 Welcome, then, Susan Stapleton, who has been the director of the Reading Birth and Women's Center in Pennsylvania for 25 years with a particular interest in birth centers. And she's the primary investigator for the study which we're about to hear about. So Susan, over to you. OK, thank you. Well, welcome, everyone, and thank you for having me. So I'm going to talk a little bit about a study that was recently published in the journals and The Lifting Living Health. I was the primary author. Tara Osburn was also a co-investigator and would like to express her regrets for being unable to be there. She is ill this morning, this afternoon. So I'd like to talk a little bit about, but this was a study of US birth centers. I'd like to talk a little bit about the infrastructure for US birth centers. The American Association of Birth Centers has published the standards for birth centers. And these are actually the only national standards in the United States that are peculiar to birth centers. The commission for the accreditation of birth centers is in place. And so there is a mechanism for birth centers to become accredited and to demonstrate their level of quality in their care and in their operations. And 41 of the 50 states have licensure, either a birth center or some other sort of facilities such as a native or a care center or a maternity center. There are various designations. Birth center staff have, at my standards and by practice, have equipment and training to manage common complications. And I'll talk a little bit later about some of the complications that were actually managed in the birth center without requiring transfer to a hospital. However, all birth centers have a system in the United States have a system, or by standards have a system, to provide access to a few care services and hospital care and obstetrician care if needed. And how that system looks can vary from one birth center to another. The design of our study, the objective was to describe current outcomes for birth centers in the United States. The most, there was a study published, the first national birth center study was published in 1989 in the New England Journal of Medicine. And that was sort of a landmark study of birth center care. However, there have been no large studies since that time. So that's, we wanted to see if things had changed in birth center care during that time. It was a prospective cohort study at birth in the 79 Midwifery-led birth centers in 33 US states from 2007 to 2010. We started out with 20,000, just over 20,000 women who were planning to give birth in the birth center when they registered for care. OK, Linda, I'm having trouble advancing the slides. OK, there we go, sorry. Our data collection was on provider-collected data. And it was done using the American Association of Birth Centers' uniform data set, which is now called the Prenatal Data Registry. It is an online data registry that includes both process and outcomes of care. It's based on the Midwifery model of care. So it collects the usual obstetrical variables, but also collects many variables that are not included in a common list of obstetrical variables. So information about use of herbs and omiotaphyx, and information about ambulation and labor and non-pharmacolastic modes of PNDB from labor and that sort of thing. The care is entered prospectively, meaning that it's entered immediately after the Prenatal visit. The client is registered in the registry. And then the data are collected continuously as she does through her pregnancy, all the way through to the final post-artum visit. There are about 189 variables. And currently, the registry contains over 65,000 episodes of care. In general, the eligibility to give birth in a birth center are a single-term pregnancy, a birth text presentation, a full-term pregnancy, and in general, no medical or obstetric risk factors that would preclude a normal vaginal birth or that would require interventions such as continuous electronic fetal monitoring or induction of labor. Both of those interventions are not allowed in birth centers and are not generally done, according to the standards, and are not generally done in birth centers. There are women, of course, the left care who had planned to give birth in the birth center during the pregnancy. So there was attrition to some of them, lost pregnancies. Some of them moved out of the area, changed providers, changed their mind, and decided not to have an out-of-hospital birth, various reasons for that. And then there is about 13% of women who left care during the pregnancy or did not need the criteria to be eligible for a birth center birth at the onset of labor. So it seems like twin-testation, preeclampsia, the most common, actually, is post-date pregnancy, later than 42 weeks, pre-vapor rupture of membrane, membrane, speech and labor, those kinds of things. So those women were transferred out either out of birth center care and may have delivered to mid-life at the hospital, but were not eligible to the labor at the birth center. About a third of the births in the study were funded by federal or state government programs, so Medicaid, Medicare, CHIP. And the demographics, this is a pretty homogenous group. 75% were non-Hispanic white, 80% were married, and 52% were cause-educated. So this is, in general, socially economically at least a very low risk group of women, as is intended for birth center care. The primary care providers in the birth centers, 80%, of the primary care providers were certified in mid-life. 14% were either CTMs or licensed mid-lives, CTMs or mid-lives who were licensed in their particular jurisdiction. And 6% were teams of certified nurse mid-lives and certified professional mid-lives working together. Credentialing for the facilities, 50% were, or 50, 63% were accredited by the commission for the accreditation of birth centers. 