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Place of Birth Preferences and Relationship to Maternal and Newborn Outcomes Within the American Association of Birth Centers Perinatal Data Registry, 2007-2020

Jolles, Diana R. PhD, CNM; Montgomery, Tiffany M. PhD, MSHP, RNC-OB; Blankstein Breman, Rachel PhD, MPH, RN; George, Erin MSN, CNM; Craddock, Jaih PhD, MSW, MA; Sanders, Sarah MPH; Niemcyzk, Nancy PhD, CNM; Stapleton, Susan DNP, CNM; Bauer, Kate MBA; Wright, Jennifer MA

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The Journal of Perinatal & Neonatal Nursing: April/June 2022 - Volume 36 - Issue 2 - p 150-160
doi: 10.1097/JPN.0000000000000647
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For birthing people of low medical risk and those experiencing an uncomplicated pregnancy, avoidance of unnecessary cesarean birth,1 successful breastfeeding initiation,2,3 and self-reported experience of respectful care4,5 can significantly differ between hospitals and other places of birth. In addition, Black childbearing people face disproportionately higher rates of poor perinatal outcomes across the nation.6 They often experience increased perinatal morbidity and mortality compared with women from all other racial/ethnic groups, even when birthing in the same hospitals and controlling for medical risk and socioeconomic status.7 Race is a social construct, not a biological difference.8 Therefore, these disparities reflect historic and ongoing systemic racism, including lack of a racially and culturally representative healthcare workforce, and inequitable access to health insurance and options for care delivery models.9,10 The healthcare delivery system perpetuates and sustains the historic oppression of those who lack access to treatment options, care systems, and culturally congruent care, thereby driving poor outcomes.11–14

In 2020, the National Academies of Sciences, Engineering, and Medicine (NASEM) underscored the need to promote research about the birth center model of care, in part, to increase awareness about this type of birth setting and also to support informed decision-making about place of birth.15 Both the American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives (ACNM) have stated their commitment to the promotion of informed decision-making and autonomy in pregnancy and birth.16,17 In studies conducted outside of the United States, evidence suggests that accountability to client preferences about place of birth is directly linked to satisfaction with care.18,19 However, limited research focuses on informed decision-making and autonomy in perinatal health, with still less research about birth setting decision making in the United States.20–26

Research about birth centers—midwifery-led, low intervention perinatal care models—demonstrates the potential to create increased equity in perinatal health outcomes.27 In studies conducted within Medicaid's Strong Start Initiative, Black birthing people experienced significantly lower rates of cesarean birth, preterm birth, and low-birth-weight babies, and higher rates of breastfeeding initiation and duration, compared with national data of Black birthing people in risk-concordant cohorts.28,29 While the percentage of birth center births is small, the rate is growing and is estimated to be close to 400 nationwide.30 Since 2004, Black birthing people experienced a 76% increase in birth center and home births.31 However, the number of birth center locations varies widely across the United States, with the Pacific Northwest, Delaware, Pennsylvania, and New Hampshire reporting a rate of birth center births greater than 1%, whereas the majority of the Deep South and Midwest—in which nearly two-thirds of all Black US residents live32—have birth center birth rates of less than 0.16%.33

Adding to the systemic issues that perpetuate racial disparities in maternal health outcomes and regional disparities in birth setting,7,31 health insurance coverage for birth center care, particularly among state Medicaid plans, remains inconsistent, limiting access to birth centers for all people who may want to experience this care.34,35 The purpose of this study was to describe sociodemographic variations in client birthplace preference and the effect of birthplace on perinatal health outcomes among medically low-risk populations.


This study was a secondary analysis of the American Association of Birth Centers (AABC) Perinatal Data Registry (PDR) between 2007 and 2020. A convenience sample of all consenting childbearing people enrolled in care within 115 AABC PDR user sites nationwide was included in the analysis. Designed by an interprofessional team of perinatal quality leaders, there are 900 process and outcome variables within the perinatal data registry that have been tested for both validity and reliability.36

As a prospective data registry, compliant with the Agency for Healthcare Research and Quality (AHRQ) registry requirements,37 there are 5 touch points for researchers within the registry: onset of prenatal care, late third trimester, birth, immediate postpartum, and 6 weeks postpartum. The primary variable of interest for this study is choice of birthplace, which is tracked at the first prenatal visit, later third trimester, on admission to the birth site, and the place of birth. Antenatal attrition was analyzed and is defined as a change from intended birth location because of a change in preference or the development of a medical risk factor necessitating a transfer to a higher level of care.

