1. Simpson, Kathleen Rice PhD, RNC, CNS-BC, FAAN

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On February 6, 2020, Birth Settings in America: Outcomes, Quality, Access, and Choice was released, the result of a multidisciplinary team committed to promoting safe, high-quality maternity and newborn care. A brief summary of types of birth setting is provided here; read the full report for in-depth coverage of multiple aspects of birth. We can do better for mothers and babies in the United States.


The vast majority of U.S. births occur in the hospital (98.4%). However, ~1% occur at home, ~.5% occur in freestanding birth centers, and these numbers, though small, are rising. One focus of the report was attempting to compare outcomes between settings. This was difficult, in part due to lack of data on birth certificates about intended place of birth. For example, ~30% of nulliparous women who choose home birth in the United States are transferred to the hospital to complete the process. A small number of women who intend to give birth at the hospital have rapid labor and birth at home before they can make it to the hospital. These types of births are misclassified as to intent for birth setting, making it a challenge to compare outcomes. Nevertheless, it appears that the relative and absolute risks of neonatal adverse outcomes of births in the home are twice that of births that occur in the hospital (absolute risks of about 1.2/1,000 vs. 0.6/1,000 for home and hospital, respectively). Proponents of home birth point to fewer interventions in the home, for example, epidurals, labor inductions, and cesareans. It is important to consider that interventions are not necessarily bad or harmful; they can be lifesaving in some cases, and very effective in relieving labor pain. Many women choose labor epidurals (75% in 2018) and to have induction of labor. Induction of labor is recommended at 41 weeks. Women who choose home birth are a self-selected highly motivated population who are hoping to avoid interventions. Because most home births are not covered by third-party payers, these women tend to be healthy White women who can afford to pay out-of-pocket. An important part of the process to select a birth setting is a careful risk assessment by a qualified healthcare professional and a thorough discussion with the woman to make sure she is aware of all options and potential maternal and fetal risks of each setting. Respect for the woman's choice, rather than what we think is best for them is critical.


Unique in the United States is three types of midwives with nationally recognized credentials: certified nurse midwives (CNMs), certified midwives (CMs), and certified professional midwives (CPMs), although other midwives who do not have one of these credentials also attend births. Most peer countries have one standardized pathway to midwifery.


Maternal mortality in the United States does not compare favorably to peer countries. Maternal mortality occurs disproportionately among Black, American Indian, and Alaskan Native women. In comparison, White, Hispanic, and Asian/Pacific Islander women have significantly lower rates of maternal death. There are many reasons for this disparity, among them the structural racism and biases experienced by many women and families. To achieve better outcomes, long-standing processes and institutions that reflect racism must be first addressed and eliminated. Gaps in knowledge are identified. Researchers will find the report helpful in proposing much-needed future research. It was a privilege to serve as part of the team.




National Academies of Sciences, Engineering, and Medicine. (2020). Birth settings in America: Outcomes, quality, access, and choice. Washington, DC: The National Academies Press. Retrieved from