5 reasons birth centers have met their moment

Childbirth Connection has been advocating for greater access to birth centers for much of our 95 year history. We opened the first urban birth center in 1975 and helped found the organization that would later become the American Association of Birth Centers (AABC). Our director from 1970 to 1995, Ruth Lubic, went on to win a MacArthur “Genius” Award for her pioneering work in birth center innovation. Although the number of birth centers has increased in the intervening decades, birth centers remain a very small segment of the health care system. Just 0.3% of U.S. births take place in birth centers.

But a new study out today and a congressional briefing next week are sure to heighten attention to this high-quality, high-value care option. Added to other trends and recent developments, we anticipate this new study will trigger rapid growth in birth centers, and more focused and innovative efforts to integrate birth centers into the health care system. Here are 5 reasons birth centers have met their moment.

1. Virtually everyone now agrees the c-section rate is too high. Birth centers are an effective solution.

Calls for attention to cesarean overuse have grown into a chorus in recent years, with major reports and research reviews, influential editorials, and an increasingly organized and vocal grassroots movement all contributing. Last year, the National Priorities Partnership Maternity Action Team announced a national goal to reduce the c-section rate in low-risk women to 15% or less and the Joint Commission announced it would require accredited hospitals to report on maternity measures including the c-section rate in low-risk first time moms.

While there is widespread agreement about the problem, however, there is considerably less certainty about the solutions.  A recent federally funded evidence review found efforts to improve hospital care have been uneven in their impact on c-section rates, and strong evidence that specific interventions reduce the risk of c-section is generally lacking. In contrast, the National Birth Center Study II, released today, reports a 6% c-section rate in women eligible for birth center care at the onset of labor, with no evidence that this low rate was associated with counterbalancing harm. With about a quarter of low-risk women having c-sections in U.S. hospitals, scaling up birth center care is a clear strategy for safely preventing many c-sections.

2. The cost of hospitalization is unsustainable. Birth centers achieve value with good outcomes and a much lower price tag.

Our recent report, The Cost of Having a Baby in the United States, outlined the high and growing costs of hospital-based maternity care, and the extent to which these costs are concentrated in the childbirth hospitalization. Since 2004, commercial payments for maternal care with both vaginal and cesarean births increased by over 50%, with out of pocket expenses borne by families increasing four-fold during that time. In 2010, Medicaid programs paid an average of $18,329 for a vaginal birth and $27,866 for a cesarean birth, with commercial insurers paying almost twice this amount ($32,093 and $51,125, respectively).

These totals were dominated by a single part of the bill: the hospital facility fee. That’s the fee paid to hospitals to cover the hospital stay, not including anesthesiology, physician/midwife care, pharmacy, radiology, etc. The average commercial insurance payment to hospitals to cover the childbirth hospitalization facility fee was $9,759 per vaginal birth and $17,140 per cesarean, while Medicaid programs paid hospital fees averaging $4,492 and $7,722 for vaginal births and cesareans, respectively.

Birth centers can reduce these costs in 2 ways. The first is the most obvious – by keeping women out of the hospital, birth centers help payers avoid hospital facility fees. Birth centers charge facility fees, too, but they are a fraction of the average fees paid to hospitals. (Although we don’t have data on the amount paid to birth centers, the AABC reported the amount charged by birth centers in 2010 averaged $2,277. Generally insurers and Medicaid programs pay considerably less than what facilities charge.) The second way birth centers may reduce costs is by reducing the use of cesareans, as well as other costly interventions including anesthesia. An independent report produced for AABC estimated that the 15,000 women in the National Birth Center Study II avoided 3,000 unnecessary cesareans and saved payers $4.5 million in the process.

3.  Payment models are coming that will reward well coordinated birth center care.

A major part of health care reform efforts has been to align reimbursement with high-quality, high-value care. There are many related and overlapping payment innovations – accountable care organizations, bundled payments, shared savings programs, and so on. The aim of all of these is to reward care that keeps people healthy, and to incentivize new care delivery models that do so efficiently. As Harold Miller, Executive Director of the Center for Healthcare Quality and Payment Reform, pointed out in his 2010 Transforming Maternity Care webinar, our current system rewards hospitalizations, c-sections, and complications. Well thought-out payment reforms can reward what our system really ought to be designed to deliver: healthy moms and healthy babies. Coordinated systems that integrate birth center care for low-risk women have a high likelihood of achieving these goals.

4. All sorts of things that used to only happen in hospitals are now commonly performed in outpatient centers.

Last year 23 million procedures occurred in ambulatory surgery centers (source).  Just 3 or 4 decades ago, virtually all of these would have taken place in hospitals. Of course, childbirth and procedures like knee surgery have almost nothing in common, but the growth of outpatient care settings has provided regulatory frameworks, payment mechanisms, care coordination models, and growing recognition that community-based alternatives to hospitals can provide safe, efficient, patient-centered care. All of these shifts pave the way for expansion of birth centers.

