In this lesson, you'll learn about the evidence on where women give birth or birth setting. And understand how this aspect of care differs between high and low resource environments. A discussion of birth setting often centers on different priorities in high versus low income countries. Frequently in high income countries, where the majority of births already occur in hospitals. Community birth or birth outside the hospital is seen as an option available to women who are explicitly seeking a different kind of care. If available, these women may choose between a birth at home, in a birth center, or in an alongside maternity care unit. On the other hand, in low income countries, women may lack access to any hospital or birth facility at all. And may be largely without emergency services. They therefore have little or no option in their birth setting choices. Despite these distinctly different contexts, risk assessment, quality of care and safety remain key to the discussion of birth setting. In high income countries, there's good evidence that community birth options are safe if the following criteria are met. The birth is attended by a qualified and regulated midwife. If the pregnancy has been low risk. And if the midwife works within an integrated and responsive healthcare system that supports referral and transfer when needed. As you can see from this table published by the UK's National Institute for Health and Care Excellence. Midwifery lead care in community settings is more likely to end in spontaneous vaginal birth rather than cesarean section or instrumental delivery like forceps. Less likely to use episiotomy, epidural, or spinal anesthesia and less likely to use blood transfusion. The numbers presented here on this table are per 1000 multiparous women giving birth. Transfer rates from these settings to a higher level of care range between 9 and 12%. They're relatively low. Neonatal outcomes are the same between birth sites across all settings for babies of low risk multiparous women. That is, women who have had babies before. These outcomes are largely the same for first time mothers as well. However, birth at home does carry a small increase risk of an adverse outcome for the baby. To review these recommendations for multiparous and nulliparous women, please link out to the UK NICE recommendations here. Again, these recommendations apply in settings where the three important criteria are met. The birth is attended by a qualified and regulated midwife. The pregnancy has been low risk and the midwife works within an integrated health care system. The national guideline arising from this research, states that healthcare providers, therefore, should quote explain to both multiparous and nulliparous women that they may choose any birth setting and support them in their choice. Despite these reassuring statistics, opinions about birth settings often differ significantly between care providers, pregnant people, their families, and even the media. For example, where community birth options are not well integrated into the healthcare system, such as is the case in the United States. Birth outside the hospital can be viewed as a very controversial choice. Yet countries that provide birth setting options within the context of a well integrated system consistently have very good results. The Netherlands, for example, is often cited as a high income country with one of the highest rates of home birth. As well as very excellent outcomes for mothers and babies. Currently in the Netherlands, just over 16% of births occur at home. In the UK, home birth is between 2 and 3%. And in the United States by contrast, the percentage of home birth is below 1%. Women choose community birth for a number of reasons. For some it may be a cultural preference. Other women may seek an environment that is more personal and individually supported. They may want to choose their care provider or desire fewer interventions, less separation from the baby after birth, and more family involvement. During the coronavirus pandemic, we saw people in some cities change their plans for a hospital birth altogether due to fear of contagion in the hospital. And alternatively, in other cities, where the healthcare system was completely overwhelmed, some hospitals closed their doors to women due to lack of capacity. A dangerous outcome for many who were left without a safe place to give birth. While there is still a need for more research in regard to birth setting in high resource settings like those I've discussed. Research from low resource settings is even more limited. Historically, in low income countries, birth in a facility was seen as a solution to high rates of maternal and neonatal mortality. Yet, as facility-based birthing has become more available, it has not consistently lead to these improved outcomes. The benefits of facility-based birth compared to home birth were investigated in a 2019 article published by Gabrysh and colleagues in The Lancet. It was a large study. They completed secondary analysis of over 119, 000 pregnancies from two large cluster-based randomized controlled trials in Ghana. They were asking the question, does facility birth reduce maternal and perinatal mortality? They compared the following outcomes. Direct maternal mortality, perinatal mortality, first day and early neonatal mortality and still birth. And they assessed this at 64 different facilities. So is a nice size study. Their results, facility birth did not necessarily convey a survival benefit for women or babies. They recommended that facility birth should only be encouraged in facilities capable of providing emergency obstetric in newborn care. While at the same time, and that's important, capable of safeguarding uncomplicated births. So facilities that were able to provide care at both ends of the spectrum. The authors concluded that this does not mean, and I'm quoting here, that we should stop recommending birth with a skilled attendant, including in facilities. But rather we should ensure that all health facilities fulfill their requirements and are actually capable of providing lifesaving emergency obstetric and newborn care. As well as providing good care for uncomplicated physiological births. Up next, you'll hear from doctor Davis Heart, who discusses her work designing physical spaces that best support childbearing people. She offers several simple suggestions about changing an existing space to help the laboring person feel more in control. And comfortable in her birth environment.
