Pregnancy, Birth and the COVID-19 Pandemic in the United States

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

Background: Out-of-hospital births have been increasing in the United States, although past studies have found wide variations between states. Our purpose was to examine trends in out-of-hospital births, the risk profile of these births, and state differences in women’s access to these births. Methods: National birth certificate data from 2004–2017 were analyzed. Newly available national data on method of payment for the delivery (private insurance, Medicaid, self-pay) were used to measure access to out-of-hospital birth options. Results: After a gradual decline from 1990–2004, the number of out-of-hospital births increased from 35,578 in 2004 to 62,228 in 2017. In 2017, 1 of every 62 births in the US was an out-of-hospital birth (1.61%). Home births increased by 77% from 2004–2017, while birth center births more than doubled. Out-of-hospital births were more common in the Pacific Northwest, and less common in the southeastern states such as Alabama, Louisiana, and Mississippi. Women with planned home and birth center births were less likely to have a number of population characteristics associated with poor pregnancy outcomes, including teen births, smoking during pregnancy, obesity, and preterm, low birthweight, and multiple births. More than 2/3 of planned home births were self-paid, compared to 1/3 of birth center and just 3% of hospital births, with large variations by state. Conclusions: Lack of insurance or Medicaid coverage is an important limiting factor for women desiring out-of-hospital birth in most states. Recent increases in out-of-hospital births despite important limiting factors highlights the strong motivation of some women to choose out-of-hospital birth.

Between 2004 and 2010, the number of home births in the United States rose by 41%, increasing the need for accurate assessment of the safety of planned home birth. This study examines outcomes of planned home births in the United States between 2004 and 2009.