A Neonatologist’s View of birth centers and CABC accreditation
Thank you for this opportunity to discuss birth centers and accreditation. I am a neonatologist and associate professor of pediatrics at the University of Missouri – Kansas City, School of Medicine. I will limit my brief remarks to 3 points: safety, education, and accountability.
#1 – Safety –
I am a new member of the Commission for the Accreditation of Birth Centers (CABC). I was not invited to the CABC because I had expertise regarding birth centers. Rather, I was invited to the CABC precisely because I am a neonatologist. The CABC values a variety of perspectives to insure that CABC-accredited birth centers are doing all that they can to protect the wellbeing of newborns.
The protection of newborns in the context of birth centers begins with limiting care to only those mothers who are low risk. It continues with having systems in place for ongoing risk assessment throughout pregnancy, labor, and delivery. It includes having systems in place for referral, both emergent and non-emergent. And finally, it must always include being prepared for the unexpected.
During my 35 years working in neonatal intensive care units, I have received infants who were born out of the hospital and who became tragedies. But, I have seen similar tragedies following low risk births in hospital labor and delivery units. The medical literature describes this quantitatively. Large studies show that the neonatal mortality rate in low risk populations in developed countries is about 1 / 1000 births (this excludes infants with lethal congenital anomalies).
- In the Netherlands: 1.39/1000
- In the United States: 0.75/1000
- In Scotland: 0.5/1000
- In England: 1.78/1000
Small differences are based upon multiple variables, but there is striking similarity here. Some studies, including those in Ireland and in British Colombia, have compared outcomes when care was led by either a midwife or an obstetrician. In each instance, the midwife groups did the same or better.
We are fortunate to have more excellent data that is very specific to our own context. The American Association of Birth Centers has reviewed and published its experience with 22,000 women cared for at 79 birth centers over a four year period.
- The data collection methods were rigorous and support the high value placed upon quality assessment in the AABC group of birth centers.
- Moreover, each of the outcomes examined (screening, referrals, morbidity and mortality outcomes, etc.) either met or exceeded professional benchmarks.
- The cumulative neonatal mortality rate was 0.4 /1000, which is the lowest among the large studies of low risk populations.
Before we leave safety, I would like to mention one related subject: C-sections. In the low risk population that we have been discussing, the neonatal mortality rates have remained unchanged since the 1980’s. Meanwhile, in the same timeframe, C-section rates have risen from less than 10% to over 30%. Babies delivered by C-Section are more likely to be admitted to the neonatal ICU, thus this is a neonatal issue. Our obstetrical colleagues are try diligently to reduce the number of unnecessary C-sections and an interesting question has emerged.
“What happens to a low risk patient when they are cared for
in an environment that is designed for high risk patients?”
This leads to my next point.
#2 – Education –
As a physician on the CABC board, I am interested to learn about the successes of the birth center model and potentially bring some of those benefits back to our hospital model of care. In the hospital setting, our culture is focused on high risk patients and complex medical problems. We dedicate fewer resources to low risk patients. And we see the results. Studies show that:
- At the hospital we do a poor job at keeping mothers and babies together in the first hour of life.
- We are not as good as we need to be at supporting breast feeding.
- Our care is expensive.
So, there is an important opportunity for hospital based practitioners to learn from our colleagues at birth centers.
#3 – Accountability –
My third point follows from the data I have reviewed: AABC and CABC are doing a good job. They are:
- AABC is setting standards
- CABC is performing monitoring, evaluation, and quality assessment
Birth Centers that are accredited by CABC using the AABC Standards for Birth Centers and the CABC Indicators are:
- Demonstrating good clinical outcomes
- Reducing health care cost
- And attracting other birth centers to join them in their worthy efforts for babies, families, and communities.
In short, birth centers that are members of AABC and accredited by CABC are accountable.
I would be happy to answer questions.