Out-of-Hospital Birth.

Since the 1970s, most births in the United States have been planned to occur in a hospital. However, a small percentage of Americans choose to give birth outside of a hospital. The number of out-of-hospital births has increased, with one in every 61 U.S. births (1.64%) occurring out of the hospital in 2018. Out-of-hospital (or community) birth can be planned or unplanned. Of those that are planned, most occur at home and are assisted by midwives. Patients who choose a planned community birth do so for multiple reasons. International observational studies that demonstrate comparable outcomes between planned out-of-hospital and planned hospital birth may not be generalizable to the United States. Most U.S. studies have found statistically significant increases in perinatal mortality and neonatal morbidity for home birth compared with hospital birth. Conversely, planned community birth is associated with decreased odds of obstetric interventions, including cesarean delivery. Perinatal outcomes for community birth may be improved with appropriate selection of low-risk, vertex, singleton, term pregnancies in patients who have not had a previous cesarean delivery. A qualified, licensed maternal and newborn health professional who is integrated into a maternity health care system should attend all planned community births. Family physicians are uniquely poised to provide counseling to patients and their families about the risks and benefits associated with community birth, and they may be the first physicians to evaluate and treat newborns delivered outside of a hospital.

Developing operational standards for Midwifery Centers.

BACKGROUND: Midwifery centres have been identified in over 56 countries. Consensus was reached on a global definition for midwifery centres, yet there is a lack of standards to assure consistent quality of care is provided. METHODS: Evidence-based standards and guidelines developed from American Association of Birth Centres (USA), Midwifery Unity Network (UK/EU), World Health Organization, International Childbirth Initiative, and White Ribbon Alliance, were gathered, duplicate standards were removed, and language was adapted for global use with sensitivity to low and middle countries (LMIC). An initial list of 52 midwifery centre standards were identified. Through an informal modified Delphi process these were reviewed by global midwifery centres experts, researchers, and midwifery centre staff at focus groups in Haiti, Mexico and Bangladesh for significance, language, and usability. The standards were then piloted at midwifery centres in eight countries (Sierra Leone, Cambodia, Bangladesh, Mexico, Haiti, Peru, Uganda and Trinidad). All feedback was incorporated into the final standards. RESULTS: A final list of 43 standards, organized into 3 domains including quality standards for care providers, dignity standards for women, and community standards for administration, were agreed on. CONCLUSION: Midwifery centres are prevalent around the globe. Identifying standards for quality of care provides a foundation for the midwifery centre model to be replicated and ensure consistent quality of care. Evidence based standards for midwifery centres in LMIC, allows systems to embrace and encourage the implementation and growth of midwifery centres to address accessible, acceptable, respectful, woman-centred, community-engaged maternal health care that participates fully in the health care system.

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

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 to 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 to 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 United States was an out-of-hospital birth (1.61%). Home births increased by 77% from 2004 to 2017, whereas 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 with 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 highlight the strong motivation of some women to choose out-of-hospital birth.

Casas de nacimientos en España. ¿Una opción segura? / Birth Centers in Spain. Are they a safe choice?

Objetivo: Analizar la evidencia científica actual sobre las casas de nacimientos (unidades gestionadas por matronas que ofrecen un entorno similar al hogar y promueven la fisiología del parto), en términos de coste-efectividad, satisfacción y seguridad, tanto materna como neonatal, así como el contexto histórico de las mismas en diferentes países y la situación actual de España en relación con el lugar de nacimiento. Material y método: Se realizó una búsqueda en las bases de datos CINAHL, PubMed, Biblioteca Cochrane y Medline, y en las guías clínicas nacionales e internacionales de distintas organizaciones científicas. Resultados: Las últimas evidencias señalan que parir en casas de nacimientos tiene beneficios obstétricos y de coste-efectividad, mayor tasa de partos espontáneos y menor tasa de intervenciones, así como una mayor satisfacción materna. Conclusiones: Parir en casas de nacimientos es una opción segura que ofrece mejores resultados obstétricos para mujeres de bajo riesgo, es más económica y su creación respondería a una demanda social

Objective: To analyse the current scientific evidence about birth centers (units managed by midwives where a homelike environment and promotion of the physiology of birth is offered) in terms of cost-effectivity, maternal satisfaction and safety for mothers and babies, the historical context of birth centers in different countries and the current birthplace situation in Spain. Method: A research was conducted using the databases: CINAHL, PubMed, Cochrane Library and Medline. National and International Clinical Guidelines as well as publications from organisations of scientific interest were also consulted. Results: The latest evidence demonstrates that giving birth in birth centers is associated with obstetric benefits, is more cost-effective, contributes to higher rates of normal vaginal deliveries and less interventions as well as higher levels of maternal satisfaction. Conclusions: Giving birth in birth centers is a safe option that provides better obstetrics outcomes to low risk women, it is more economical and it constitutes a response to a social demand

Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: A systematic review and meta-analysis.