37% were not accredited by anyone. A couple of the CABC accredited birth centers were also accredited by joint commission, which primarily credits hospitals in the United States. All the birth centers in the study were licensed, except for two, and states where licensure was unavailable. General outcomes, 84% of the women who entered labor planning to get birth at the birth center did so. And I think I left that off the slide, but there were 18,574 women who were eligible for care at the birth center when labor started. 93% had a normal decimal birth, 1% had an assisted decimal birth, and 6% had a caesarean birth. These numbers include, the last three numbers include the women who were transferred to the hospital, as well as the women who gave birth at the birth center. Transfers in labor, a little, about 4.5% were actually referred to the hospital in labor prior to admission to the birth center. We call these pre-admission IP transfers. Most of these were the kinds of things requiring the sort of transfer were brief presentations that had not been identified prior to the onset of labor. The most common one was term rupture of labor, rupture of membranes without onset of labor. And then 12% of the women who were admitted, 12% of women were referred to the hospital in labor after they had been admitted to the birth center. And the most common reason is here, for this kind of referral, was failure for breast and labor or abnormal or prolonged labor. Primarily, first stage of labor, more common than second stage labor. And this was obviously much more common in prima gravitas than in women who had had to abuse before and will purpose women. 94% of the transfers to the hospital were non-emergencies, again mostly for prolonged labor. So these women got in the car, drove to the hospital, and had tuition augmentation of labor once they got there. Fewer than 1% of the transfers, actually 140, required emergency transfers. The most common reason for emergency transfer in labor were non-referring fetal heart rate patterns that were heard on intermittent auscultation. Since prisoners do not do continuous electronic fetal monitoring, if the midwives hear variable decelerations or any kind of concerning heart rate pattern when they're auscultating with a handheld Doppler, they transfer to the hospital for continuous electronic monitoring, very manageable at the site. Transfers after birth, 2% of women were transferred after giving birth, and 0.4% of those were emergency transfers. The most common reason for emergency transfer, for transfers in general, and for emergency transfers, postpartum, were retained postpartum and postpartum hemorrhage. About 93% of the postpartum hemorrhages were managed after birth center without the need for transfer to the hospital. 2.2% of infants were transferred after birth at the birth center. 0.6% of those were emergencies. So the most common reason, again, both for a non-emergency and emergency neonatal transfer, were or was respiratory issues ranging from mild to shanty tachypnea all the way up to significant respiratory distress. There were no maternal deaths in the sample. Fetal and newborn mortality rates were low, and were comparable to low risk births in the hospital. That's a difficult comparison to make because it's sometimes hard to find cohorts that are comparable to the birth center sample. And so we use midwifery hospital births around the world, and some low risk obstetrician births as well. Last time, 1%, 0.47% was the stillbirth rate. So that's 0.47 per 1,000 women. And 0.40 newborn deaths or neonatal deaths per 1,000 women. So again, comparable to those found in studies of similar low risk births in the hospital. So about 84% of the women who planned to get birth in the birth center actually did so. Fewer than 1 in 16 had a cistern birth. And although this was not a cost study, we did look at the potential cost savings of this sample. And we estimated that there was a cost savings of possibly greater than $30 million just in facility services for these 15,570 births. That's something that needs more study. And but it's certainly an impressive figure in a time when the United States and other countries as well are really concerned about escalating health care costs. The most significant take home point for us, some of my slides are now upside down, the most significant take home point for us was that in over two decades of a time when there was increasing intervention in Congress in the United States, in every way, increasing use of the infection, increasing use of electronic field monitoring, increasing use of epidural, practically every intervention. With no particular improvement in outcomes and in some cases, worse outcomes. The birth and outcomes have remained remarkably consistent. Birth centers in the United States seem to be doing the same thing that they were doing in 1989 when the first study was published. And seem to be doing it with the same good outcomes that they were doing at that time. So that is the end of my presentation. I'll be happy to address some of the questions that I see popping up over here. Yes, have you noticed the questions as they've gone by? Or shall we retap a little bit? I think the first question was regarding B-backs and whether or not C-backs were allowed within