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Birth centers

Susan Stapleton, DNP, CNM, FACNM
Judith P Rooks, CNM, MPH, MSc
Section Editor
Susan M Ramin, MD
Deputy Editor
Kristen Eckler, MD, FACOG


The United States out-of-hospital (OOH) birth rate hovered around 1 percent during the 1970s, '80s, and '90s, but began to rise during 2008 [1], reaching 1.4 percent in 2013 [2]. Of slightly more than 56,000 OOH births that year, 64 percent were home births and 23 percent took place in free-standing birth centers [2]. For women thought to be at low risk for obstetric complications when they go into labor, entering labor care at a birth center can result in greater satisfaction, cost savings, and the same or better outcomes than in-hospital births [3].

This topic will provide a brief history of the development of birth centers in the United States and the evidence regarding the birth center model of care. Home birth is reviewed separately. (See "Planned home birth".)


For most of the 20th century, out-of-hospital births took place in the mother's home, maternity homes, clinics, or a birth room in a doctor's office. During the first half of that century, those sites served women who did not have access to, could not afford, or did not want the services of clinicians and acute care hospitals. During this era, the first American nurse-midwifery services were established to provide care for the poor, eg, the Frontier Nursing Service in Kentucky, the Maternity Center Association in New York City, and La Casita, operated by the Medical Mission Sisters in Santa Fe.

The proportion of births in hospitals rose from 37 percent in 1935 to 97 percent in 1960, and reached 99 percent by the 1970s [4]. Several developments after World War II led to this change: (1) The GI Bill broadened opportunities for medical education, which resulted in doubling of the number of medical schools and new physicians; (2) the Hill Burton Act promoted the construction of community hospitals, which improved access to hospital care; (3) hospitals offered methods of pain relief in labor that were unavailable in the home; and (4) the expansion of employer-based health insurance and the beginning of Medicaid paid for care for pregnant women but only for maternity services provided by clinicians and hospitals, not for out-of-hospital births.

As a result, birth moved from mostly in homes to mostly in hospitals and from care provided mostly by traditional midwives to care provided by clinicians. Since births in American hospitals were attended exclusively by clinicians assisted by nurses, nurse-midwifery did not develop in the United States as it had in other similarly developed countries. In contrast, midwifery had been well-established in Europe since the 1700s, and the movement of births from homes to hospitals was accompanied by the movement of midwives into hospitals.