BACKGROUND: The comparative safety of different birth settings is widely debated. Comparing research across high-income countries is complex, given differences in maternity service provision, data discrepancies, and varying research techniques and quality. Studies of births planned at home or in birth centres have reported both better and poorer outcomes than planned hospital births. Previous systematic reviews have focused on outcomes from either birth centres or home births, with inconsistent attention to quality appraisal. Few have attempted to synthesise findings. OBJECTIVE: To compare maternal and perinatal outcomes from different places of birth via a systematic review of high-quality research, and meta-analysis of appropriate data (Prospero registration CRD42016042291). DESIGN: Reviewers searched CINAHL, Embase, Maternity and Infant Care, Medline and PsycINFO databases to identify studies comparing selected outcomes by place of birth among women with low-risk pregnancies in high-income countries. They critically appraised identified studies using an instrument specific to birth place research and then combined outcome data via meta-analysis, using RevMan software. FINDINGS: Twenty-eight articles met inclusion criteria, yielding comparative data on perinatal mortality, mode of birth, maternal morbidity and/or NICU admissions. Meta-analysis indicated that women planning hospital births had statistically significantly lower odds of normal vaginal birth than in other planned settings. Women experienced severe perineal trauma or haemorrhage at a lower rate in planned home births than in obstetric units. There were no statistically significant differences in infant mortality by planned place of birth, although most studies had limited statistical power to detect differences for rare outcomes. Differences in location, context, quality and design of identified studies render results subject to variation. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: High-quality evidence about low-risk pregnancies indicates that place of birth had no statistically significant impact on infant mortality. The lower odds of maternal morbidity and obstetric intervention support the expansion of birth centre and home birth options for women with low-risk pregnancies.

[The evolution of places of birth]. / L'évolution des lieux de naissance.

Since the beginning of the 19th century, medical advances have drastically cut the number of deaths at birth, ensuring a maximum level of safety of childbirth today. However, there is increasing demand for alternative forms of childbirth which take into account more the expectations of the future parents as well as the psychological and relational dimensions. The current experimentation involving birth centres could lead the way for the development of such possibilities from 2018.

Trends and Characteristics of United States Out-of-Hospital Births 2004-2014: New Information on Risk Status and Access to Care.

BACKGROUND: Out-of-hospital births are increasing in the United States. Our purpose was to examine trends in out-of-hospital births from 2004 to 2014, and to analyze newly available data on risk status and access to care. METHODS: Newly available data from the revised birth certificate for 47 states and Washington, DC, were used to examine out-of-hospital births by characteristics and to compare them with hospital births. Trends from 2004 to 2014 were also examined. RESULTS: Out-of-hospital births increased by 72 percent, from 0.87 percent of United States births in 2004 to 1.50 percent in 2014. Compared with mothers who had hospital births, those with out-of-hospital births had lower prepregnancy obesity (12.5% vs 25.0%) and smoking (2.8% vs 8.5%) rates, and higher college graduation (39.3% vs 30.0%) and breastfeeding initiation (94.3% vs 80.8%) rates. Among planned home births, 67.1 percent were self-paid, compared with 31.9 percent of birth center and 3.4 percent of hospital births. Vaginal births after cesarean (VBACs) comprised 4.6 percent of planned home births and 1.6 percent of hospital and birth center births. Sociodemographic and medical risk status of out-of-hospital births improved substantially from 2004 to 2014. CONCLUSIONS: Improvements in risk status of out-of-hospital births from 2004 to 2014 suggest that appropriate selection of low-risk women is improving. High rates of self-pay for the costs of out-of-hospital birth suggest serious gaps in insurance coverage, whereas higher-than-average rates of VBAC could reflect lack of access to hospital VBACs. Mandating private insurance and Medicaid coverage could substantially improve access to out-of-hospital births. Improving access to hospital VBACs might reduce the number of out-of-hospital VBACs.

Out-of-hospital births in the United States 2009-2014.

