Why Care in Community Birth Settings Works So Well for All Birthing People

Carol Sakala

Maternity care in "community birth" settings — both birth centers and planned home birth — is associated with lower rates of preterm and cesarean birth and higher breastfeeding rates compared to similar people with standard physician-led and hospital-based maternity care. These are among the favorable results listed in Improving Our Maternity Care Now Through Community Birth Settings. The report was developed in partnership with the American Association of Birth Centers, American College of Nurse-Midwives, Birth Center Equity, National Association of Certified Professional Midwives, and National Black Midwives Alliance. We conclude that these care settings are an essential part of the solution to the nation's maternal health crisis, especially when they offer culturally congruent care to people impacted by racism and other forms of discrimination.

It may feel counterintuitive for some that maternity care delivered in community birth settings can be so successful relative to standard maternal care when the midwives who lead it may have fewer years of education, the care settings lack many widely used obstetric technologies, and this care is far less costly. For example, an obstetrician interviewed for the Washington Post article about our new report expressed skepticism about how preterm birth rates in community birth settings could be reduced relative to standard care.

The answer is that the exemplary Midwives Model of Care can thrive in birth centers and planned home births. When prenatal and postpartum visits are not limited to 15 or so harried minutes and may last up to an hour, there is time to form a strong relationship, develop mutual respect and trust, educate, build confidence, and take preventive measures. This approach guards the space to understand and address concerns, including answering questions, allaying fears, addressing social needs, and creating a thoughtful birth plan.

A strong understanding of and respect for the innate abilities of birthing people and their fetuses and newborns for safe labor, birth, postpartum transitions, attachment, and breastfeeding lead to optimal care environments and practices and result in positive birth experiences. As with all health care, this model's success also depends on knowing and taking appropriate action when higher levels of care and other expertise are needed.

This model can also advance birth equity. For example, an analysis of participants in the federal multi-site Strong Start evaluation of birth center care found no differences by race in experience of care or in cesarean and breastfeeding rates. By contrast, there are deep inequities for each of these indicators among people with standard care. However, this model is especially powerful for mitigating the effects of racism and other harms when it involves culturally-congruent care led by people whose experiences, challenges, and sources of strength are similar to those of birthing families. Research demonstrates that such culturally congruent care, for example, the care offered by the Roots Community Birth Center in Minneapolis, provides additional benefits for people facing structural racism and other harmful social conditions. The new report includes case studies of the Strong Start program and the Roots Community Birth Center, showing impressive results relative to standard care.

So, the answer to the obstetrician's question is that the investment in high-quality maternity care that is relationship-based and individually tailored reduces stress and promotes health. This type of maternity care enables many who would have had preterm births (and other adverse outcomes) with standard care to have full-term births and other optimal outcomes through community birth care.

Increased access is especially urgent for birthing people of color who face disproportionately high rates of cesareans and other interventions, high rates of preterm birth and other adverse outcomes, and low breastfeeding rates. Birthing people's interest in these options greatly exceeds current access and use. The new report calls on federal and state policymakers and private sector leaders to implement many recommendations to eliminate existing barriers.

Back

Search the Blog