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National VitalStatistics ReportsVolume58,Number11 March3,2010

TrendsandCharacteristicsofHomeandOtherOut-of-HospitalBirths intheUnitedStates,19902006byMarianF.MacDorman,Ph.D.,andFayMenacker,Dr.P.H.,C.P.N.P.,DivisionofVitalStatisticsEugeneDeclercq,Ph.D.,BostonUniversitySchoolofPublicHealthAbstract

ObjectivesThis reportexamines trendsand characteristicsofout-of-hospitalandhomebirths in theUnitedStates.

MethodsDescriptivetabulationsofdataarepresentedandinter-preted.

ResultsIn2006,therewere38,568out-of-hospitalbirthsintheUnitedStates,including24,970homebirthsand10,781birthsoccurringinafreestandingbirthingcenter.Afteragradualdeclinefrom1990to2004, thepercentageofout-of-hospitalbirths increasedby3% from0.87%in2004to0.90%in2005and2006.Asimilarpatternwasfoundfor home births. After a gradual decline from 1990 to 2004, thepercentage ofhomebirths increasedby5% to 0.59% in2005andremainedsteadyin2006.ComparedwiththeU.S.average,homebirthrates were higher for non-Hispanic white women,married women,womenaged25andover,andwomenwithseveralpreviouschildren.Homebirthswere less likely thanhospitalbirths tobepreterm, lowbirthweight,ormultipledeliveries.Thepercentageofhomebirthswas74%higher inruralcountiesof less than100,000population than incountieswithapopulationsizeof100,000ormore.Thepercentageofhomebirthsalsovariedwidelybystate; inVermontandMontanamorethan2%ofbirthsin20052006werehomebirths,comparedwithlessthan0.2%inLouisianaandNebraska.About61%ofhomebirthsweredelivered bymidwives.Amongmidwife-delivered home births,one-fourth (27%) were delivered by certified nurse midwives, andnearly three-fourths (73%)weredeliveredbyothermidwives.

DiscussionWomen may choose home birth for a variety ofreasons, including a desire for a low-intervention birth in a familiarenvironmentsurroundedbyfamilyandfriendsandculturalorreligiousconcerns.Lackof transportation inruralareasandcost factorsmayalsoplayarole.Keywords:homebirth cout-of-hospitalbirthcbirthingcenterbirth

IntroductionIn the last several decades, there have been considerablechangesinchildbearingpatternsintheUnitedStates.Historically,the

percentageofout-of-hospitalbirthsdeclinedfrom44%in1940to1%in 1969, and has remained about 1% for several decades (13).Out-of-hospital births include those born in a residence (i.e., homebirths),inafreestandingbirthingcenter(i.e.,onethatisnotpartofahospital), clinic or doctors office, or other location. Some out-of-hospitalbirthsareintentional,whereasothersareunintentionalduetoanemergencysituation(i.e.,precipitouslabororlaborcomplications,couldnotgettothehospitalintime).Thisreportexaminestrendsandcharacteristicsofhomeandotherout-of-hospitalbirths in theUnitedStates from1990 to2006.

MethodsDatashown in thisreportarebasedonbirthcertificates for the

approximately4.3millionlivebirthsregisteredintheUnitedStatesin2006, and equivalent data from previous years.Descriptive tabula-tionsarepresentedandanalyzed.Recordswhereplaceofbirthwasnot statedwere excludedbefore percentageswere computed.Thisreport includes data on items that are collected on both the 1989RevisionoftheU.S.StandardCertificateofLiveBirth(unrevised)andthe 2003 Revision of the U.S. Standard Certificate of Live Birth(revised); see Technical Notes. Data on place of delivery werecomparable between the two revisions, although the 2003 revisionadded a new data item onwhether a home birthwas planned orunplanned. Information from the new item is presented for the 19states that had adopted the revised birth certificate by January 1,2006 (California, Delaware, Florida, Idaho, Kansas, Kentucky,Nebraska, New Hampshire, New York (excluding New York City),North Dakota, Ohio, Pennsylvania, South Carolina, South Dakota,Tennessee,Texas,Vermont,Washington,andWyoming), toprovide

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and Prevention

National Center for Health StatisticsNational Vital Statistics System


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Clinic or Clinic ordoctor's Other doctor's Otheroffice 7.2 office 6.22.4

Home

59.0

1.1

Home

64.7

Birthingcenter

31.4

Birthing

center28.0

1990 2006

SOURCE: CDC/NCHS, National Vital Statistics System.