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Literature review current through: Sep 2016. | This topic last updated: Feb 1, 2016.
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  1. MacDorman MF, Matthews TJ, Declercq E. Trends in out-of-hospital births in the United States, 1990-2012. NCHS Data Brief 2014; :1.
  2. Martin JA, Hamilton BE, Osterman MJ, et al. Births: final data for 2013. Natl Vital Stat Rep 2015; 64:1.
  3. Swartz W, Jackson D, Lang J, et al. The BirthPlace collaborative practice model: results from the San Diego Birth Center Study. Prim Care Update Ob Gyns 1998; 5:207.
  4. Rooks JP. Midwifery and Childbirth in America, Temple University Press, Philadelphia 1997. p.35.
  5. www.childbirthconnections.org. (Accessed on April 11, 2013).
  6. DeJong RN Jr, Shy KK, Carr KC. An out-of-hospital birth center using university referral. Obstet Gynecol 1981; 58:703.
  7. Rooks JP, Weatherby NL, Ernst EK, et al. Outcomes of care in birth centers. The National Birth Center Study. N Engl J Med 1989; 321:1804.
  8. Stapleton SR, Osborne C, Illuzzi J. Outcomes of care in birth centers: demonstration of a durable model. J Midwifery Womens Health 2013; 58:3.
  9. Blue Cross and Blue Shield of Greater New York. Maternity Center Association's Childbearing Center: 1976-1977 Cost Analysis. Health Affairs Research, New York 1978.
  10. Lieberman E, Ernst EK, Rooks JP, et al. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol 2004; 104:933.
  11. The Commission for the Accreditation of Birth Centers. Policy regarding vaginal birth after cesarean section in accredited birth centers. May 2010.
  12. The American Association of Birth Centers. VBAC Position Paper, January 2008. http://www.birthcenters.org/about-aabc/position-statements/vbac-study. (Accessed on April 04, 2012).
  13. Personal communication. Mike Civitello, Product Sales Manager. Porter Instrument Division, Parker Hannifin Corporatio, 245 Township Line Rd, Hatfield, PA 19440, USA.
  14. Lieberman E, O'donoghue C. Unintended effects of epidural analgesia during labor: a systematic review. Am J Obstet Gynecol 2002; 186:S31.
  15. Mayberry LJ, Clemmens D, De A. Epidural analgesia side effects, co-interventions, and care of women during childbirth: a systematic review. Am J Obstet Gynecol 2002; 186:S81.
  16. Viswanathan M, Hartmann K, Palmieri R, et al. The use of episiotomy in obstetrical care: a systematic review. Evid Rep Technol Assess (Summ) 2005; :1.
  17. Rooks JP, Weatherby NL, Ernst EK. The National Birth Center Study. Part III--Intrapartum and immediate postpartum and neonatal complications and transfers, postpartum and neonatal care, outcomes, and client satisfaction. J Nurse Midwifery 1992; 37:361.
  18. American Public Health Association. Guidelines for Licensing and Regulating Birth Centers. American Journal of Public Health 1983; 73.
  19. Commission for the Accreditation of Birth Centers 2012. http://www.birthcenteraccreditation.org/find-accredited-birth-centers/. (Accessed on March 23, 2012).
  20. Personal Communication, Kate Bauer, Executive Director, The American Association of Birth Centers, March 2015.
  21. Senjem R, Commission for the Accreditation of Birth Centers Executive Director, 2015, personal communication.
  22. American Association of Birth Centers. Uniform Data Set Data Registry 2010.
  23. Commission for the Accreditation of Birth Centers. Indicators for Compliance with Standards 2010.
  24. News, Birth 2007; 34:352.
  25. Rooks JP, Weatherby NL, Ernst EK. The National Birth Center Study. Part I--Methodology and prenatal care and referrals. J Nurse Midwifery 1992; 37:222.
  26. Rooks JP, Weatherby NL, Ernst EK. The National Birth Center Study. Part II--Intrapartum and immediate postpartum and neonatal care. J Nurse Midwifery 1992; 37:301.
  27. Sakala C, Corry MP. Evidence-Based Maternity Care: What It Is and What It Can Achieve. Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund. October 2008.
  28. Menacker F. Trends in cesarean rates for first births and repeat cesarean rates for low-risk women: United States, 1990-2003. Natl Vital Stat Rep 2005; 54:1.
  29. Birthplace in England Collaborative Group, Brocklehurst P, Hardy P, et al. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011; 343:d7400.
  30. Evers AC, Brouwers HA, Hukkelhoven CW, et al. Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study. BMJ 2010; 341:c5639.
  31. Mathews TJ, MacDorman MF. Infant mortality statistics from the 2007 period linked birth/infant death data set. Natl Vital Stat Rep 2011; 59:1.
  32. Pasupathy D, Wood AM, Pell JP, et al. Time of birth and risk of neonatal death at term: retrospective cohort study. BMJ 2010; 341:c3498.
  33. Begley C, Devane D, Clarke M, et al. Comparison of midwife-led and consultant-led care of healthy women at low risk of childbirth complications in the Republic of Ireland: a randomised trial. BMC Pregnancy Childbirth 2011; 11:85.
  34. Janssen PA, Saxell L, Page LA, et al. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 2009; 181:377.
  35. Alliman J, Phillippi J. Maternal outcomes in birth centers: An integrative review (in press). J Midwifery Womens Health 2016; 61.
  36. Reddy K, Reginald PW, Spring JE, et al. A free-standing low-risk maternity unit in the United Kingdom: does it have a role? J Obstet Gynaecol 2004; 24:360.
  37. David M, von Schwarzenfeld HK, Dimer JA, Kentenich H. Perinatal outcome in hospital and birth center obstetric care. Int J Gynaecol Obstet 1999; 65:149.
  38. Gottvall K, Grunewald C, Waldenström U. Safety of birth centre care: perinatal mortality over a 10-year period. BJOG 2004; 111:71.
  39. Schmidt N, Abelsen B, Øian P. Deliveries in maternity homes in Norway: results from a 2-year prospective study. Acta Obstet Gynecol Scand 2002; 81:731.
  40. Waldenström U, Nilsson CA, Winbladh B. The Stockholm birth centre trial: maternal and infant outcome. Br J Obstet Gynaecol 1997; 104:410.
  41. Waldenström U, Nilsson CA. Experience of childbirth in birth center care. A randomized controlled study. Acta Obstet Gynecol Scand 1994; 73:547.
  42. Morano S, Cerutti F, Mistrangelo E, et al. Outcomes of the first midwife-led birth centre in Italy: 5 years' experience. Arch Gynecol Obstet 2007; 276:333.
  43. Campos SE, Lana FC. [Results of childbirth care at a birthing center in Belo Horizonte, Minas Gerais, Brazil]. Cad Saude Publica 2007; 23:1349.
  44. Waldenström U, Nilsson CA. A randomized controlled study of birth center care versus standard maternity care: effects on women's health. Birth 1997; 24:17.
  45. Byrne JP, Crowther CA, Moss JR. A randomised controlled trial comparing birthing centre care with delivery suite care in Adelaide, Australia. Aust N Z J Obstet Gynaecol 2000; 40:268.
  46. Tracy SK, Dahlen H, Caplice S, et al. Birth centers in Australia: a national population-based study of perinatal mortality associated with giving birth in a birth center. Birth 2007; 34:194.
  47. Jackson DJ, Lang JM, Swartz WH, et al. Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care. Am J Public Health 2003; 93:999.
  48. Eakins PS. Free-standing birth centers in California. Program and medical outcome. J Reprod Med 1989; 34:960.
  49. Garite TJ, Snell BJ, Walker DL, Darrow VC. Development and experience of a university-based, freestanding birthing center. Obstet Gynecol 1995; 86:411.
  50. Snowden JM, Tilden EL, Snyder J, et al. Planned Out-of-Hospital Birth and Birth Outcomes. N Engl J Med 2015; 373:2642.
  51. Fullerton JT, Severino R. In-hospital care for low-risk childbirth. Comparison with results from the National Birth Center Study. J Nurse Midwifery 1992; 37:331.
  52. Bernitz S, Rolland R, Blix E, et al. Is the operative delivery rate in low-risk women dependent on the level of birth care? A randomised controlled trial. BJOG 2011; 118:1357.
  53. http://innovation.cms.gov/initiatives/strong-start/ (Accessed on June 30, 2015).
  54. Health Insurance Association of America. Research Bulletin: The Cost of Maternity care in the United States, Washington DC, 1989.
  55. American Association of Birth Centers. Birth Center Savings. Perkiomenville, PA 2010.