OBJECTIVE: To evaluate recent trends of out-of-hospital births in the US from 2009 to 2014. METHODS: We accessed data for all live births occurring in the US from the National Vital Statistics System, Natality Data Files for 2009-2014 through the interactive data tool, VitalStats. RESULTS: Out-of-hospital (OOH) births in the US increased from 2009 to 2014 by 80.2% from 32,596 to 58,743 (0.79%-1.47% of all live births). Home births (HB) increased by 77.3% and births in freestanding birthing centers (FBC) increased by 79.6%. In 2014, 63.8% of OOH births were HB, 30.7% were in FBC, and 5.5% were in other places, physicians offices, or clinics. The majority of women who had an OOH birth in 2014 were non-Hispanic White (82.3%). About in one in 47 non-Hispanic White women had an OOH in 2014, up from 1 in 87 in 2009. Women with a HB were older compared to hospital births (age ≥35: 21.5% vs. 15.4%), had a higher live birth order(≥5: 18.9% vs. 4.9%), 3.48% had infants <2500 g and 4.66% delivered <37 weeks' gestation. 4.34% of HB were patients with prior cesarean deliveries, 1.6% were breech, and 0.81% were twins. CONCLUSIONS: Since 2004 the number of women delivered out of the hospital, at home and in freestanding birthing centers has significantly increased in the US making it the country with the most out of hospital births among all developed countries. The root cause of the increase in planned OOH births should be identified and addressed by the medical community.

Trends in out-of-hospital births in the United States, 1990-2012.

Although still relatively rare, out-of-hospital births have accounted for a growing share of U.S. births since 2004. In 2012, 1.36% of U.S. births were born outside a hospital, up from 1.26% in 2011 and 0.87% in 2004. The 2012 level is the highest level since 1975. Most of the total increase in out-of-hospital births from 2004­2012 was a result of the increase among non-Hispanic white women, and by 2012, 1 in 49 births to non-Hispanic white women (2.05%) occurred outside a hospital. In 2012, six states had 3%­6% of their births occur outside a hospital. For an additional five states, between 2% and 3% of their births were out-of-hospital births. Variations in the percentages of out-of-hospital births by state may be influenced by differences in state laws pertaining to midwifery practice or out-of-hospital births, as well as by the availability of a nearby birthing center. The number of U.S. birthing centers increased from 170 in 2004 to 195 in 2010 and to 248 in January 2013; 13 states still did not have a birthing center in the most recent period. Compared with hospital births, home and birthing center births tended to have lower risk profiles, with fewer births to teen mothers and fewer preterm, low birthweight, and multiple births. From 2004 through 2012, there was a decline in the risk profile of out-of-hospital births, with fewer births in 2012 than in 2004 to teen and older mothers and fewer preterm and low birthweight births. The lower risk profile of out-of-hospital than hospital births suggests that appropriate selection of low-risk women as candidates for out-of-hospital birth is occurring. Although not representative of all U.S. births, 88% of home births in a 36-state reporting area (comprising 71% of U.S. births) were planned in 2012. Unplanned home births are more likely than planned home births to be born preterm and at low birthweight.

Recent Trends in Out-of-Hospital Births in the United States.

INTRODUCTION: Although out-of-hospital births are still relatively rare in the United States, it is important to monitor trends in these births, as they can affect patterns of facility usage, clinician training, and resource allocation, as well as health care costs. Trends and characteristics of home and birth center births are analyzed to more completely profile contemporary out-of-hospital births in the United States. METHODS: National birth certificate data were used to examine a recent increase in out-of-hospital births. RESULTS: After a gradual decline from 1990 to 2004, the number of out-of-hospital births increased from 35,578 in 2004 to 47,028 in 2010. In 2010, 1 in 85 US infants (1.18%) was born outside a hospital; about two-thirds of these were born at home, and most of the rest were born in birth centers. The proportion of home births increased by 41%, from 0.56% in 2004 to 0.79% in 2010, with 10% of that increase occurring in the last year. The proportion of birth center births increased by 43%, from 0.23% in 2004 to 0.33% in 2010, with 14% of the increase in the last year. About 90% of the total increase in out-of hospital births from 2004 to 2010 was a result of increases among non-Hispanic white women, and 1 in 57 births to non-Hispanic white women (1.75%) in 2010 was an out-of-hospital birth. Most home and birth center births were attended by midwives. DISCUSSION: Home and birth center births in the United States are increasing, and the rate of out-of-hospital births is now at the highest level since 1978. There has been a decline in the risk profile of out-of-hospital births, with a smaller proportion of out-of-hospital births in 2010 than in 2004 occurring to adolescents and unmarried women and fewer preterm, low-birth-weight, and multiple births.