Sociodemographic variables included in the study are years of education, body mass index (BMI), maternal age, gravidity, parity, marital status, and third-party payer. Core maternal clinical outcomes include mode of birth (vaginal or cesarean), induction of labor (including medically indicated and elective), utilization of epidural anesthesia in labor, and postpartum hemorrhage. Infant outcomes include birth weight in pounds, low birth weight (<5.5 lb), Apgar score of less than 7 at 5 minutes, and neonatal intensive care unit (NICU) admission. Attrition is tracked throughout the perinatal episode of care including antepartum, intrapartum, newborn, and postpartum.

Variables are stratified by race and ethnicity. Race is self-reported and collected using the National Vital Statistics Categories including American Indian, Asian, Black, Hawaiian/Pacific Islander, mixed, unknown, and White. Ethnicity is categorized as Hispanic or non-Hispanic. Race was a mandatory field within the data set, and there are no missing data. Ethnicity became mandatory for reporting in sociodemographic variables in 2012. As such, missing data are excluded from the descriptive frequency analysis. Bivariate categorical variables were formed (ie, Black and non-Black; Hispanic and non-Hispanic) to further explore the relationship between race, ethnicity, and core clinical outcomes. Race and ethnicity are not mutually exclusive. For this analysis, they are treated separately.

To examine variations in sociodemographic indicators and maternal and newborn clinical outcomes by intended place of birth, descriptive frequency analysis was conducted (see Table 1). There were 872 cases missing complete data for sociodemographic variables (eg, educational status, BMI, age, marital status, third-party payer), which were not mandatory throughout the study time frame; hence, these cases were excluded from the analysis.

Table 1. - Intended and actual birthplace by within race and ethnicity groups, American Association of Birth Centers Perinatal Data Registry, 2007-2020 (N = 173 195)
Birth center Hospital Total (N = 173 195)
Intendeda (n = 132 775) Admittedb (n = 110 799) Birthplacec (n = 95 296) Intendeda (n = 24 980) Admittedb (n = 54 208) Birthplace (n = 74 885)
Black 9 503 (66.1) 7 231 (50.3) 6 182 (43.0) 4 226 (29.4) 6 642 (46.2) 7 662 (53.3) 14 377 (8.3)
American Indian 745 (66.4) 613 (54.6) 504 (44.9) 309 (27.6) 463 (41.3) 570 (50.8) 1 123 (0.6)
Asian 2 524 (70.1) 2 088 (58.0) 1 724 (47.9) 893 (24.8) 1 343 (37.3) 1 714 (47.6) 3 601 (2.1)
Hawaiian/Pacific Islander 333 (74.4) 264 (59.0) 224 (50.0) 86 (19.3) 155 (34.8) 199 (44.5) 448 (0.3)
Mixed race 1 716 (81.2) 1 322 (63.6) 1 086 (51.4) 268 (12.7) 678 (32.1) 930 (44.0) 2 114 (1.2)
Undisclosed 5 002 (72.6) 4 037 (58.6) 3 348 (48.6) 1 722 (25.0) 2 638 (38.3) 3 360 (48.2) 6 890 (4.0)
White 100 373 (81.0) 85 007 (68.6) 73 607 (59.4) 16 109 (13.0) 32 342 (26.1) 48 866 (35.4) 123 918 (71.5)
Hispanic 12 579 (60.7) 10 237 (49.4) 8 621 (41.6) 7 367 (35.5) 9 947 (48.0) 11 584 (55.9) 20 724 (12.0)
aBirthplace intention at first prenatal visit.
bFirst place of admission regardless of birthplace.
cIncludes elective hospitalization and hospitalization for medical indications, including antepartum, preintrapartum, and intrapartum transfers of care.

Finally, a sample of medically low-risk childbearing people, eligible for community birth upon admission in labor, was used to explore clinical variations by race, parity, and admission site to inform the state of the science (see Table 2).

