82 American Association of Birth Centers Perinatal Data RegistryTM user sites. Quality outcomes exceeded national benchmarks across all geographic regions in both rural and urban settings. A stable and predictable rate of transfer to a higher level of care was demonstrated across geographic regions, with over half of the population remaining appropriate for birth center level of care throughout the perinatal episode of care. Controlling for socio demographic and medical risk factors, outcomes were as favorable for clients in rural areas compared with urban and suburban communities. CONCLUSIONS: Rural populations cared for within the birth center model of care experienced high-quality outcomes. HEALTH POLICY IMPLICATIONS: A major focus of the United States maternity care reform should be the expansion of access to birth center models of care, especially in underserved areas such as rural communities.

Strong Start in birth centers: Socio-demographic characteristics, care processes, and outcomes for mothers and newborns.

BACKGROUND: A recent Center for Medicare and Medicaid Innovation report evaluated the four-year Strong Start for Mothers and Newborns Initiative, which sought to improve maternal and newborn outcomes through exploration of three enhanced, evidence-based care models. This paper reports the socio-demographic characteristics, care processes, and outcomes for mothers and newborns engaged in care with American Association of Birth Centers (AABC) sites. METHODS: The authors examined data for 6424 Medicaid or Children's Health Insurance Program (CHIP) beneficiaries in birth center care who gave birth between 2013 and 2017. Using data from the AABC Perinatal Data Registry™, descriptive statistics were used to evaluate socio-behavioral and medical risks, and core perinatal quality outcomes. Comparisons are made between outcomes in the AABC sample and national data during the study period. RESULTS: Childbearing mothers enrolled at AABC sites had diverse socio-behavioral risk factors similar to the national profile. The AABC sites exceeded national quality benchmarks for low birthweight (3.28%), preterm birth (4.42%), and primary cesarean birth (8.56%). Racial disparities in perinatal indicators were present within the Strong Start sample; however, they were at narrower margins than in national data. The enhanced model of care was notable for use of midwifery-led prenatal, labor, and birth care and decreased hospital admission. CONCLUSIONS: Birth center care improves population health, patient experience, and value. The model demonstrates the potential to decrease racial disparity and improve population health. Reduction of regulatory barriers and implementation of sustainable reimbursement are warranted to move the model to scale for Medicaid beneficiaries nationwide.

The Experience of Pain Dismissal in Adolescence.

CONTEXT: Pain in adolescence has psychosocial effects lasting into adulthood, including increased likelihood of pain in adulthood and higher rates of depression and anxiety. Many adolescents with chronic pain describe skepticism of pain reports, but this has not yet been evaluated in a sample of typically developing adolescents. OBJECTIVE: The current study sought to describe the experience of perceived pain dismissal during adolescence in a community sample. METHOD: Nearly 2000 (1931) emerging adults were recruited from the community and answered open-ended questions regarding whether they had experienced dismissal of their pain in adolescence, who dismissed their pain, characteristics of the dismisser, and what that experience was like. Qualitative responses were coded using a Delphi method. RESULTS: One in 10 young adults reported an experience of pain dismissal during adolescence. Young adults reported that dismissals by parents and physicians were the most distressing. Often, this experience was associated with a lasting sense of hostility toward the person who dismissed their pain, as well as anger, self-directed negativity, damage to the relationship, and feelings of isolation. CONCLUSIONS: One in 10 young adults reported at least one instance of dismissed pain and half of these instances involved a parent or medical provider. Results suggest a lasting negative impact of perceived dismissal. Pain in adolescence is a complicated experience and the current study indicates that parents and physicians need further guidance on how best to respond to reports of pain.

Dietary and weight-related behaviors and body mass index among Hispanic, Hmong, Somali, and white adolescents.

BACKGROUND: The population of the United States is becoming increasingly ethnically and racially diverse, much of it due to immigration patterns. However, little is known about dietary intake and weight-related concerns and behaviors of youth from some ethnic-minority groups, especially Hispanic, Hmong, and Somali adolescents. OBJECTIVE: Our aim was to describe dietary intake and weight-related concerns and behaviors among Hispanic, Hmong, and Somali adolescents and compare them with white adolescents. DESIGN: We performed a cross-sectional analysis of data from Eating and Activity in Teens 2010, a population-based study in the Minneapolis/St Paul metropolitan area. PARTICIPANTS/SETTING: Current analysis includes 1,672 adolescents (Hispanic: n=562 [33.6%]; Hmong: n=477 [28.5%]; Somali: n=113 [6.8%]; white: n=520 [31.1%]; mean age=15.0 years). Adolescents completed classroom surveys and had their height/weight measured during the 2009-2010 academic year. STATISTICAL ANALYSIS: Multivariable regression models, adjusted for socioeconomic status, age, and school as a random effect were used to examine racial/ethnic differences for each outcome variable for boys and girls. RESULTS: There were numerous differences in the behaviors of Hispanic, Hmong, and Somali adolescents as compared with whites. Hispanic and Somali youth consumed fruit and fast food more frequently. Hmong adolescents consumed sugar-sweetened beverages less frequently, and Somali boys consumed energy and sport drinks more frequently than whites. Compared with white boys, overweight/obesity was higher among Hispanic and Hmong. A higher percentage of Hmong and Somali adolescents engaged in unhealthy weight control behaviors. Body satisfaction was lower for all Hmong adolescents compared with whites. CONCLUSIONS: There were varying areas of concern in dietary intake, weight, and weight-related concerns and behaviors among adolescents in all ethnic groups. Future nutrition and physical activity interventions that include adolescents from these ethnic and cultural groups can benefit from, for example, modifying intervention strategies to the specific priority behaviors within the target population.

The American Association of Birth Centers: history, membership, and current initiatives.

The American Association of Birth Centers (AABC) is a multidisciplinary membership organization dedicated to the birth center model of care. This article reviews the history, membership, and current policy initiatives of the AABC. The history of AABC includes the promotion of research, education, and national and state policies that are supportive of birth center care. Current AABC priorities address three main pressures to birth center sustainability: high malpractice insurance rates, the lack of a federally mandated birth center facility fee, and low rates of certified nurse-midwife/certified midwife reimbursement. The AABC is addressing these concerns through lobbying, collaborating with other national organizations, and the promotion of birth research.