the birth centers. They are. Obviously, birth centers that are not accredited, and it would be dependent upon any state regulations that govern either birth centers or midwifery practice in the jurisdiction. But for accredited birth centers, the C-A-B-C, I can't remember the exact year, but actually revised their position and does allow the two C-backs in accredited birth centers. And some birth and birth centers may request approval from the C-A-B-C to do primary B-backs as well. And there are specific criteria for those, for example, being within some reasonable distance of a hospital that has 24 step in the anesthesia and obstetrical coverage in-house, and having a collaborative physician who is willing to accept those transfers and that sort of thing. So there was a time period, and actually in our study, we don't have very many B-backs because the data were primarily collected in a time where at least the beginning of our study period, B-backs were not allowed in the accredited birth centers. And most births, the majority of birth centers actually did not attend B-backs. However, since that time, more and more birth centers in the United States have started attending B-backs in the birth centers. Thank you very much. I think there was another question. But if anybody has any questions, would they perhaps like to pop them in the chat box because we've got plenty of time for discussion? There was another question from Diane who said that certain things were not allowed. And her question was, would women be supported if they did not fit the criteria, but wanted to have their birth outside of hospitals, I'm guessing? It depends a great deal on the birth center. Obviously, accredited birth centers have specific criteria that they are mandated to follow. And many of the states in which there are midwifery or birth center regulations also have mandated criteria. And that varies widely in the United States, from one state to another. In general, I would say it depends. Some of the birth criteria are softer, if you want to use the term, than others. So for example, brief events when in general and accredited birth centers, well, not in general, in accredited birth centers, those procedures, those births are not allowed. And the birth centers, there are no accredited birth centers at least that we're aware of that are attending brief events when in the birth center. And non-accredited birth centers, again, it depends completely on the state licensure. In many of the birth centers in the United States, the midwives also have hospital privileges. And so some of the things that are not allowed in the birth center, the midwives can continue providing care at the hospital, either independently or collaboratively with their collaborative physicians. So for example, people who need induction of labor for post-states or ruptured membranes at term without labor, preeclampsia, those kinds of things, those can be done, those births can be attended by the midwives if they have hospital privileges. They simply can't have to go to the hospital instead of being allowed to deliver at the birth center. So if a woman was wanting to, who did not fit the criteria, wanted to have her birth outside of a hospital preferably in a birth center, would she therefore, and she was refused, would she then give birth at home, what would happen? That varies. Again, a great deal, and there are no specific rules about that. Certainly some of those women do give birth at home with other midwives who have different risk criteria. In some states, birth centers are regulated more frequently than home birth. And so there may be criteria that would not allow a birth center birth that would not be included in the regulations for home birth. So that's a great deal from one state to another in the United States. In general, the midwives try to communicate with the mother, talk about the risks and benefits of being in one place over the other, explain why they prefer not to do or do not do a particular procedure. So it's difficult for a type of birth in the birth center and hope to come to some compromise. But the bottom line is that certain things, if for a credit, are simply not allowed yet. It is a difficult situation, one that birth center midwives struggle with all the time. So I see there's, and I may be going out of order, Linda, if I am, tell me. But I see there's a question, how do you feel about a birth center open to buy an OB and supervised by that OB for the purpose of midlifery model of care, but that has all the modern OB conveniences, which implies that a C-section will be performed? From my perspective and from the perspective of the American Association of Birth Centers, that's a maternity hospital and not a birth center. Birth centers are designed for low risk birth, which certainly would be hard to make the case that a C-section is a low risk birth. So there are places calling themselves birth centers like that, but our position would be that those are not merely birth centers. Those are something else, many hospitals, maternity birth centers, but not birth centers. What we know about birth centers, what we know about their safety and about their outcomes over all of these years is that those outcomes are achieved following specific criteria and caring only for low risk women and avoiding interventions that make women into high risk women, so epidurals, ketosin, inductions, and augmentations. Those things are procedures that increase the risk of various and specific complications. And so, need to be in the hospital. And birth centers are not allowed