Table 2. - Sample qualified for admission to community birth setting, exclusion criteria medical risks and equivocal utilization exclusions
Medical history exclusions Current pregnancy exclusions Exclusion risk factors at onset of labor
Smoker, cervical abnormality, chronic hypertension, type II diabetes, heart disease class II-IV, HIV+, seizures requiring treatment, substance use, thrombophilia, thyroid disease requiring medication, uterine abnormality Antepartum transfer: Attrition medical, attrition nonmedical, unknown lost to follow up, antepartum medical referral
Procedures: Cerclage, fetal echocardiography, cervical length sonography, sonogragraphy for any trimester vaginal bleeding, external cephalic version
Medications: Antihypertensive, heparin, insulin, oral anticoagulation, oral hypoglycemic, progesterone, steroids for lunch maturity, antidepressant, thyroid replacement, tocolytics
Antepartum hospitalization: Abruption, anemia (severe), congenital anomaly, gestational hypertension, hyperemesis, infection current pregnancy, intrauterine fetal demise, intrauterine growth restriction or small for gestational age, macrosomia, malpresentation, maternal death, maternal intensive care admission, multiple gestation, nonreassuring fetal testing, post-term pregnancy (42+ wk), preeclampsia, HELLP syndrome, preterm birth 32-36 wk, very preterm birth, second-trimester bleeding, smoking, substance use, Rh sensitization, induction of labor, all indications
Preadmission referrals: Malpresentation, maternal fever, prolonged prodromal labor, meconium-stained amniotic fluid on admission, hypertension, nonreassuring fetal heart rate, term rupture of membranes no labor, unplanned out born
Equivocal pregnancy history exclusions
Previous caesarean delivery, intrauterine growth restriction, gestational hypertension, preeclampsia, very preterm birth <32 wk, preterm birth 32-36 wk, Rh sensitization
Equivocal medical history exclusions
Intrauterine fetal demise, neonatal death, shoulder dystocia, gestational diabetes, abruption, vaginal bleeding second trimester, <16 y old, body mass index <18 >35
Equivocal current pregnancy exclusions
Diet-controlled diabetes, beyond 41.1 wk' gestation, prelabor rupture of membranes preterm and at term

Nationally endorsed quality measures were explored including utilization of episiotomy, cesarean birth, and exclusive breastfeeding on discharge from birth facility. To further explore variations in clinical outcomes by race within the low-risk sample, researchers separated nulliparas and multiparas since they are known to have separate and distinct risks. Logistic regression was conducted to assess the odds of various clinical outcomes comparing various race and ethnicity categories with White non-Hispanic clinical outcomes within the sample. The subset of medically low-risk childbearing people qualified for birth center admission in labor but choosing hospital admission by preferences is placed within the regression model to assess hospital admission as a driver of clinical outcomes within medically low-risk populations.

The AABC PDR has been determined to be under exempt status with the New England Institutional Review Board. The research describes variations in birthplace preference by sociodemographic categories and subsequently explores the effect of place of admission (birth center or hospital) on clinical outcomes for medically low-risk childbearing people to inform the state of the science around shared decision-making.


Of the 173 195 pregnant people initiating prenatal care within the AABC PDR user sites, nearly three-fourths of the study participants identified as White non-Hispanic (n = 123 918; 71.5%). Most people reported an intention to give birth within the birth center setting upon first prenatal visit, with the highest percentage of intended community birth among mixed race (n = 1716; 81.2%) and White non-Hispanic (n = 100 373; 81.0%) people. Across all races and both ethnicity categories, childbearing people expressed a preference for hospital birth less than 30% of the time, except for the Hispanic community, which demonstrated a higher desire for intended hospital birth (n = 7367; 35.5%).

Antenatal attrition, changing from intended birth site either for medical risk factors or for preferences, was 24.8% across all race and ethnicity categories. Variations exist by race and ethnicity, with Black people having the highest attrition (n = 4845; 33.7%) and White non-Hispanic people having the lowest (n = 28 005; 22.6%). Transfer to the hospital, after admission in labor to the birth center (ie, for elective reasons including pain medication or medical indications such as hypertension or protracted labor), occurs at a rate of 14%, with fewer variations across racial and ethnic categories. Once admitted to the birth center in labor, Hispanic people demonstrated the lowest transfer to hospital rate (n = 2549; 12.3%) while mixed race people experience the highest intrapartum transfer rate (n = 424; 20.1%). Fewer variations in intrapartum transfer to the hospital occurred between Black (n = 1969; 13.7%), American Indian (n = 159; 14.2%), Asian (n = 572; 15.9%), and White non-Hispanic people (n = 17 472; 14.1%).