Figure2.Percentageofout-of-hospitalbirths,byplaceofdelivery:UnitedStates,1990and2006

2 NationalVitalStatisticsReports,Vol.58,No.11,March3,2010some insight into this important characteristic of home births.However,whilethe19statesrepresent49%ofU.S.births,theresultscannot be generalized to all births and could change significantlywhendata fromallstatesareavailable;see TechnicalNotes.

ResultsTrends inhomeandout-of-hospitalbirths

In2006, therewere 38,568out-of-hospitalbirths in theUnitedStates,including24,970homebirthsand10,781birthsoccurringinafreestanding birthing center (Table1). A small number of birthsoccurredeitherinaclinicordoctorsoffice(414),inanotherspecifiedlocation (2,403), or with place of birth not stated (363). In 2006,out-of-hospitalbirthsrepresented0.90%ofthe4,265,555birthsintheUnited States. After a gradual decline from 1990 to 2004, thepercentageofout-of-hospitalbirths increasedby3% from0.87% in2004to0.90%in2005and2006(Table1andFigure1).Patternsforhomeandbirthingcenterbirths,themajorityofout-of-hospitalbirths,mirrored those for all out-of-hospital births, with a gradual declinefrom 1990 to 2004, followed by an increase in 2005 that wassustainedin2006.Thus,thepercentageofhomebirthsdeclinedfrom0.67%in1990to0.56%in2004,andthenincreasedby5%to0.59%in 2005 and 2006. The percentage of births in a birthing centerdecreasedfrom0.36%in1990to0.23%in2004,andthenincreasedto0.25% in2005and2006.

Amongout-of-hospitalbirths in2006,nearly two-thirds (64.7%)occurredathome,28.0% inafreestandingbirthingcenter,1.1%inaclinicordoctorsoffice,and6.2%elsewhere(Figure2).From1990to2006, the proportion of out-of-hospitalbirths thatwere home birthsincreasedfrom59.0%to64.7%,whiletheproportionofbirthingcenterbirths declined slightly from 31.4% to 28.0%. The proportion thatoccurredinaclinicordoctorsofficedeclinedfrom2.4%in1990to1.1%in2006.Mostoftherestofthisreportwillfocusonhomebirthsbecausetheyarethe largesttypeofout-of-hospitalbirths,representingnearlytwo-thirds (65%)ofallout-of-hospitalbirths.

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1990 1992 1994 1996 1998 2000 2002 2004 2006

Percent


Total out of hospital

Home

Birthing center

Figure1.Percentageofallbirths thatwerebornoutofahospital,athome,or inabirthingcenter:UnitedStates,19902006

Variations inhomebirthsbymaternaland infantcharacteristicsTable2showsdataonplaceofbirthbyavarietyofmaternaland

infantcharacteristics.Race and ethnicityNon-Hispanic white women were more

likely to have a home birth than women of other race and ethnicgroups. The percentage of home births for non-Hispanic whitewomen (0.86%)wasabout three times that fornon-Hispanicblack,AmericanIndian,andAsianorPacificIslanderwomen(0.250.31%),andabout four times that forHispanicwomen(0.19%) (Table2).

Overall,81%ofhomebirthsweretonon-Hispanicwhitewomen,comparedwith54%ofhospitalbirths(Figure3).Only8%ofhomebirthswere tonon-Hispanicblackwomen,comparedwith15%ofhospitalbirths.Hispanicwomen comprised 8% of home births and 25% ofhospitalbirths.

Maternal ageThe percentage of home birthswas lowest forwomen aged 1519 years (0.19%), and increased with increasingmaternalagetoahighof1.41%formothersaged45yearsandover(Table2).

Marital statusThe percentage of home birthswas 2.7 timeshigher for married women (0.77%) than for unmarried women(0.29%).

Live birth orderThe percentage of home births increasedrapidlywith increasingbirthorder.Althoughonly0.3%of firstbirthswere home births, this percentage increased rapidly until 7.70% ofbirthswitha livebirthorderof8orhigherwerehomebirths.

Birthplace of motherWomen born in the 50 states and theDistrictofColumbia(D.C.)were2.6timesmorelikelytohaveahomebirth thanwomenbornoutside the50statesandD.C.However, forwomenbornoutsidethe50statesandD.C.,therewasconsiderablevariationbycountryoforigin.Amongplacesoforiginwithmorethan10,000birthstoU.S.mothersin2006,thepercentageofhomebirthswas low (less than one-half theU.S. average) forwomen born inMexicoandPuertoRico.However,2.4%ofbirths toCanadian-bornwomenwerehomebirthsfour times theU.S.average.

