More pregnant people are taking control of their childbirth experience by choosing to birth in a community setting rather than a hospital, according to the Centers for Disease Control. Community birth settings include birth centers and planned home births, and the number of people choosing one of these options rose 20 percent between 2019 and 2020. The sharpest increases occurred in Black, Indigenous and Hispanic communities.
While concerns about COVID exposure in hospitals certainly contribute to this trend, other likely factors include the desire to retain more autonomy during birthing, deciding who will be present, preventing unnecessary interventions and restrictions, and avoiding the disrespect that too often occurs in hospitals. Black, Latinx, and Indigenous families may also be responding to the higher risk of maternal mortality and morbidity they face and the impact of discrimination and structural racism in hospitals that result in lower-quality care. The National Partnership for Women & Families explores these trends and the benefits of birthing in the community in a new report, Improving Our Maternity Care Now Through Community Birth Settings.
From 2019 to 2020, the increase in people choosing to give birth in their communities was greatest for Black parents (30%), followed by Indigenous (26%) and Hispanic (24%) parents. This increase is particularly striking because these communities are the least likely to have access to these options. The report includes recommendations to rectify this inequity.
Birth centers and home birth settings share similar characteristics, including shared decision-making and individually-tailored care. Both center midwifery-led relationship-based care that builds trust, educates, answers questions, and limits medical interventions to only those truly needed.
Research shows birthing people experience better care and better health outcomes in community birth settings compared to hospitalization. Lower rates of preterm birth and cesarean birth and higher rates of breastfeeding were all cited. Parents who choose to birth in their communities also report higher satisfaction rates and respectful experiences with their care providers.
Care in these settings is much less costly than hospital care. An analysis published in the International Journal of Environmental Research and Public Health estimates that the U.S. would save $321 million annually for every 1% of births that shifted from hospitals to homes and $189 million annually with each 1% shift from hospitals to birth centers.
Cost and lack of access are key barriers to community birth. Community birth centers and home births are less likely to be covered by traditional insurance than hospital births. For example, in 2020, only three percent of hospital births were paid for out of pocket. By contrast, 34 percent of families using birth center care paid out of pocket, while 70 percent of families choosing planned home births paid for that care out of pocket. In addition, licensure for some types of midwives and birth centers varies widely across states, making it difficult to find or access that type of care in some states.
Five national organizations contributed to the new report: the American Association of Birth Centers, American College of Nurse-Midwives, Birth Center Equity, the National Association of Certified Professional Midwives, and the National Black Midwives Alliance.
The National Partnership’s Vice President for Health Justice, Sinsi Hernández-Cancio, said it is essential to increase access to community birth settings without delay. “We can’t afford to wait. A dire maternal health crisis compounded by the COVID-19 pandemic demands we mitigate needless harm right now. For some people, that means staying out of hospitals if they can.” Hernández-Cancio said, “More people die from pregnancy and childbirth in the U.S. than any other industrialized nation. And that is just the tip of an enormous iceberg of the pain, trauma, and disability caused by near misses. These tragedies should not be part of anyone’s birth story, yet for Black, Indigenous, and other People of Color, it is all too common. Expanding access to a full range of birth settings is one way to help birthing people to have more and better options to be supported and stay safe.”
Aubre Tompkins, MSN, CNM, President of the American Association of Birth Centers, said, “There is strong evidence to support community birth as a high-value care model to advance birth equity. It is critical that barriers in policy and payment be removed to improve access in all communities and especially for birthing people and families of color.”
“The American College of Nurse-Midwives (ACNM) believes that every family has the right to freedom of choice and self-determination in maternity care, including place of birth,” said Catherine Collins-Fulea, DNP, CNM, FACNM, President of the American College of Midwives. “This report is instrumental in demonstrating how community birth settings, and the midwives that lead them, are changing the landscape of maternal health care and improving outcomes for all, especially people of color.”
In a joint statement, Nashira Baril, MPH and Leseliey Welch, MPH, MBA, co-directors of Birth Center Equity said, “This report offers rich and compelling data to support the wisdom that Black, Indigenous, communities of color have long known: that the best way to ensure safe, culturally reverent, and liberatory birthing experiences is to invest in community-led solutions. To curb the crisis of maternal health and the inequitable ways it bears down on communities of color, the US must redress divestment in midwifery and the economic barriers that block community birth infrastructure development. Birth Center Equity is proud to partner with the National Partnership for Women & Families and others to create and implement policy solutions to ensure that community birth centers are equitably accessible and resourced.”
“This report constitutes a powerful case for the critical role for the model, settings, and providers of community birth in addressing overall poor perinatal outcomes in our country, and especially in eliminating the unconscionable disparities and inequities impacting Indigenous and communities of color,” said Khailylah (“Kiki”) Jordan, LM, CPM, president of the National Association of Certified Professional Midwives, “NACPM is pleased to partner with the National Partnership for Women & Families and the complement of partners participating in this report to disseminate the good news of what can be accomplished by elevating community birth in our perinatal care system to achieve health justice. NACPM looks forward to collaborating to promote these vital recommendations to policymakers and payers to ensure universal and equitable access to community birth and health for all childbearing people and their babies.”
National Black Midwives Alliance Executive Director Jamarah Amani said recently, “Without incorporating midwifery models of care as the standard for perinatal health we will continue to see the maternal health crisis escalate as we have during the COVID-19 pandemic. The growing demands of Black families for access to community birth reflects a need to develop and expand the workforce of culturally-centered, community-based midwives, providers who are trained to ground their practices in respect, dignity and autonomy.”
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Improving Our Maternity Care Now Through Community Birth Settings is a companion report to Improving Our Maternity Care Now Through Midwifery and part of the Improving Our Maternity Care Now series supported by a generous grant from the Yellow Chair Foundation.
