New birth center study does not show what its authors claim it shows

Isolated Aid Kit With Green Dollar Sign

A new study of birth centers, published yesterday, is being hailed by midwifery advocates. While it does demonstrate that giving birth in birth centers accredited by the American Association of Birth Centers is safe, it does NOT show that birth centers have a lower C-section rate than hospital care for comparable risk women, and therefore, it does NOT show that increasing birth center births would save millions of dollars.

The study is Outcomes of Care in Birth Centers: Demonstration of a Durable Model, by Stapleton, Osbourne and Illuzi.

The study found that birth in accredited birth centers was very safe:

There were no maternal deaths. The intrapartum fetal mortality rate for women admitted to the birth center in labor was 0.47/1000. The neonatal mortality rate was 0.40/1000 excluding anomalies.

This is comparable to death rates for low risk hospital birth.

So far, so good. Then the authors, in their efforts to promote birth centers, go far beyond the data. They claim:

The cesarean birth rate in this cohort was 6% versus the estimated rate of 25% for similarly low-risk women in a hospital setting.21 Had this same group of 15,574 low-risk women been cared for in a hospital, an additional 2934 cesarean births could be expected. The Medicare facility reimbursement for an uncomplicated cesarean birth in a hospital in 2011 was $4465.49 Given the increased payments for facility services for cesarean birth compared with vaginal birth in the hospital, the lower cesarean birth rate potentially saved an additional $4,487,524. In total, one could expect a potential savings in costs for facility services of more than $30 million for these 15,574 births.

But the C-section rate for comparable risk births in the hospital is NOT 25%. It is far lower, in the range of 4-8%. Indeed, I’m not sure where they even got their estimate of a 25% C-section rate for comparable risk births since does not appear in the reference specifically cited to support this number.

The first rule of scientific comparisons is to compare like to like. Therefore, when looking for the appropriate comparison group for women who give birth in accredited birth centers, we must restrict the group to low risk women, with single babies, at term, without intrauterine growth retardation. Furthermore, we must exclude from the comparison group any women who have pre-existing medical problems or pregnancy complications, since they would be excluded from delivering at the birth center.

In addition, we must take into account that women choose to deliver in a birth center are a self-selected group who differ markedly from the general population. They are more likely to be white, married and well educated and they are far less likely to smoke, drink alcohol or be obese.

What is the appropriate comparison group? It’s women who choose to deliver in the hospital with a CNM. There are a number of studies performed in the past 2 decades that look at outcomes for women who delivered with CNMs in a hospital. The C-section rate in that group ranges from 4-8%. Moreover, women who give birth in the hospital have access to pain relief, something that most women want.

There is no particular benefit to delivering in a birth center with a CNM as compared to delivering in a hospital with a CNM. There’s no decrease in C-section rate, and no savings from C-sections that were avoided. If the same group of 15,574 low-risk women had been cared for in a hospital by CNM, an additional 2934 cesarean births would NOT have been expected. Indeed, no additional C-sections would have been expected.

So while this paper makes an excellent argument for the safety of accredited birth centers that employ strict eligibility criteria, it does NOT show that birth centers reduce the C-section rate or save money by doing so.

  • Squillo

    Bingo! Give the doc a ceegar. I live 5 minutes from a hospital, and I bet I could save the state lots of hc $ by delivering low-risk mothers in my living room. When things go pear-shaped and I have to emergency transfer them, the excess cost involved doesn’t get tied to me. It’s those pesky docs with their NICUs and their transfusions that cost all that money.

  • Mary Lou

    Watch the documentary “The Business of Being Born” and tell me that hospital births in the US aren’t a huge money-maker. You’ll be shocked at some of the things you’ll learn (such as the fact that MOST OBs have never attended a natural birth!) For low-risk cases, midwife-attended births are the way to go. Let women do what their bodies are meant to do and stop making us feel like “patients” who are somehow abnormal if we don’t give birth flat on our backs within a time frame convenient for the money-grubbing docs and hospitals.

    • AA

      > (such as the fact that MOST OBs have never attended a natural birth!).

      Does this phrase make sense to ANYONE? Really, 25% or more of vaginal births in the US are without epidural or spinal analgesia. An OBGYN attends hundreds of births during their residency alone. RIght, they’ve never seen a birth without an epidural. That’s quite a logical assumption. All of that “research” on the Internet about “I gave birth naturally in a hospital!” THey must be liars too.

      • Roadstergal

        And remember, kids, epidural analgesia is the boogey analgesia that makes your VB unnatural. Gas, tubs, injections, anything a midwife can do keeps that shiny ‘natural’ badge. You want to be natural, right? RIGHT?

    • yugaya

      “You’ll be shocked at some of the things you’ll learn (such as the fact that MOST OBs have never attended a natural birth!)”

      See kids, that’s what happens when you get your information on clinical training from washed-out talk show host propaganda pieces – you get it all wrong. An OB will see by the end of their residency more natural births than an average quack midwife will in a lifetime.

    • SporkParade

      They aren’t a huge money-maker. Most OBs these days are on salary, and so their pay is unaffected by the mode of birth or the number of interventions involved. If they’re in private practice as opposed to a hospital employee, they pay a huge amount in malpractice insurance, simply because the payouts are so large and the juries usually don’t actually care if the doctor is guilty so long as someone pays. Also, what’s so great about natural birth, anyway? I don’t understand why the fact that my body is capable of vaginally delivering a baby means that I need to be in absolute agony while I give birth. But that means anesthesiologists and monitoring and IV fluids and a urinary catheter, and I’m fine with that.

