In a throwback twist on birth trends, California is seeing a sustained increase in the number of women choosing to give birth in settings other than a hospital, a shift that has accelerated as the pandemic has created. riskier and more expensive conditions in many hospitals.
About 5,600 people gave birth outside a hospital in California in 2020, compared to about 4,600 in 2019 and 3,500 in 2010. The change occurred during a widespread ‘baby bust’, so the proportion births outside of hospitals fell from 0.68% in 2010 to 1.34% in 2020, according to a KHN analysis of provisional data from the California Department of Public Health. The proportion of births outside of hospitals remained relatively high – 1.28% – from January to July 2021.
From 2009 to 2019, the proportion of nationwide births outside of hospitals increased from 1.01% in 2009 to 1.56% in 2019. National data for 2020 and 2021 are not yet available.
Births outside of hospitals usually take place with the assistance of licensed midwives working in clients’ homes or in independent âbirth centersâ. Either way, expectant parents typically meet with midwives several times during pregnancy to get comfortable, express their hopes for the pregnancy, and learn about the birthing process.
Intentional home births and births in birthing centers run by midwives are generally limited to âlow riskâ pregnancies. Women who give birth in these settings generally do not have serious pre-existing health problems such as diabetes or high blood pressure that could complicate the birth of their babies; they give birth to a child – no twins or triplets; and they are not expected to undergo a breech birth, in which the baby emerges with the feet first, said Erina Angelucci, a certified nurse midwife at the Best Start Birth Center in San Diego.
Midwives interviewed said they have heard many more women in recent years turning to home births to avoid epidurals, induced labor and other invasive procedures common in hospital delivery rooms.
âI think people are looking to be more independent during childbirth and less to ‘put up with whatever is going on’,â said Shari Stone-Ulrich, certified nurse midwife and clinical director of midwifery services at Best start.
Many people want to avoid Caesarean sections unless it is absolutely necessary, several midwives have said. About 30% of births in California hospitals last year were by caesarean section, although that number has declined in recent years, according to state data.
âFor first-time mothers, Caesarean sections in hospitals are very high,â Miriam Singer, 32, who gave birth to her son, Eitan, told Best Start a few weeks ago. âSo knowing that the birthing center is going to work with you and understand that it will be a longer process and just make sure that everything is going well, you are really minimizing your chances of having a caesarean or an emergency. “
The singer has three older children, aged 4, 6 and 9. Three of her children were born in an independent birth center and one was born at home.
âBirth is just a very natural part of life, and it should be approached as something natural, and we should follow our body and listen to our body throughout the process,â she said. “I find the approach in hospitals perhaps a little more like an emergency.”
As the coronavirus swept across California, families sought births outside of hospitals for other reasons. Some did not want to give birth in a setting where they feared contracting covid-19. Others bristled with rules restricting the presence of partners and family members during labor.
âHome birthing practices were immediately filled to capacity,â said Kaleem Joy, a certified professional midwife and clinical director of the California Birth Center in Rocklin. More recently, when some local hospitals announced that they would be restricting visitors again, “we went from six to 10 calls a week toâ¦ I think we got a hundred a day,” Joy added.
State health data shows positive results for the vast majority of out-of-hospital births. However, these figures do not take into account the fact that complicated and risky deliveries are, when possible, transferred to hospital.
A 2015 study in the New England Journal of Medicine found that planned out-of-hospital births in Oregon were associated with higher rates of perinatal deaths and newborn seizures than in-hospital births, although such results are rare in both cases. On the flip side, the study also found that births planned outside the hospital more often resulted in unassisted vaginal deliveries and lower rates of obstetric interventions.
Out-of-hospital birth rates varied widely between urban and rural California counties. These births were most common in Nevada County, a rustic community in the northern state known for its bohemian enclaves and passionate homeschooling movement. About 1 in 10 mothers gave birth at home last year in Nevada County. Four other predominantly rural counties in Northern California also recorded particularly high rates: Tuolumne (6.8%), Mendocino (6.6%), Shasta (5.4%) and Humboldt (5.3%).
Among the most populous counties with at least 2,500 births in 2020, the highest rates of out-of-hospital births were recorded in Sonoma (3.6%), Placer (2.9%) and Santa Barbara (2, 1%). Rates were lowest in the largely agricultural Central Valley, particularly in Tulare, Merced, Solano, Fresno, San Joaquin and Kern counties.
The analysis also found racial and educational disparities between those giving birth in a hospital and those giving birth at home or in a free-standing birthing center last year.
White women gave birth outside of hospitals at a rate twice that of African Americans, about four times that of Hispanics, and about six times that of Asians. In addition, people with a four-year college degree gave birth outside hospitals at a rate nearly three times that of people without a four-year degree, according to state figures.
These numbers likely reflect long-standing socio-economic disparities in health care that are exacerbated by the reluctance of some insurance companies to cover births outside of a hospital, said Katherine Hemple, legislative consultant for California. Association of Licensed Midwives.
Additionally, Medi-Cal, the public insurance program for low-income Californians, typically does not cover home births, a policy that is the subject of intense debate. The program is more likely to cover deliveries in birthing centers run by midwives.
A customer paying cash for a delivery to the California Birth Center or the Best Start Birth Center will be billed about $ 8,000, officials at those facilities said. For comparison, the average cost of out-of-pocket expenses for families with employer insurance giving birth in a hospital was around $ 4,500, according to a 2020 study published in the journal Health Affairs.
Rosanna Davis, a certified professional midwife and chairman of the board of the California Association of Licensed Midwives, said the preference for out-of-hospital births would increase even faster if the state and insurance companies offered support more important financial.
âThere are a significant number of people who would choose midwifery care,â she said, âbut access is limitedâ.
Phillip Reese is a data communications specialist and assistant professor of journalism at California State University-Sacramento.
This story was produced by KHN, which publishes California Healthline, an independent editorial service of the California Health Care Foundation.
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