Plurality, birthweight, and gestational ageThe percentage ofhigh-riskbirths(i.e.,multiplepregnancy,lowbirthweight,andpreterm)


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81.4

7.7 8.2

0.62.4

54.3

14.6

24.7

1.15.7

0

10

20

30

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60

70

80

90

Non- Non- Hispanic AIAN API Non- Non-

Hispanic

black

Hispanic AIAN API

Percent

Hospital

Hispanic Hispanic Hispanic

white black white

Home

NOTE: AIAN is American Indian or Alaska Native, API is Asian or Pacific Islander.


Figure3.Percentdistributionofhomeandhospitalbirths,byraceandHispanicoriginofmother:UnitedStates,2006

3NationalVitalStatisticsReports,Vol.58,No.11,March3,2010

was lower forhomebirths than forhospitalbirths. In2006,1.0%ofhome births were multiple births, compared with 3.4% of hospitalbirths(Figure4).Only5.2%ofhomebirthswerelowbirthweight(lessthan2,500grams), comparedwith8.3%ofhospitalbirths.Preterm(less than 37weeks of gestation) births comprised 7.2% of homebirths,and12.9%ofhospitalbirths.Geographicdifferences

The percentage of home birthswashigher in counties of lessthan 100,000 population than in countieswith a population size of


7.2

12.9

5.2

8.3

1.0

3.4

0

2

4

6

8

10

12

14

Preterm Low birthweight Multiple birth

Home Hospital

Figure4.Percentageofhomeandhospitalbirthswithselectedcharacteristics:UnitedStates,2006

100,000 or greater (Table2). For counties of less than 100,000population,0.87%ofbirthswerehomebirthscomparedwith0.50%forcountiesof100,000populationormore.

Therewerealsolargedifferencesinthepercentageofhomebirthsbystate.Forthestateanalysis,2yearsofbirthdatawerecombinedtoproducemorestableestimates(Tables3and4andFigures5and6). In13 states (Alaska,Colorado,Hawaii, Idaho,Maine,Montana,Nevada,Oregon,Pennsylvania,Utah,Vermont,Washington,andWis-consin)more than1%ofbirthswerehomebirths; forMontanaandVermontmorethan2%werehomebirths.Incontrast,ineightstates(Alabama, Louisiana, Mississippi, Nebraska, New Jersey, RhodeIsland,SouthDakota,andWestVirginia)lessthan0.3%ofbirthswerehomebirths.

Elevenstates(Alabama,California,Kansas,Kentucky,Maryland,Minnesota,NewHampshire,NorthCarolina,Ohio,Virginia,andWis-consin)hadstatisticallysignificantincreasesinthepercentageofhomebirths from 20032004 to 20052006; for nine of these states theincreasewas15%ormore (Table4andFigure6). In contrast, fivestates (Arkansas,Florida, Indiana,Nevada,andWyoming)hadsta-tisticallysignificantdecreases in thepercentageofhomebirths from20032004 to20052006; for twoof thesestates thedecreasewas15%ormore.

Thepercentageofbirthsoccurringinafreestandingbirthingcenterwasstronglyinfluencedbytheavailabilityofsuchfacilitiesinparticularstates.Severalstatesdidnothaveafreestandingbirthingcenter(4),andthusreportednobirthswithinabirthingcenter.Thestateswiththehighestpercentageofbirths inabirthingcenterwereAlaska(3.2%),Idaho (1.2%), D.C. (0.9%), Washington (0.8%), and Pennsylvania(0.7%)(Tables3and4).


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MT

WY

ID

WA

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NVUT

CA

AZ

ND

SD

NE

CO

NM

TX

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KS

AR

LA

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PA

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CT

RI

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MEVT

NH

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DC

10 highest

United States percentage of home births = 0.59

Significantly higher than the U.S. average

Not significantly different from the U.S. average

Significantly lower than the U.S. average

10 lowestSOURCE: CDC/NCHS, National Vital Statistics System.