    • The Bofa on the Sofa

      I could watch Hairspray. It’s probably about as close to reality.

    • Megan

      The vast majority of OB’s are on salary and insurance companies pay a global fee for a birth. That fee doesn’t change regardless of how many times they see the patient prenatally, how many interventions are used or the mode of delivery. So there is no financial motive to do any intervention unless it’s seen as necessary for safety. Also, since most OB’s work in a group practice and are on a shift model, there’s no motive to get done faster either because they leave the same time regardless (though I know many OB’s who stay with a patient they’ve been caring for even past the time their shift ends). If you didn’t get your information from Ricki Lake, perhaps you’d know these things.

      • Squillo

        I’ve seen several people state in various places that most OBs (in the US) are on salary, but I’ve never been able to put my hands on an actual statistic. The 2015 Medscape Physician Compensation Report states that 59% of male physician respondents and 72% of female physician respondents said they were employed, but there’s no breakdown by specialty. Have you seen any specialty-specific stats?

    • The Bofa on the Sofa

      such as the fact that MOST OBs have never attended a natural birth

      How many OBs have you talked to? Because, you know, we have a bunch of OBs and even GPs around here that have done deliveries, and every single one of them has attended a “natural birth.” Where are the OBs who have never attended one?

      money-grubbing docs

      Did you know that the general practice of homebirth midwives is to require full payment, up front, and it is non-refundable, even if they drop you off at the door of the hospital and you deliver there.

      Now, I’m not going to begrudge those midwives their business practice, but at the same time, I’m not seeing midwives who are working for free. They insist on getting their money.

    • Roadstergal

      “You’ll be shocked at some of the things you’ll learn”

      I dunno, I’m already going in thinking that Riki Lake is scientifically ignorant and morally bankrupt. I doubt I’ll be shocked.

    • Amy Tuteur, MD
    • Nick Sanders

      Please define “natural birth” and explain what makes the distinction important.

    • Sarah

      Let women do what they want with their bodies, but if you’re low risk I’m entitled to decide what’s best for you. And apparently I also get to pronounce on what your body was designed to do.

    • demodocus

      Why should an ob be incompetent to do what that Cleveland basketball player was able to do recently? My ob did nothing more than check my cervix a couple times, ask if I wanted pain relief, and give me magnesium when i was heading towards eclampsia. He even stayed several hours past his shift to see my little boy into the world. My mother’s assorted obs certainly saw a woman have a “natural” birth, since she hated pain meds, had a scary high tolerance for pain, and zero complications.

    • araikwao

      I’m not even an OB (yet…), and I’ve attended a number of natural births as a med student. So that “fact” is wrong. I wonder what else from that doco might be spun a particular way to push a particular agenda?

      • Squillo

        Hell, I’ve only “attended” two hospital births, one with a CNM (induced, epidural) and one NSVD with an OB. (Ergo, 50% of all hospital births are “natural,” and 100% of all OB-attended hospital births are “natural.” Right?)

    • Charybdis

      How do you define “natural birth”? And the time frame is not for the doc’s convenience, no matter how much you insist on it. After the membranes rupture, you have to worry about infection and there is a time frame involved with that. And if labor stalls for awhile, this is often a sign that something has gone awry. As much as the NCB woo slingers run on and on about hospitals making you punch a clock if you deliver there, there is some truth to that. The longer labor goes on, the greater the chances of complications developing. A hospital and OB would not allow you to go on laboring for 36- 48 hours after rupturing your membranes, nor would they allow you to push unproductively for HOURS on end.
      As for the “money grubbing”, nearly all OB’s get a flat fee from the insurance companies and that covers the prenatals, delivery, and postnatal checkups. And if I remember correctly, my OB’s fee was something like $3600.00 for a vaginal delivery and $5000.00 for a C-section. From what I’ve read, the midwife’s fee is $5000.00 and up, payable in full, upfront. They aren’t doing what they do out of the goodness of their hearts by any stretch of the imagination.
      You should have to qualify FOR a homebirth if you want one; it should NEVER be the first, nor the default option. And if you “trust your body and birth” enough, why then do you go running to the hospital when things go sideways? If you choose the homebirth option because “women have been doing it this way forever and it’s the best way”, then you should have to live with the true consequences of that decision like women have had to do since forever.

    • Our bodies are “meant” to kill us about 1% of the time during childbirth. That’s the natural maternal mortality rate. The natural perinatal mortality rate is closer to 10%.

      I would far rather not take a 1 in 100 chance of dying, thanks anyways. I don’t trust a midwife to figure out when my low-risk turns into a high-risk FIX IT NOW situation, nor would I trust her to have the knowledge or tools necessary to fix it.

  • guard
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  • amazonmom

    Same at the hospital where I work. Moms with an IUFD get a room away from the busy areas where you can hear infants. The anesthesiologist puts them at the top of the priority list and they get their choice of all the pain control options we have available, if they want something else we get it ASAP. We usually have multiple anesthesiologists on the premises so very few of the moms have to wait at all.

  • frontier

    It was actually the midwife that arrived with saddle bag in hand and that is why babies arrived in the bag. Before then, women would give birth with an older family member in attendant who had knowledge in helping with childbirth.