Are freestanding birth centers "safer" than hospitals?

Expectant Mother: I've been hearing rumors of several infant deaths in your care over the past couple of years and a baby who is currently in the RNICU fighting for its life.  Should I be worried? 

Local Freestanding Birth Center: Here is an updated stat sheet (shows "data" through 2010, even though it's half-way through 2012).  Having your baby at our birth center is still safer than the hospital.  

Expectant Mother:  Really, safer than the hospital?  

Local Freestanding Birth Center: "Freestanding birth centers have demonstrated superior safety.  Safe and satisfying outcomes include significantly lower cesarean rates than the nation-wide average of 32%."  "Birth is as safe as life gets."  

I feel compelled to address some of the myths women are being told in our own community.  The first is noting that safety should be defined as much, much more than whether or not you have a cesarean.  The way your baby is born has nothing to do with whether the labor & delivery was "safe".  What matters most is whether you both come through the experience alive.  

Safety is defined by Merriam-Webster dictionary as, "the condition of being protected from, or unlikely to cause danger, risk, or injury."  Ignoring risk factors, inviting clients to opt out of assessments that would determine risk,  and pretending that risks don't exist during childbirth, is not what I would consider safe.  Implying that having a cesarean is the enemy, a danger to be avoided, or that having one is "un-safe" creates a fear in expectant mothers that shouldn't be perpetuated.  Consider for example a mother who ends up needing a cesarean for reasons that couldn't be avoided in order to keep her baby safe.  Her first thoughts would be about how dangerous it is for her and baby instead of understanding its necessity.  A planned, pre-term cesarean without medical conditions is one thing, a cesarean that saves lives is another.  Using statistics as scare tactics and without context is unethical.    

I would also note that having a "satisfying" birth has nothing to do with safety.  Approaching birth with the priority being about the "experience" instead of the safety of babies and mothers is absurd.  While I believe that everything should be done that possibly can be done to ensure the experience is positive, ultimately the safety of the baby matters more.  It is not acceptable to sacrifice safety for a satisfying experience, rather the two should work together with an understanding that sometimes safety takes the driver's seat.  The mother I mentioned in the previous paragraph who had to have a cesarean, deserves to know her baby was born just the way he or she needed to be and to be no less satisfied because of it.  When cesareans are made out to be the standard by which we measure safety, we have a real conflict of interest on our hands.   

While I appreciate that no major surgery, cesareans included, come without risks, there are many more immediately dangerous circumstances that can come during labor that could cost your baby his life, put him at risk, and place him in a situation that is ultimately not safe at all in a freestanding birth center setting. ACOG President Kenneth L. Noller, MD, MS, states, “Even a normal pregnancy can become high-risk with little or no warning, and serious, sometimes life-threatening complications may arise for the woman and her fetus.”  He noted that shoulder dystocia occurs in one in every 200 births and listed the frequency of other complications:

• prolapsed umbilical cord: 1 in every 200 births
• life-threatening maternal hemorrhage: 1 in 250
• eclamptic seizures: 1 in 500
• uterine inversion: 1 in 700
• Apgar score of 0–3 at 5 minutes: 1 in 100 to 200.

These situations should be considered far more dangerous for your baby than a cesarean, and furthermore should be the foundation for discussions about the safety of out-of-hospital birth and it's relative "safety".  Instead, the birth center in this example is referencing cesarean rates and not addressing the real complications mothers need to be aware of if they are going to be truly "informed" about the risks they are embarking upon by choosing a freestanding birth center.  Neglecting to share the real risks that would define measures by which safety could be adequately assessed is not informed consent, nor is it honest, nor is it honoring the rights of women to make choices for their own well being.  No one can argue that based on proximity alone and immediate access to medical technology, hospital birth has to be considered safer than having a baby farther away...even if it's "only 12 minutes from the hospital".     

I need to state the obvious, of course a freestanding birth center with no medical equipment or medical personnel, is going to have a lower cesarean rate when compared to a hospital.  They are comparing apples to oranges here.  A freestanding birth center doesn't do surgery and would have a cesarean rate of 0%.  A hospital, taking on all kinds of high risk births including breech and delivery of multiples, etc, would of course have a higher cesarean rate in comparison.  Does this mean they are somehow not as safe in overall practices?  The claim doesn't even make sense.  Nothing about the rate of cesarean in either birth center or hospital addresses why a birth center would be safer.  Wouldn't the outcome, a baby and mother who are alive, be a better determining factor of safety, regardless of how the baby is born?  The statement about cesarean rates is nothing more than a distraction, a way to avoid answering the question, a way to influence a woman's feelings about cesarean delivery in a subtle way. 

Mothers also need to understand that a freestanding birth center in Michigan is not a licensed facility and does not report their outcomes to the state or anyone else.  There is no data to support the claim that giving birth outside the hospital is somehow safer than giving birth in the hospital. In fact, when babies who die are transferred to the hospital in an effort to save their lives, they are counted as the hospital's loss, as we learned from personal experience.  There is no body of oversight, no third party checking the "data" on the handouts a birth center distributes, and nothing that gives what is printed on that paper any kind of credibility.  There cannot be evidence to prove the birth center's safety if there is no reported data about outcomes that would directly demonstrate safety margins. 

Studies that have been done to compare safety and mortality rates of out-of-hospital birth to in-hospital birth, consistently show that out-of-hospital birth is 3-4 times more risky.  (See Wisconsin's WISH website)  Another interesting point to be made here is that MANA (Midwife Alliance of North America) did conduct their own study about mortality rates in home birth. When the study was completed, they decided to keep the results private, only issuing the release of their findings to researchers who sign a contract, agreeing to use the information to advance the cause of midwifery.  Hmmm, something to hide? 

A birth center's safety can only be considered "superior" when compared to free or unassisted birth.  You don't want to find yourself in a room with a care giver who views cesarean rates as the defining standard for safety assumptions.  Please make sure you have real conversations about risks and safety before choosing to have your baby outside of a hospital or hospital run birth center.  Are hospital's perfect?  No, but real risks, like your baby not surviving, are even higher when you choose to have your baby at a freestanding birth center.  Make sure you're in the hands of a care provider who is being honest with you about potential complications, risks, and all matters that would impact you or your baby's safety.  It is one thing to be honestly and accurately informed in making choices about where to have your baby, and quite another to make a choice without knowing the truth.