Compared with people preferring hospital birth at the first prenatal visit, those intending birth center birth had higher average years of education (15 vs 13.2 years), were slightly older (29.3 vs 27.7 years), and more often nulliparous (1 vs 1.3 pregnancies). People preferring birth center were more likely to have normal BMI (24.8 vs 27.7), less use of public insurance (28.2 vs 50.2), and higher rates of marriage (79.2% vs 54.5%), compared with those preferring hospital births. Those preferring hospital birth were more likely to be overweight or obese, publicly insured, and single.

Before controlling for medical risk factors, both maternal and newborn outcomes varied by a person's intended place of birth on admission to prenatal care. Those who intended to give birth at a birth center had notable differences in outcomes compared with those intending to give birth at a hospital: more vaginal births (91.9% vs 82.5%), less induction of labor (11.1% vs 19.6%), lower utilization of epidural anesthesia (11.1% vs 43.6%), higher exclusive breastfeeding at discharge (96.4% vs 74.7%), and higher exclusive breastfeeding at 6 weeks postpartum (80.6% vs 62.0%). People who intended birth center birth were more likely to have a newborn of normal birth weight, with a higher incidence of low birth weight among those planning hospital birth on admission to prenatal care (1.8% vs 4.2%). See Table 3 for more sociodemographic indicators and clinical outcomes.

Table 3. - Sociodemographic, maternal, and neonatal outcomes by intended place of birth on first prenatal visit, AABC UDS/PDR 2007-2020 (N = 172 323)
Birth center (n = 132 119) Home (n = 5 427) Hospital (n = 30 801) Undecided (n = 3 976) Total (N = 172 323)
Sociodemographic variables, mean
Education, y 15.0 13.7 13.2 14.0 14.6
BMI 24.8 24.6 27.7 25.7 25.2
Maternal age, y 29.3 30.2 27.7 28.4 29.0
Gravidity (total pregnancies) 2.4 3.5 2.8 2.6 2.5
Parity (pregnancies >20 wk) 1.0 2.0 1.3 1.0 1.1
Married, n (%) 104 638 (79.2) 4 808 (88.6) 16 786 (54.5) 2 544 (64.0) 129 561 (74.9)
Insurance, n (%)
Public insurance 37 257 (28.2) 955 (17.6) 15 426 (50.2) 1 709 (43.0) 55 526 (32.1)
Private insurance 76 100 (57.6) 2 420 (44.6) 11 026 (35.8) 1 737 (43.7) 91 678 (53.0)
Tricare 5 284 (4.0) 217 (4.0) 554 (1.8) 103 (2.6) 6 227 (3.6)
Self 16 911 (12.8) 1 920 (36.6) 2 864 (9.3) 473 (11.9) 22 314 (12.9)
Quality indicators, n (%)
Maternal outcomes
Vaginal birth 121 417 (91.9) 5 091 (93.8) 25 411 (82.5) 3 487 (87.7) 155 435 (90.2)
Cesarean birth 10 702 (8.1) 336 (6.2) 5 390 (17.5) 489 (12.3) 16 887 (9.8)
Induction 14 665 (11.1) 581 (10.7) 6 037 (19.6) 529 (13.3) 21 712 (12.6)
Epidural 17 572 (13.3) 315 (5.8) 13 429 (43.6) 1 451 (36.5) 32 569 (18.9)
Infant outcomes
Birth weight, lb, mean 7.7 7.9 7.5 7.6 7.7
Birth weight <5.5 lb, mean 1.8 2.0 4.2 3.7 2.3
Apgar score at <7 min, mean 1.1 1.7 1.6 1.7 1.2
Exclusive breast, n (%) 127 363 (96.4) 5 302 (97.7) 23 008 (74.7) 3 531 (88.8) 159 398 (92.5)
Exclusive breast—6 wk, n (%) 106 488 (80.6) 4 846 (89.3) 19 097 (62) 2 891 (72.7) 133 722 (77.6)
Abbreviations: AABC, American Association of Birth Centers; BMI, body mass index; PDR, Perinatal Data Registry; UDS, uniform data set.

