Effect of Birth Center Care on Clinical and Cost Outcomes

High rates of cesarean birth are a significant health care quality issue and freestanding birth centers have shown potential to reduce rates of cesarean birth. Measuring this potential is complicated by lack of randomized trials and limited observational comparisons. Cesarean rates vary by provider type, setting, clinical and nonclinical characteristics of women, but our understanding of these dynamics is incomplete. We sought to isolate labor setting from other risk factors in order to assess the effect of birth centers on the odds of cesarean birth. We generated two low risk cohorts admitted in labor to hospitals (N= 2527) and birth centers (N= 8776) using secondary data obtained from the American Association of Birth Centers (AABC). All women received some portion of prenatal care in the birth center and received midwifery care in labor. Some women had the option of giving birth in the hospital or the birth center and chose to labor in the hospital. Analysis was intent to treat according to site of admission in spontaneous labor. We used propensity score adjustment and multivariable logistic regression to control for cohort differences and measured effect sizes associated with setting. We found 32% to 38% decreased odds of cesarean in the birth center cohort and a remarkably low overall cesarean rate of less than 5% in both cohorts. Our findings suggest that low rates of cesarean in birth centers are not attributable to clinical status alone. Furthermore, the low cesarean rates seen in birth centers are partly transferable to hospitals. The entire birth center care model including prenatal preparation, and relationship based midwifery care should be studied, promoted and implemented by policy makers interested in achieving appropriate cesarean rates in the U.S.