to do any of those things. Now, I'm certainly aware, as the person who asks that question, there are birth centers too. And most of them are started by physicians or physicians who don't really quite either understand or buy into the midwifery model care or the birth center model. And so they have various reasons for opening these facilities. But in fact, we don't really know very much about the outcomes in those facilities. We don't know whether those things are safe. And we do know that the model that I'm talking about and the model in this study, and in the 1989 study, we know a lot about the safety using those criteria. And the other side of that coin, I guess, is hospital labor delivery units, which are truly acute care facilities calling themselves birth centers. A few states have birth center regulations that prohibit that, but they don't really enforce it very much, very stringently as a rule. And so for consumers and childbirth families, it can be very difficult to know what you're talking about when you say birth center. Is it this place like the one, like the places that I'm talking about in the study and that I'm going to be putting on the study, is it the obstetrician facility who sort of takes the medical model and moves it outside the hospital, is it the acute care service inside labor and delivery with oak furniture. It can be very difficult for consumers to know what that means so that they can make informed choices. And I see another question that says, can women in birth and accredited birth centers go past 42 weeks? That's not one of those sort of hard and fast risk criteria. We recommend that 42 weeks be used as a cutoff for birth center birth. And the primary reason for that risk criteria came from the 1989 study, which found quite a significant difference in adverse outcomes among the women who were past 42 weeks. However, that was in 1989. And when those data were collected, the test of fetal surveillance testing was not nearly as accurately reliable, or even as common as it is now. So most birth centers that are accredited or most birth centers have some cutoff. And 42 weeks is a common one. Some use 41, because as many of you probably know, pregnancies are getting shorter in the United States. And 41 has become the new post-state cutoff in many areas. I would say the majority of birth centers still use 42. But if you have a mother, for example, who has uncertain dating, or who is 42 weeks and has very reassuring fetal testing, then birth centers will often consult with the collaborative physician, review the case, and make a decision to, and of course with the mother, and make a decision to continue the surveillance and in the hopes that spontaneous labor will be done. So that's one of those first thoughts, this criteria that we talked about with birth centers. But there's a fair amount of leeway. Again, unless specific state regulations for either midwifery or for birth centers dictate otherwise, which sometimes they do. OK, Susan, I've been dripping in and out. Had a bit of difficulty staying here. I thought you were gone. I missed that last question. Have we answered the question that was asked by Geraldine about the transfer rate being so low? No, I didn't see that one. What she said was that the transfer rate was quite low. So did you allow people in the birth centers that were having their first baby? And that was allied to my thoughts because we have a lot of birth centers and similar things in the UK. And one of the biggest reasons why those who have their first baby transfer out is because of their desire to have an epidural, which, of course, the birth center doesn't give. So we have a lot more transfers for reason of analgesia. Where do you stand in that? There are no, most birth centers, I don't know of any birth centers, who prohibit primate gravitas. None of them do epidurals. Well, it's up maybe that one obstetrician place that we were talking about before. They use a lot. What we find is that they use the average, when we looked at the data on the use of non-pharmacologic pain relief and labor, the average woman in labor used five different methods of pain relief. The most common one and the one that people probably use the most and feel has the most effect is the immersion of water in labor. The sample included slightly more, and I don't have this study in front of me, so I may be wrong in this, but I think there were slightly more primate gravitas than multigravitas in the sample, if I remember correctly. There was not, if there was a difference, it wasn't much. So these transfer rates include the primate gravitas, who obviously transfer more often. The desire for an epidural is actually not one of the more common reasons for transferring labor. It is a reason, but it wasn't particularly common. And that may be because the birth centers are doing a really good job of using other means of pain relief, or it's more likely it's that those women who know or suspect that they are going to want an epidural in labor risk themselves out by choosing to have a hospital birth in the first place. And certainly most birth centers in which the midwives have hospital privileges and in which they attend planned hospital births find that their overall number of hospital, the proportion of hospital births, planned hospital births to planned birth center births, tends to sort of creep up over the years. Thank you. There's a few more questions in the chat box. Would you like to choose one that you would like to answer yourself? Well, and I just have a comment about nitrous, which reminded me of