Of all people initiating prenatal care, more than one-third met inclusion criteria for admission to community birth centers upon evaluation in labor at term and were not excluded on the basis of equivocal utilization factors (see Table 4; n = 70 927; 40.9%).

Table 4. - Within-group race and ethnicity, core clinical outcomes, elective hospitalization, and low medical risk sample
Black, n (%) Hispanic, n (%) White non-Hispanic, n (%) Other, n (%) Total, n (%)
All sample demographics 14 377 (8.3) 20 724 (12.0) 123 918 (71.5) 14 176 (8.2%) 173 195 (100)
Qualified for birth center admission (n = 70 927)
Low medical risk 4 376 (30.4) 7 513 (36.3) 53 832 (43.4) 5 206 (36.7) 70 927 (40.9)
Maternal outcomes
Epidural 757 (17.3) 1 367 (18.2) 5 167 (9.6) 70 (13.6) 8 014 (11.3)
Episiotomy 70 (1.6) 135 (1.8) 1 076 (2.0) 98 (1.9) 1 418 (2.0)
Cesarean birth 284 (6.5) 428 (5.7) 2 207 (4.1) 296 (5.7) 3 262 (4.6)
Neonatal outcomes
Low birth weight <5.5 101 (2.3) 82 (1.1) 322 (0.6) 62 (1.2) 567 (0.8)
Apgar score <7 at 5 min 26 (0.6) 60 (0.8) 484 (0.9) 41 (0.8) 567 (0.8)
Neonatal intensive care unit admission 48 (1.1) 82 (1.1) 699 (1.3) 46 (0.9) 851 (1.2)
Exclusive breastfeeding at discharge 3 964 (90.6) 6 603 (87.9) 52 593 (97.7) 4 878 (93.7) 68 018 (95.9)
Exclusive breastfeeding at 6 wk 3 150 (72.3) 5 056 (67.1) 45 380 (84.3) 4 045 (77.7) 57 734 (81.4)
Elective hospital admission (n = 9 419)
Admitted to hospital elective 1 113 (25.4) 2 205 (29.3) 5 186 (9.6) 915 (17.6) 9 419 (13.3)
Maternal outcomes
Epidural 508 (45.7) 1 014 (46.0) 2 006 (38.7) 338 (37.0) 3 861 (41.0)
Episiotomy 33 (3.0) 68 (3.1) 181 (3.5) 20 (2.2) 282 (3.2)
Cesarean birth 135 (12.2) 158 (7.2) 414 (8.0) 47 (5.2) 753 (8.1)
Neonatal outcomes
Low birth weight <5.5 42 (3.8) 41 (1.9) 72 (1.4) 30 (3.3) 188 (2.0)
Apgar score <7 at 5 min 12 (1.1) 17 (0.8) 51 (1.1) 6 (0.7) 94 (1.0)
Neonatal intensive care unit admission 5 (0.5) 11 (0.5) 36 (0.7) 3 (0.3) 565 (0.6)
Exclusive breastfeeding at discharge 791 (71.1) 1 470 (66.7) 4 755 (91.7) 704 (77.0) 7 704 (81.8)
Exclusive breastfeeding at 6 wk 652 (58.6) 1 142 (51.8) 3 848 (74.2) 584 (63.9) 6 244 (66.3)

Nearly one in 7 childbearing people who met criteria for community birth chose to be admitted to the hospital in the absence of medical indication (n = 9419; 13.3%). When examining the sample of all people who entered care and those who qualified for birth center admission, there were variations by race. Black people were coded less frequently within the medically low-risk category (30.4%) than White non-Hispanic people (43.4%).

The childbearing people giving birth within the AABC model of care exceeded national quality benchmarks for all reported measures and demonstrated population health. The primary cesarean birth rate was 4.6% within the low-risk sample across all race and ethnicity categories, with minimal variations noted. Similarly, newborn outcomes had few variations by race with low Apgar scores (<7 at 5 minutes; 0.8%), low rates of NICU admission (1.2%), and low rates of neonatal death (0.1%).