4 NationalVitalStatisticsReports,Vol.58,No.11,March3,2010

Figure5.Percentageofhomebirths,bystate:UnitedStates,20052006Attendantatbirth

In2006,61%ofhomebirthsweredeliveredbymidwives16%by certified nurse midwives (CNMs), and 45% by other midwives(Figure7).Othermidwives refer tomidwiveswhoarenotCNMsorcertifiedmidwives, and, for example,may include certified profes-sionalmidwives,or laymidwives (5). In 1990,43%ofhomebirthswere delivered by midwives, 13% by CNMs, and 30% by othermidwives.

In2006,only7.6%ofhomebirthsweredeliveredbyphysicians,asharpdeclinefrom1990,when21.6%ofhomebirthsweredeliveredbyphysicians(Figure7).Inboth1990and2006,alargeproportionofhomebirthsweredeliveredbyotherbirthattendants(31%and36%,respectively). Other refers toany other personwhodelivered thebabysuchasafamilymember,emergencymedicaltechnician,ortaxidriver.

In 2006, 99.9% of physician deliveries occurred in a hospital,0.02%inabirthingcenter,and0.05%inahome(Table5).ForCNMs,96.7%ofdeliveriesoccurred inahospital,2.0% inabirthingcenter,and1.2%inahome.Incontrast,forothermidwives,only24.7%werehospitalbirths,while17.7%werebirthingcenterbirthsand56.5%werehomebirths.Forbirthswithanotherbirthattendant,57.8%wereborninhospital (theymayhavebeenbornen-route to thehospital; seeTechnicalNotes),and35.3%werebornathome.

PlannedandunplannedhomebirthsThe2003RevisionoftheU.S.StandardCertificateofLiveBirth

addedan itemwhichasks, forhomebirths,whether thehomebirthwasplannedorunplanned.For2006,thesedataareavailablefor19states, comprising 2.1million births or 49% of allU.S. births.Thisarea is not representative of the overall U.S. population so theseresultsarenotgeneralizable to the totalpopulation;see TechnicalNotes.Table6 shows the number of births by birth attendant andplace of birth for the 19-state area; 0.61percent of births in the19-stateareawerehomebirths,comparedwith0.59percentofbirthsfor theUnitedStates as awhole (Table5), and the percentage ofhome and out-of-hospital births by birth attendant were similarbetween the twoareas.

In2006,83%ofhomebirths inthe19-stateareawereplannedhomebirths;however, thispercentagevariedgreatlybyattendantatbirth(Table6).Ofhomebirthsdeliveredbymedicaldoctors,only31%wereplannedtodeliverathome.Incontrast,forhomebirthsdeliveredbydoctorsofosteopathy,79%wereplannedhomebirths.Forcertifiednursemidwivesandothermidwives,nearlyall,98%and99%,respec-tively, of home births were planned home births, whereas almosttwo-thirds(65%)ofhomebirthsattendedby otherattendantswerereportedasplanned.


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MT

WY

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WA

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CA

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SD

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CO

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VAWV

OH

MI

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MD

DE

NJ

CTRI

MA

MEVT

NH

AK

HI

VADC

Significant increase

No significant change

Significant decreaseSOURCE: CDC/NCHS, National Vital Statistics System.

Figure6.Change inthepercentageofhomebirthsbystate,20032004 to20052006

Physician

7.6

Other

31.4Other35.9

Physician

21.6

CNM

12.7

CNM

16.3

Other midwife

29.8

Other midwife

44.6

1990 2006

NOTE: CNM is certified nurse midwife.


Figure7.Percentageofhomebirths,bybirthattendant:UnitedStates,1990and2006

5NationalVitalStatisticsReports,Vol.58,No.11,March3,2010

About17%ofhomebirths in the19-state reportingareawereunplannedin2006(Table6).Unplannedhomebirthsarelikelyemer-genciesperhapsinvolvingprecipitouslabororothercomplicationsthatmight result in poorer-than-average outcomes when occurring in asettingunprepared for this typeofdelivery.