Safety of non-medically led primary maternity care models: a critical review of the international literature.

The Australian government has announced major reforms with the move to a primary maternity care model. The direction of the reforms remains contentious; with the Australian Medical Association warning that the introduction of non-medically led services will compromise current high standards in maternity services and threaten the safety of mothers and babies. The purpose of this paper is to conduct a critical review of the literature to determine whether there is convincing evidence to support the safety of non-medically led models of primary maternity care. Twenty-two non-randomised international studies were included representing midwifery-led care, birth centre care and home birth. Comparative outcome measurements included: perinatal mortality; perinatal morbidity; rates of medical intervention in labour; and antenatal and intrapartum referral and transfer rates. Findings support those of the three Cochrane reviews, that there is sufficient international evidence to support the conclusion of no difference in outcomes associated with low risk women in midwifery-led, birth centre and home birth models compared with standard hospital or obstetric care. These findings are limited to services involving qualified midwives working within rigorous exclusion, assessment and referral guidelines, limiting the number of urgent intrapartum transfers that come with increased risk of perinatal mortality.

Australian maternity reform through clinical redesign.

The current Australian national maternity reform agenda focuses on improving access to maternity care for women and their families while preserving safety and quality. The caseload midwifery model of care offers the level of access to continuity of care proposed in the reforms however the introduction of these models in Australia continues to meet with strong resistance. In many places access to caseload midwifery care is offered as a token, usually restricted to well women, within limited metropolitan and regional facilities and where available, places for women are very small as a proportion of the total service provided. This case study outlines a major clinical redesign of midwifery care at a metropolitan tertiary referral maternity hospital in Sydney. Caseload midwifery care was introduced under randomised trial conditions to provide midwifery care to 1500 women of all risk resulting in half of the publicly insured women receiving midwifery group practice care. The paper describes the organisational quality and safety tools that were utilised to facilitate the process while discussing the factors that facilitated the process and the barriers that were encountered within the workforce, operational and political context.

Parto humanizado: uma realidade na Casa de Parto? / Humanizing delivery: a reality in a Birth Center? / Humanización del parto: una realidad en la Casa de Parto?

Objetivo: conhecer a percepção das puérperas sobre a assistência desenvolvida na Casa de Parto de São Sebastião doDistrito Federal. Metodologia: trata-se de estudo descritivo e exploratório, de abordagem qualitativa, com dez mulheresque vivenciaram o parto e puerpério na Casa de Parto após a aprovação do projeto de pesquisa pelo Comitê de Ética emPesquisa da Secretaria de Estado em Saúde do Distrito Federal com parecer nº 264/2007. Resultados: as categoriastemáticas encontradas foram: Assistência no pré-natal, Assistência no processo de parturição e Assistência no puerpério.Nas análises das falas das puérperas foi referido ações referentes à humanização da assistência no momento da parturiçãoe puerpério, contudo as mesmas relataram escassez de orientações e informações no Pré-natal que julgaram serimportantes para vivenciar o parto e puerpério com segurança. Conclusão: o presente estudo evidenciou que o trabalhodesenvolvido na instituição corresponde a uma assistência humanizada às parturientes que são acolhidas na Casa de PartoSão Sebastião. Tais procedimentos utilizados estão em sintonia com as recomendações da Organização Mundial de saúde, oque foi constatado nos depoimentos colhidos das puérperas participantes do estudo.(AU)

Objective: to know the women's perception in the postpartum about the provided health assistance during the labor and delivery at San Sebastian Birthing Center in District Federal, Brazil's capital. Methodology: this is about a qualitative study, performed with ten women who experienced the delivery and postpartum period in this birthing center. The project was approved by the Ethics Committee of the Health State Secretary of the District Federal with protocol number 264/2007. Results: the themes of the study were found and classed in the following way: Pre-natal assistance, birth process and puerperal assistance. The women's narrations were analyzed and it was referred in the major statements, humanization's actions in the delivery moment and in the puerperal period, however the same women related scanty orientations and information in pre-natal appointments that would be very relevant to live these experiences with selfcontrol and safety. Conclusion: the present study evidenced that at San Sebastian Birthing Center, the executed work correspond to a humanized assistance that is offered to the pregnant women who are admitted at this birthing center. The procedures that are used in this birthing center are humanized and they are according to World Health Organization's recommendations, which were confirmed by the collected report of the women who participated of the study.(AU)