Within the medically low-risk sample, there were variations in both maternal and newborn outcomes by race and ethnicity. Black and Hispanic people utilized epidural anesthesia twice as much as White non-Hispanic people (17.3% and 18.3% vs 9.6%, respectively). Important variations exist within the neonatal outcomes for Black childbearing people, with a low birth weight that was 3.8 times higher than that of White non-Hispanic people (2.3% vs 0.6%). Similarly, medically low-risk Black and Hispanic people have rates of exclusive breastfeeding at discharge and 6 weeks postpartum that were one-third lower than their White non-Hispanic counterparts (72.3% and 67.1% vs 91.7%, respectively).

The people in this sample who chose hospital admission in labor, in the absence of medical indication, experienced poorer outcomes than those who elected for birth center admission. Cesarean birth is double for both Black and White non-Hispanic people who choose hospital admission in the absence of medical complication. Of note, epidural utilization in the total sample of low risk is 11.3% compared with 41.0% in the sample of people who elected to be hospitalized on admission in labor. People admitted to the hospital had lower NICU admissions than those admitted to birthing centers (0.6% vs 1.2%). Medically low-risk people who choose hospital as their preferred site of birth are less likely to choose exclusive breastfeeding, across all categories of race and ethnicity.

Finally, nulliparous Black, Hispanic, Asian, and Native Hawaiian/Pacific Islander people demonstrated significantly higher odds of cesarean birth than White non-Hispanic people in this sample (see Table 5).

Table 5. - Logistic regression race and ethnicity and core clinical indicators among medically low-risk childbearing people, qualified for birth center admission in labor, AABC PDR, 2007-2020 (N = 70 927)a
Race/Ethnicity Cesarean Episiotomy Epidural Breastfeedingb
Nullipara Multipara Nullipara Multipara Nullipara Multipara Nullipara Multipara
Black 1.296c [1.09-1.54] 1.454 [0.99-2.14] 0.528c [0.35-0.79] 1.414 [0.83-2.42] 1.083 [0.93-1.27] 1.010 [0.79-1.29] 0.544c [0.41-0.72] 0.516c [0.37-0.72]
Hispanic 1.495c [1.33-1.68] 0.883 [0.55-1.43] 0.934 [0.68-1.27] 1.092 [0.73-1.64] 1.365d [1.07-1.74] 1.000 [0.74-1.34] 0.454c [0.35-0.59] 0.418c [0.31-0.57]
American Indian 1.161 [0.75-1.80] 0.775 [0.17-3.62] 0.627 [0.21-1.88] 1.000 [1.00-1.00] 1.430 [0.87-2.35] 1.277 [0.37-4.37] 1.104 [0.50-2.44] 0.333c [0.17-0.65]
Asian 1.422c [1.13-1.78] 1.487 [0.79-2.80] 0.938 [0.68-1.30] 0.968 [0.45-2.06] 1.071 [0.87-1.32] 0.673 [0.32-1.41] 0.365c [0.24-0.56] 0.226c [0.09-0.55]
Native Hawaiian/Pacific Islander 2.115c [0.97-4.60] 0.842 [0.14-5.09] 1.033 [0.25-4.22] 1.000 [1.00-1.00] 1.458 [0.79-2.71] 0.402 [0.13-1.28] 0.725 [0.18-2.99] 0.599 [0.19-1.85]
Admission place—Hospital 1.974c [1.54-2.53] 5.019c [3.64-6.91] 1.983c [1.37-2.88] 2.947c [1.48-5.87] 6.936c [4.68-10.27] 31.582c [22.86-43.64] 0.212c [0.15-0.30] 0.105c [0.07-0.15]
Observations 29-406 38-929 26-692 38-223 21-930 27-943 24-599 32-954
Pseudo-R 2 0.03 0.07 0.03 0.03 0.11 0.32 0.14 0.27
Mean dependent 0.11 0.01 0.04 0.01 0.23 0.07 0.94 0.96
Abbreviations: AABC, American Association of Birth Centers; PDR, Perinatal Data Registry.
aThe values given are odds ratio [95% CI].
bExclusive breastfeeding on discharge from birth facility.
cP < .01.
dP < .05.