what Elsa is going to say and answer to the previous question. There are, as far as I know, only two birth centers in the United States which are using nitrous oxide, ALDH, and labor. It's growing, and as those of you from many other countries know, nitrous can be really useful in labor. And unfortunately, the United States is sort of behind the curve in terms of the use of nitrous. However, that's changing slowly. And more and more birth centers are looking into the use of nitrous as it's another option that they can offer to women in labor. So our studies included no women who were using nitrous or no birth centers who were using nitrous oxide in labor. So I see a question from Center about birth centers that care primarily for poorer populations. This is a very, this sample is certainly not a group of low socioeconomic women. And therefore, you would expect, and as a result, the risk factors were many of the psychosocial risk factors that you would see in that population did not occur in this population. There are really only a small number of birth centers in the United States that are caring for this poorer population in terms of the demographics, lower education, more racial variation, lower socioeconomic status in general. Their outcomes, interestingly enough, the individual outcomes in those birth centers have really not any different from the outcomes that we find overall. The number of those clients in our sample is obviously really small. You can't see a whole lot about it, but if you look at the individual statistics of those birth centers, they're really very similar. Their transfer rates are very similar. Their mortality rates, their rates of serious morbidity are very similar. So it's interesting that birth centers can achieve this. Well, actually, the American Association of Birth Centers has actually just received a federal grant to, and we will be looking only at Medicaid recipients, women who are Medicaid recipients, who have this factor for pre-term birth. So it will be interesting to see what we find in that. It's called the Sponsor Grant. It will be interesting to see what we find compared to the sample in the studies that I presented today. There was also a question about the rate of water birth. What your water birth rate was. You know that? What it is? I don't know off the top of my head. I think we actually have a couple of my colleagues who are actually in the process of just analyzed a lot of birth data from the sample and are in the process of writing that up and submitting it. So that will be out, but I don't know when. It was, I don't remember the percent. It was relatively low. While most birth centers use immersion in water and labor for pain relief, the number of women who actually get birth in the water is the less. Interestingly, the finding when they did their data analysis on the water birth in the sample, they found that the water birth had a lower incidence of adverse outcomes. But we did not take to mean that water birth is safer than birth on land. We took it to mean that the middleizer is probably doing a pretty good job of getting people out of the water when there are risk factors that would increase their risk for adverse outcomes. But I don't have any specific water birth data from this study. But we don't have any, based on this preliminary analysis, that my colleagues have done. It will be as good or maybe better than sending outcomes in this study to see if there are other questions that we haven't talked about. I see a question from Catherine. Does the woman in the midlife sign a contract as the beginning of caroling out responsibilities of each? All birth centers, or the birth centers that I'm familiar, have lots of consent forms and mostly, more specifically, a general consent form that actually, and these birth centers are accredited birth centers are required to do this sort of informed consent. So they go through what kinds of things can be done in the birth center, what kinds of things cannot be done in the birth center, what kinds of things will require transfer, what's the responsibilities of both the birth center or the midwives and the client, what those responsibilities are over the course of the pregnancy. So the informed consent process for birth centers, particularly accredited birth centers, is usually required to be pretty robust. And part of that reason for that is because we've found that no surprises is sort of a good approach. So if you have someone in labor who needs to transfer, you want to have had that conversation with her prior to the need for transfer. And things go a lot more smoothly. I don't know if somebody is asking a question about group these steps. Right. Yeah, groupie steps, I see someone in Oregon says groupie steps is a risk factor. It's not in general, it's not in terms of CADC accreditation. And I would say in most birth centers, again, with which I'm familiar, groupie steps is not a factor that prevents birth in the birth center. Most birth centers have the mother give birth at the birth center, provide, talk to her about the CDC guidelines in terms of groupie steps screening during pregnancy and antibiotic prophylaxis in labor. Birth centers sometimes do have various approaches for providing follow-up care for these mothers and babies. Many of them, of course, would start in the pregnancy when they're very much educated about what to watch for or how to know if their baby is OK or not, signs of infection in babies and that sort of thing. But also, it is not uncommon for the birth center to do earlier follow-ups. So they might do a