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[Editorial] Childbirth settings in the US

Tags: General

Despite spending more than many comparable countries, the US has the highest incidence of maternal and neonatal mortality and morbidity of any high-resource country, particularly among black and Native American women. A report published by the National Academies of Sciences, Engineering, and Medicine (NASEM) shows that although most US births take place in hospitals, a growing proportion occurs in birth centres or at home. Based on the available data, there is a statistically significant increase in the relative risk of neonatal death in the homebirth setting, but also a consistently lower risk of medical intervention during labour and resulting maternal morbidity. However, these data are difficult to disentangle since planned and attended homebirths are not separated from unattended or unplanned homebirths. International studies suggest that births at home or in birth centres might be as safe as hospital births, but only when part of a seamlessly integrated and regulated system, which is not widespread in the US.

The NASEM report makes a number of welcome recommendations to improve the quality of care but it also recognises that disparate outcomes are influenced by system-level factors and social determinants of health embodied in policies and laws that are built on long-established gender biases and racism. Importantly, expanding workforce diversity and providing non-clinical, culturally appropriate support workers are recommendations that can address this disparity, and therefore improve maternal and neonatal outcomes.

Birth options for women everywhere are limited by structural inequalities. Such problems are, of course, not unique to the US, with poor access to good quality, respectful maternity care, including adequate pain relief, all too common across health systems. Data have shown that mistreatment in labour is common worldwide. The NASEM report discusses this issue in the US, and rates are not much different. It is time to be honest that the options for women giving birth are often inadequate. Women's power in society has been limited, with historically too many decisions made on their behalf. In childbirth, this has resulted in a failure to deliver real change.
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