Objetivo: conocer la percepción de las puérperas acerca de la asistencia desenvuelta en la Casa de São Sebastião del Distrito Federal. Metodología:trata-se de uno estudio qualitativo con diez mujeres que tuvieran sus partos e puerpérios en la Casa Del Parto. Las categorías temáticas encontradas fueron: Asistencia durante la gestación, Asistencia en el proceso de parturición y Asistencia en el puerpério. El proyecto fue aprobado por el Comité de Ética de la da Secretaria de Estado em Saúde do Distrito Federal com parecer nº 264/2007. Resultados: en análisis a las respuestas de las puérperas, fue citado acciones acerca de la humanización de la asistencia durante la parturición y puerpério, entretanto las mismas relataron la escasez de orientaciones y informaciones en el prenatal que juzgaban importantes para la seguridad en el parto y puerperio. Conclusiones: el presente estudio evidencio que el trabajo desenvuleto en la instituición corresponde a una asistencia humanizada a las parturientes que son acollidas en la Casa del Parto. Los procedimientos utilizados estan en sintonia con las recomendaciones de la Organización Mundial de Salud, lo que fue constatado en los depoimientos collidos de las puérperas participantes del estudio.(AU)

Trends and characteristics of home and other out-of-hospital births in the United States, 1990-2006.

OBJECTIVES: This report examines trends and characteristics of out-of-hospital and home births in the United States. METHODS: Descriptive tabulations of data are presented and interpreted. RESULTS: In 2006, there were 38,568 out-of-hospital births in the United States, including 24,970 home births and 10,781 births occurring in a freestanding birthing center. After a gradual decline from 1990 to 2004, the percentage of out-of-hospital births increased by 3% from 0.87% in 2004 to 0.90% in 2005 and 2006. A similar pattern was found for home births. After a gradual decline from 1990 to 2004, the percentage of home births increased by 5% to 0.59% in 2005 and remained steady in 2006. Compared with the U.S. average, home birth rates were higher for non-Hispanic white women, married women, women aged 25 and over, and women with several previous children. Home births were less likely than hospital births to be preterm, low birthweight, or multiple deliveries. The percentage of home births was 74% higher in rural counties of less than 100,000 population than in counties with a population size of 100,000 or more. The percentage of home births also varied widely by state; in Vermont and Montana more than 2% of births in 2005-2006 were home births, compared with less than 0.2% in Louisiana and Nebraska. About 61% of home births were delivered by midwives. Among midwife-delivered home births, one-fourth (27%) were delivered by certified nurse midwives, and nearly three-fourths (73%) were delivered by other midwives. DISCUSSION: Women may choose home birth for a variety of reasons, including a desire for a low-intervention birth in a familiar environment surrounded by family and friends and cultural or religious concerns. Lack of transportation in rural areas and cost factors may also play a role.

Las casas de parto dentrodel sistema hospitalario / Birth Centers in hospitals

Las casas de parto son unidades obstétricas de bajo riesgo dirigidas pormatronas. Desde la década de 1990, ha habido un resurgimiento de estoscentros. El propósito de esta revisión es examinar la evidencia científicasobre los beneficios de las casas de parto vinculadas al sistemasanitario. Los estudios encontrados señalan que estos centros aumentansignificativamente la probabilidad de tener un parto vaginal, de nonecesitar anestesia epidural y de disminuir las intervenciones médicas.No obstante, también insisten en que estas unidades deben estar dotadasde personal altamente cualificado y utilizar unos protocolos clínicosbien definidos. Se necesitan más estudios para conocer tanto los beneficioscomo los riesgos de la atención obstétrica de la mujer de bajo riesgo (AU)

Birth Centers within Hospitals are low risk obstetric units managed bymidwives. Since the 1990s there has been a resurgence of these units.The purpose of this revision is to study the scientific evidence on thebenefits of birth units linked to the Health System. Studies indicate thatthese units significantly increase the probability of having a vaginalbirth, of not needing epidural anaesthesia and of reducing medical intervention.However, it has also been stressed that these units must beequipped with highly qualified staff who use well defined protocols. Furtherstudies are needed to learn both about the benefits and the risks ofobstetric assistance for low risk women (AU)