Of note, being admitted to a hospital in the absence of medical indication was an independent driver of cesarean birth for both nulliparous and multiparous people. Multiparas who chose to be admitted to the hospital in the absence of medical indication had an odds of cesarean birth 5 times greater than multiparas who elected for birth center admission (OR = 5.02; 95% CI, 3.64-6.91; P < .01). There were no significant variations by race and ethnicity for episiotomy, other than Black nulliparas experiencing significantly lower episiotomy rates (OR = 0.53; 95% CI, 0.35-0.79; P < .01). However, choosing to be admitted to the hospital in the absence of medical indication was an independent risk factor for experiencing an episiotomy. At a rate 3 times that of nulliparous people, multiparous people had the highest risk for episiotomy during birth (OR = 2.95; 95% CI, 1.48-5.87; P < .01). There were no variations in epidural utilization noted by race within the logistic regression. Hispanic nulliparas were 37% more likely to receive an epidural than White non-Hispanic people in this sample (OR = 1.37; 95% CI, 1.07-1.74; P < .05). Elective hospitalization was correlated to the largest relationship to epidural utilization, with both nulliparas and multiparas demonstrating significantly higher odds of epidural utilization (OR = 6.9 and 31.5, respectively).

People choosing to be admitted to the hospital in the absence of medical indication, regardless of race or ethnicity, were significantly less likely to be discharged exclusively on breastfeeding (P < .01). Exclusive breastfeeding on discharge from birth facility continued to demonstrate significantly lower rates within the logistic regression model across all race and ethnicity categories for both nulliparas and multiparas with few exceptions. American Indian nulliparas (OR = 1.10; 95% CI, 0.50-2.44; P < .01) and Native Hawaiian/Pacific Islander people (OR = 0.72; 95% CI, 0.18-2.99; P < .01) did not have significantly lower breastfeeding rates than White non-Hispanic people. The lowest odds of breastfeeding were demonstrated by elective hospitalization site of first admission for both nulliparas (OR = 0.212; 95% CI, 0.15-0.30; P < .01) and multiparas (OR = 0.11; 95% CI, 0.07-0.15; P < .01).


Childbearing people receiving care at AABC PDR user sites between 2007 and 2020 experienced high-quality outcomes across all race and ethnicity categories. The national quality indicators of cesarean birth, breastfeeding, normal birth weight, and exclusive breastfeeding exceeded nationally reported rates during the study time period for all sociodemographic categories that were explored.38,39 Variations in preferred place of birth were noted by both race and ethnicity. Based on the data controlling for medical risk factors and equivocal utilization criteria, place of admission in labor has an impact on maternal and newborn outcomes. Medically low-risk childbearing people across all sociodemographic categories had poorer outcomes when choosing to be admitted to the hospital setting in the absence of medical indication. These findings further the state of the science by supporting the option of community birth for childbearing populations of low medical risk, including exploration of unintentional harm associated with hospital admission in the absence of medical risk factors.

Racially and ethnically minoritized people were underrepresented within the sample of people utilizing birth centers compared with national reports of childbearing people by race and ethnicity.31 There is no biological foundation for race. It is a social construct8; yet, there are clear racial and ethnic disparities in birthplace preferences and perinatal outcomes within this sample. Higher cesarean birth, small for gestation age, and lower breastfeeding rates among minoritized people warrant further analysis. Inadequate access to the birth center model of care is a form of structural racism.12

New models of care are needed for minoritized childbearing people.40 Other forms of structural and systemic racism have been highlighted in the literature to drive poor health outcomes.41–45 Barriers to access within underserved communities have previously been researched and include structural barriers such as state licensing,46,47 midwifery climate scores,48 and private and public reimbursement policies.49–51 Based on the findings of this research, most childbearing people accessing the model intend community-based birth and at least half of the population is admitted to the birth center setting in labor. Expanding access to birth center model care is a pathway to improving health equity in the United States.27 More research is needed to understand the variation in utilization of the birth center model of care by minority populations and the relationship to access to the model.

