Grants

Supporting women and birthing people to make informed decisions by providing information about birth setting options and variations in models of care by birth setting is a critical patient-centered strategy to ensure equitable access to low-intervention birth settings. Policies that expand affordable health insurance to cover midwifery care in all birth settings are needed to enable people to make informed choices about birth location that align with their values, individual pregnancy characteristics, and preferences.

Rates of maternal morbidity and mortality in the United States lag behind other high-income countries. One proposed solution is to develop an integrated system of maternity care consisting of levels of care based on medical risk. As smooth transitions between different levels will be necessary, better definition of successful collaboration in this context is needed. Participating in review of transfers, hospital department meetings, and QI activities resulted in statistically significant lower cesarean sections, as did participating in emergency drills. Attending social events with the department and attending classes at the hospital resulted in statistically significant higher rates of transfer from birth center to hospital. These transfers occurred without a concurrent increase in cesarean sections.

Slow or arrested progress in labor is the most frequent (64%) indication for nonemergent transfer of laboring people from freestanding birth centers to the hospital. After the 2014 publication of the Consensus Statement on Safe Prevention of Primary Cesarean Delivery (Consensus Statement), many freestanding birth centers changed their clinical practice guidelines to allow more time for active labor in the birth center prior to hospital transfer. The result of these changes has not been evaluated in birth centers. Evaluation of adoption of guidelines based on the Consensus Statement in hospitals has shown inconsistent results. We found no evidence that making these practice changes was associated with better outcomes. Two hours of a lack of documented cervical change in active labor is likely long enough to diagnose arrested progress in labor.

A pilot project conducted at 34 American Association of Birth Centers (AABC) Strong Start sites included 553 beneficiaries between 2015 and 2016 to explore client perceptions of high impact components of care. Participants demonstrated high engagement with care and trust in pregnancy, birth, and parenting. Beneficiaries achieved their preference for vaginal birth (89.9%) and breastfeeding at discharge through 6 weeks postpartum (91.7% and 87.6%). Beneficiaries reported having time for questions, felt listened to, spoken to in a way they understood, being involved in decision making, and treated with respect. There were no variations in experience of care, cesarean birth, or breastfeeding by race. Medicaid beneficiaries receiving prenatal care at AABC Strong Start sites demonstrated high levels of desired engagement and reported receiving respectful, accessible care and high-quality outcomes. More investment and research using client-reported data registries are warranted as the US works to improve the experience of perinatal care nationwide.

Interprofessional care teams were associated with lower rates of labor induction and overall cesarean utilization as well as higher rates of vaginal birth after cesarean. There was consistency in cesarean rates among women with higher risk for complications.

The present analysis shows associations between certain individual characteristics and elective hospitalization during labor for birth center clients. Health record data and questionnaire responses indicated a variety of reasons for electing hospitalization, illustrating the complexity of clients’ decision-making during pregnancy and birth.

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. 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.

Women who gave birth in birth centers believed that the birth center culture and environment, the midwifery model of care in the birth centers, internal influences including the belief that birth is a normal physiologic process, and outside influences including family support and positive birth stories contributed to their confidence for physiologic birth.

Preliminary analysis shows that most of the midwives see potential benefits of a video-calling service, including enhanced assessment capacity through visual cues and increased reassurance for women and their partners. However, some midwives had significant concerns about introducing video calls into early labor care, including doubts about the reliability of the technology and discordant phone types. Within the health care context, legal issues, confidentiality, privacy concerns, and appearing professional, empathic, and focused during video calls were raised. Discussion between midwives about which women had internet access raised concerns about equity.

We interviewed 21 midwives (18 CNMs, 3 CPMs/equivalent) from 18 birth centres in 11 US states, 45% with hospital practice privileges. Midwives relied on and engaged in embodied practice in evaluating each labour and making decisions concerning management of labour. Midwives considered time a useful but limited measure as a guiding factor in management. Though ideas of time and progress do play an important role in the decision-making process of midwives, their usefulness is limited due to the continual, multifactorial, and multisensory nature of the assessment. Relationship with the transfer hospital structured midwives' decision-making about transfers.

Women with obese BMIs without medical comorbidity can receive safe and effective midwifery care at freestanding birth centers while anticipating a low risk for cesarean birth. The risks of potential, obesity‐related perinatal complications should be discussed with women when choosing place of birth; however, pregnancy complicated by obesity must be viewed holistically, not simply through the lens of obesity.

Consumer demand for water birth has grown within an environment of professional controversy. Access to nonpharmacologic pain relief through water immersion is limited within hospital settings across the United States due to concerns over safety. The study is a secondary analysis of prospective observational Perinatal Data Registry (PDR) used by American Association of Birth Center members (AABC PDR). Among childbearing women of low medical risk, personal preference should drive utilization of nonpharmacologic care practices including water birth. Both land and water births have similar good outcomes within the community setting.