home visit at 24 hours instead of 48 hours for that family. They might do more than one home visit, so 1 at 24 or 1 at 48, just to check on the baby. They might have the baby seen by the pediatrician or the pediatric care provider earlier than they normally would. I know of a couple of birth centers where the mother gives birth in the birth center and then the mother and baby are transferred to the collaborative hospital for a 48-hour stay, which is unfortunate, but it is in a couple of cases that I know of what they are required to do. But in general, group B stuff is not considered a factor that would prevent a mother from giving birth at a birth center. It's normal practice in the UK to give IV antibiotics, and that's one of the reasons why women with group B have to give birth somewhere where intravenous drugs can be given. And so in the birth centers in the UK, they don't do interferdum prophylaxis. I would have to ask those who work in a birth center that Geraldine Butcher is the one who's talking about this just at the moment, Geraldine. Down here. OK. Are you saying Geraldine Butcher is on? OK. So it looks like. Birth centers in the United States generally, again, unless prohibited by state regulations for midwifery or birth centers, generally have IV, can do IV antibiotics, and some other kinds of IV medications in the birth center. OK. Any other questions from anybody? I'm sure there are any further up. Still got five minutes. If anyone has any questions, can we answer the question about the other five or the other four pain relieving measures used? Geraldine Butcher asked that earlier on. Oh, OK. Water was the most common one. Ambulation and position change, I believe, was second. And then I'm not sure of the order of the others. But continuous presence of a trained support person, massage and touch. And then I can't remember if this is just one. But it may have been music and auditory kinds of interventions, music, I mean. So all the things that families and mothers would do that, really. And the kids would do that, right? Right, yes. Obviously, the protocols about group B streps and antibiotics varies across the UK as well. There's a few different things. So do you use TENS in your birth centers? There are some birth centers that use TENS. That was not one of them more widely. It was fairly uncommon. It was used occasionally by some birth centers. Same with acupuncture, verbal and homeopathic interventions for various things, for pain, also for hemorrhoids, for prolonged labor, those kinds of things. So where do you see, just to kind of conclude, where do you see your birth centers going? Are they going to increase in numbers, do you think? Do you have obstetric units which have a birth center component to it at all? We have a few of those. And again, you'll have to sort of sort out the acute care labor and delivery units that are calling themselves birth centers from the in-near hospital birth centers that are truly birth centers. But we have some very good models of birth centers using the model of care that I'm talking about here, and the midwifery model of care, that are located inside hospitals. We have another, we also have birth centers that are owned and operated by hospitals but are located on the hospital grounds but are outside of the hospital building. In order to be accredited by the CADC, the birth center can be inside the hospital, but it has to be separate from the acute care services. It can't simply be a part of labor and delivery. There has to be many distinctions between the two so that it truly is a birth center wherever it's located. And it's really not the location that matters. It's the people who are there providing the care and their philosophy and practice style and the policies and practice model within the birth center wherever it's located. So you can have a very medical model place that the person from Florida was talking about before that's free-standing, or you can have an in-hospital birth center that is very much in the birth center model, as we were talking about here. In answer to your question about where birth centers are going, I think we're seeing a huge growth in birth centers in the United States. More and more birth centers are opening. More and more birth centers are needing to open the second birth center because their first birth center has outgrown its space and they need more space. And so they're actually opening. Many, many birth centers are opening second birth centers in the same community or in nearby communities. We're seeing a lot more attention to birth centers in general in the United States on the federal level by payers in many different ways. So it's an exciting time, I think, for birth centers in the United States. Thus, getting this very large federal five-year federal grant for looking at the birth center model of care was, I think, is certainly indicative of the growing interest in birth centers in the United States. So we had a conference not too long ago and someone who didn't like birth centers said, the next thing you know, we'll have a birth center. If that happens, we'll have a birth center at every block. And those of us in the audience who like birth centers said, yes, that's exactly what we're aiming for here. And that's a fantastic way to close that session. And it's very nice to hear that that's the way things are going in the States. I have to say thank you very much, Susan, for your presentation and for the discussion that we've had thereafter. Thank you, and thanks, everyone. Thank you. OK, so I'm going to close this session now.