5. Women want it.

Last but certainly not least, demand for birth center care is growing. According to the AABC, the number of centers in the United States has grown by 27% in just the past 3 years, accelerating a growth trend that has been seen for decades.  And this growth has happened while the overall birth rate has declined. From 2007-2010 the annual number of U.S. births decreased by 7.3% and the annual number of birth center births increased by 21.7%. We don’t know how many women want birth center care but don’t have the option available in their communities, or cannot afford it due to inadequate insurance coverage. (Stay tuned, results from Listening to Mothers III due out in May will provide some insight on these questions.)

Are you involved in birth centers? What do you see as the remaining obstacles for expanding access?

Filed in Blog, Clinicians, Consumers, Costs - Charges - Value, Hospitals and Health Systems, New Reports and Resources on Thu., Jan 31, 2013

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10 Responses to “5 reasons birth centers have met their moment”

  1. Jessica English, CD(DONA), LCCE, BDT(DONA) says:

    This is such an important study, it is one more step in moving toward meaningful change in our maternity care system. One thing that strikes me about the coverage of this study is that no one is discussing the fact that the birth centers included are led by both CNMs and CPMs. I am thrilled to see any opportunity for both types of midwives to be recognized for their high-quality care. I hope we will see only more collaboration and collegiality between CPMs and nurse midwives.

  2. Hello Jessica, Thank you for your comments. The National Birth Center Study II is being covered many media outlets today whose articles are promoting midwife-led birth centers, such as Time magazine, About.com and others. Our own article explaining the study, at birthcenters.org/research, makes it quite clear that this study is of midwife-led birth centers. I hope you will take the time to check out some of these other resources as well. We all bring different perspectives with the same goal–better care for mothers and babies. Thanks for all the work you with families and doulas.

  3. Jessica English says:

    Oh my comment was not at all a criticism of AABC! I have read and shared many of the media reports and your own reports from your site. I would just like to see more media coverage of the fact that both CPMs and CNMs were included, which I think is wonderful and very important part of this discussion. It’s good news!

  4. Jill Alliman, CNM, MSN says:

    As a birth center midwife for 27 years, I applaud your blog, Amy. This is a concise outline and description for building on the evidence in this new study to improve maternity care in the US.
    Although the two messages being emphasized today are that birth centers lower the risk of cesarean and other medical procedures, and save health care dollars, the message about midwifery-led care is central. This study included centers with both types of credentialled midwives as the primary providers of care: CNM’s and CPM’s. AABC is about supporting women’s rights to have high quality birth center care, and this study’s outcomes show why.

  5. Amy Romano Amy Romano says:

    Thanks to all of you for your thoughts. I believe birth centers have the outcomes they do not because of the physical space but because they are a vehicle for midwife-led, woman-centered care. The midwives who delivered the care in the birth centers, and the doctors and nurses who collaborated with those midwives when hospitalization was necessary, are absolutely to thank for the excellent outcomes in the NBCS II. I agree that we need more research to understand those care processes.

    I realize now that this post should have acknowledged CPM/CNM/CM/LM-led care more directly. I think birth centers are poised for major growth because of the trends I mentioned. But the growth won’t be sustained or successful if midwife-led care and physiologic birth don’t grow in prominence along with them.

  6. Thanks, Amy, for this great post about a very important article. I am of the opinion that the less frequently we use terms like CPM/CNM/CM/LM, and the more frequently we say “midwife,” the better. There are many paths to the kind of care that produces these stellar outcomes, but rather than highlight the differences, I think it’s best to use a term that we can all share. As you point out, birth centers are a space for the “bridge group” of providers who give midwife-led, woman-centered care to practice.

    My two cents,

  7. Victor Berman, MD (retired) says:

    I am thrilled to see the growth of birth centers. My wife, Salee Berman,CNM and I founded the first birth center in California and published our book, “The Birth Center” in the 1970s Our success and C-sec rate was similar to the new study. As most of you know, Salee died 5 years ago She would also have been thrilled with the increase in birth cenrters and the expanded role of midwives. I am apalled at the numbers of elective induction and elective C-sec that has become common today The active participation of midwivs was instrumental in our success.
    Vic Berman, MD

  8. Such interesting statistics and trending…as a former L & D nurse I always have second thoughts about Birthing Centers but I am coming to understand that so much progress has been made since I began practice in the 70′s to make this a totally viable option if the moms are carefully screened throughout pregnancy. I do think the c-section rate is too high and elective c-sections are way to high!

  9. Liz says:

    It is unfortunate that this study excludes data from most of the birth centers in the US.

    What kind of outcomes can we expect from the 248 known birth centers in the US? And do we know what inclusion criteria is or is not used by the majority of birth centers?

    I ask this because there are plenty of birth centers that openly advertise their acceptance of high-risk births: twins, breeches, VBAC. Some of these centers are licensed. Some are not. Many of these midwives are licensed. Can we say that the results of this most current study can be replicated with birth centers that do not adhere to strict risk-out criteria?

    I would be very surprised if that were the case.

  10. Susan Stapleton says:

    Your point is an excellent one, Liz. As we discussed in the study limitations, it is not possible to generalize these findings to all birth centers. What we know is that these excellent outcomes are achieved by birth centers adhering to the AABC Standards for Birth Centers. These Standards are evidence-based and have stood the test of time. We don’t know much about outcomes in birth centers that do not use these Standards to guide their practice.