Feb. 6, 2020

No Hospital, Birth Center, or Home Birth Is Risk-Free — But Better Access to Care, Quality of Care, and Care System Integration Can Improve Safety for Women and Infants During Birth, Says Report

WASHINGTON — A new report from the National Academies of Sciences, Engineering, and Medicine finds that there is no risk-free setting for giving birth, whether at home, in a birth center, or in a hospital. But with changes such as appropriate and continuous risk assessment during pregnancy and investment in the maternity care workforce, giving birth in the U.S. can be safer than it is today.

Birth Settings in America: Outcomes, Quality, Access, and Choice finds low-risk births that occur in birth centers have a slightly increased risk of poor neonatal outcomes, and similar to slightly elevated rates of neonatal mortality, when compared with hospital births. Home and birth center births have lower rates of interventions than hospital births, such as cesarean birth or induction of labor. This means women giving birth at home or in birth centers also have lower rates of intervention-related injuries and complications, such as infection or postpartum hemorrhage. The fact that women choosing out-of-hospital birth settings want fewer interventions contributes to these lower rates. The study also found increases in the risk of neonatal death in home births compared with births in a hospital setting, although the precise magnitude of the difference is difficult to assess given flaws in the underlying data.

The vast majority of U.S. women – nearly 98.4 percent – give birth in a hospital, but the percentage of women choosing to give birth at home or in birth centers is growing. Black and Native American women experience the highest rates of maternal and neonatal morbidity and mortality. The report says racism and sexism are foundational drivers of poor outcomes in maternity care. The experiences of women of color, especially black and Native American women, such as intergenerational trauma, marginalization, intolerance, and economic disadvantage, create risk factors for pregnancy and childbirth.

International studies suggest that home and birth center births may be as safe as hospital births for low-risk women and infants when they are part of an integrated and regulated system, multiple provider options are covered by insurance, providers are well qualified and have the knowledge and training to manage complications, transfer to a different birth setting is seamless, and risk assessment occurs throughout pregnancy.

Some women report a gap between the care they expect and want and the care they receive when giving birth, the report finds. Women want safety, freedom of choice in birth setting and provider, choice among care practices, and respectful treatment. Not enough data was available for the committee that wrote the report to evaluate how birth setting impacts maternal mortality and severe maternal morbidity.

Improving Home and Birth Center Settings

Incorporating home and birth center settings into an integrated and regulated maternity and newborn care system — providing continuous risk assessment, access to consultation, seamless transfer between birth settings, written birth plans, and well-qualified and trained maternity care providers — can improve maternal and neonatal outcomes. Improving maternity care providers’ and birth centers' ability to access state licensure and accreditation could also improve access to care.


Improving Hospital Settings

Hospital participation in quality improvement initiatives, such as the Alliance on Innovation in Maternal Health or the National Network of Perinatal Quality Collaboratives, and adoption of national standards and guidelines have been shown to improve outcomes for women and newborns. Hospitals can ensure pregnant women receive respectful, appropriate, timely, and responsive care by providing nonsurgical maternity care services if a woman requests them, such as vaginal birth after a prior cesarean birth. Hospitals can also consider developing midwifery-led units for low-risk births and enabling greater collaboration between midwives, doctors, and nurses.


Access and Choice for Pregnant Women

The report emphasizes that women have the right to informed choice of the setting in which they give birth, and to exercise that choice, they must have access to options. Online decision aids and risk-assessment tools can help pregnant women evaluate risk, birth settings, providers, and specific care practices, and decide which options are best for them.


In addition, access to birth setting options is constrained by other factors, including the ability to pay. Only a limited number of insurance payers offer coverage for in-home care or birth-center care, and many beneficial maternity care services, such as doulas, are not covered at all. Ensuring adequate payment from Medicaid and Medicare to health care providers for maternity and newborn care is critical to improving access. The report also says efforts are needed to pilot and evaluate high-value payment models in maternity care, in which payment is tied to the quality of care provided.

Birthing facilities are also unevenly distributed, and many women do not have access to prenatal care, birthing, or postnatal care nearby. The report says research is needed to study and develop models for maternity care in underserved areas, both rural and urban.

The Maternity Care Workforce

To improve access and reduce racial and ethnic disparities in the quality of care, investments are needed to expand the pipeline for the maternity and newborn care workforce. This includes community health workers, doulas, maternity nurses, and others. Greater opportunities for interprofessional education, collaboration, and research across all birth settings are also critical to improving quality of care.


The study — undertaken by the Committee on Assessing Health Outcomes by Birth Settings — was sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The National Academies are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln. For more information, visit nationalacademies.org. 

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