Where people prefer to give birth is a preference that is based on the intersection of multiple social determinants of health. Like race and ethnicity, educational status, eating habits (BMI), family support structure, and public or private payer were all demonstrated to have a relationship to birthplace intentions and place of birth. When exploring clinical outcomes by intended place of birth, before controlling by medical risk factors, the people who intended hospital birth had poorer clinical outcomes, including increased antenatal attrition to higher levels of care. This finding supports the midwifery concept that pregnant people have the right to self-determination and that they are partners in the care process, capable of understanding underlying medical risk factors.4,52

This research furthers the state of the science on elective hospitalization in labor, demonstrating that healthy low-risk people experience poorer clinical outcomes when hospitalized for childbirth in the absence of medical complications.28 Variations in epidural utilization clearly drive preference for hospital birth and are a right for every community. Of note, less than half of people in the sample of those choosing hospital in the absence of medical indications gave birth with an epidural. It is unclear what drives people to prefer hospital birth in the absence of medical risk factors or for preference for anesthesia. Based on the results of the logistic regression, demonstrating independent effects from hospital admission, more research is warranted to ensure that evidence-based practice is being followed within the hospital setting, minimizing the risk of iatrogenic cesarean birth.1,28 These practices can include support for nonpharmacologic pain interventions, monitoring beliefs and attitudes about cesarean birth, and the overall use of recommendations from the ACOG regarding support for physiologic birth and patient preferences.53–55

The ideal maternity care system supports health and wellness and ensures that the care provided is matched to the client's specific preferences and needs. Previous research has demonstrated that the birth center model of care promotes this type of optimality.27,34,56 Using the foundations of shared decision-making, clients are honored for their preferences and drive care utilization. Clinicians and systems of care have the responsibility to understand what drives decision making and clarify any knowledge gaps or value conflicts, while ensuring access to care that accounts for client preferences.17


As the nation struggles with creating a safe healthcare system for birthing families, there is value in focusing the lens on healthy people of low medical risk. First, we can highlight wellness, resilience, and optimality, which are all important for population health. Second, the scientific findings guide us to understand where systems are broken. The findings that demonstrated increased harm to multiparous people in this study are important to consider. Previous research has shown that healthy, medically low-risk people are most vulnerable to iatrogenic harm.57 Upstream approaches that focus on the largest population of childbearing people who are healthy and at low medical risk are required to decrease the underuse of effective health promotion and disease prevention components of perinatal care. Examples include macro-level support for racially diverse midwifery-led care,58–61 doulas,62–64 and the enhanced wellness-based care provided by the birth center model.4,56 These underutilized and undervalued components of the current “Maternal Levels of Care” movement are essential starting points for all pregnant people, rather than optional entry points.27,65–68

The variations in clinical outcomes based on race and ethnicity within this sample also warrant future research. Variations in rates of antenatal transfer are important to analyze in an attempt to develop care models to address root causes of poor outcomes. In this analysis, clinician scholars can interrogate the current systems that may be supporting racial and ethnic maternal and neonatal outcome disparities. For example, is there evidence of life course trauma or systemic oppression in the indications for antenatal transfer? What is driving cesarean birth rates within minority populations? Are there variations for cesarean indicators by race and ethnicity? Are the systems of antenatal, intrapartum, and postpartum transfer integrated?69,70

The nursing and healthcare implications of this study are wide ranging. Ideally, childbearing people are given the option to select a birthplace to their liking and one that will meet their and their family's needs.26 Healthcare administrators, policy makers, and providers can align to support birthplaces with the best outcomes and determine what can be done to replicate those outcomes in other, less equitable birthplaces.


Although there is strength of this study in the number of participants included and the methods utilized, limitations exist. The AABC uniform data set/PDR user sites represent the midwifery-led model of care, which is not the most utilized model within the United States. Thus, there are concerns about the degree of sampling bias or self-selection among study participants, yet these are not calculations that can be generated. At this time, it is also not known what motivates childbearing people to choose the birth center practice as a site of care at the first prenatal visit. This researched focused on population health preferences for place of birth. Further research is needed to include preferences for mode of birth and preferences for infant feeding type, as these preferences were not explored within this research. Rather, mode of birth and infant feeding were used as outcome variables in this study. These unanswered questions limit the generalizability of the study outside of the context of the midwife-led practice models.


This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation. Future studies are needed for utilizing qualitative methods to help scholars and clinicians understand the reason birthing people prefer to give birth at one location over another, with further exploration of structural racism and root causes of clinical variations that are social and not biological. This study contributes to the growing body of literature that ideal maternal child health systems support communities in a system of integrated care that matches preferences and medical risk factors with evidence-based care.


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birthing center; birth equity; birth preferences; maternal outcomes; newborn outcomes

© 2022 The Authors. Published by Wolters Kluwer Health, Inc.