DiscussionIn 2006, therewere38,568out-of-hospitalbirths in theUnited

States; of these, 24,970were home births.After a gradual declinefrom1990to2004,thepercentageofout-of-hospitalbirthsincreasedby 3% from 0.87% in 2004 to 0.90% in 2005 and 2006.Asimilarpatternwasfoundforhomebirths,whichcomprisednearlytwo-thirds(65%)ofallout-of-hospitalbirthsin2006.Afteragradualdeclinefrom1990 to 2004, the percentage of home births increased by 5% to0.59%in2005andremainedsteadyin2006.Homebirthsdifferfromhospitalbirthswith respect tomanycharacteristics.Homebirthsaremoreprevalent fornon-Hispanicwhitewomen,marriedwomen,andwomen aged 25 years and over. Women with several previouschildrenarealsomore likely tohaveahomebirth,andhomebirthmaybefavoredbysomeselectpopulationswithin theUnitedStatesthat tend to have larger families (6).Women born outside the 50statesandD.C.were less likely tohaveahomebirth thanwomenborn in the50statesandD.C.with theexceptionofCanadian-bornwomen,whoweremorelikelytohaveahomebirth.Itisinterestingtonotethattheincreaseinhomeandout-of-hospitalbirthsintheUnitedStates was paralleled by an increase in out-of-hospital births inCanada(from0.8%ofbirthsin2003and0.4%2004to1.1%in2005and2006) (7).

The lowerpercentagesofmultiple, low-birthweight,andpretermdeliveriesforhomebirths,comparedwithhospitalbirths,suggestthat


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6 NationalVitalStatisticsReports,Vol.58,No.11,March3,2010prenatalriskassessmentsarebeingdoneto identifylow-riskwomenascandidatesforhomebirth.Becausethehomebirthcategorycontainsboth planned home births and unplanned home births due to anemergencysituation(i.e.,precipitouslabor,couldnotgettothehospitalin time) it is unlikely that higher-risk low-birthweight, preterm, andmultiple births can be completely eliminated from the home birthcategory.

Therewasalsoalargevariationinthepercentageofhomebirthsbystate.Differencesinthepercentageofhomebirthsbystatemaybeinfluencedbyvariationsinstatelawsregardingmidwiferypractice(asmidwives deliver the majority of home births) or home births (8,9).Factorsrelatedtotheavailabilityofbirthingfacilitiesmayalsoplayaroleinthechoiceofbirthplace.Forexample,Alaskahadthehighestpercentageofout-of-hospital(5.3%),andfreestandingbirthingcenter(3.2%)births,andthethirdhighestpercentageofhomebirths(1.9%).The long distances and severe weather in Alaska may mean thatwomen living in ruralareasmaynotalwayshaveeasyaccess toahospital birth. Cultural factors and personal preferences may alsoinfluencewomenschoiceofbirthplace(6,911).

The2003revisedbirthcertificatehasanitemonwhetherahomebirthwasplannedorunplanned.Whilethesedatawereonlyavailablefor 19 states in 2006, and were not generalizable to the total U.S.population, about 17% of home births were unplanned. Unplannedhomebirthsmay representapreviouslyunidentifiedhigh-riskpopu-lation.

Homeandout-of-hospitalbirth isthesubjectofongoingcontro-versy in theUnitedStates. In2007, theAmericanCollegeofObste-triciansandGynecologists,citingconcernsaboutthesafetyofhomebirthformothersandinfants,issuedapolicystatementopposinghomebirth(12),astatementsupportedbyaresolutionpassedatthe2008American MedicalAssociation annual meeting (13). In contrast, theWorldHealthOrganization,theAmericanCollegeofNurseMidwives,and the American Public Health Association all support home andout-of-hospitalbirthoptions for low-riskwomen (1416).

ThepercentageofhomebirthsintheUnitedStatesiscomparableto that in most other industrialized countries (17). However, in theNetherlands, about 30% of births occur at home (17). In addition,Englandhasexperiencedanincreaseinitshomebirthratefrom1.0%in1983to2.9%in2007(18),whilehomebirthsinNewZealandhaveincreasedto2.5%ofbirthsin2004(19).TheincreaseinhomebirthsinEnglandhasbeenlinkedtosupportforhomebirthbyBritainsRoyalCollege of Obstetricians and Gynaecologists and Royal College ofMidwives(20).

Women may prefer home over hospital birth for a variety ofreasons, including a desire for a low-intervention birth in a familiarenvironmentsurroundedbyfamilyandfriends,andculturalorreligiousconcerns(6,911).Lackoftransportationinruralareasandcostfactorsmayalsoplayarole in thedecision tohaveahomebirth(6,911).References1. Curtin SC, Park MM. Trends in the attendant, place and timing of

births, and in the use of obstetric interventions: United States,198997. National vital statistics reports vol. 47 no 27. Hyattsville,Maryland:NationalCenter forHealthStatistics.1999.

2. MartinJA,HamiltonBE,SuttonPD,etal.Births:Finaldata for2006.Nationalvital statistics reports;vol 57 no 7. Hyattsville, MD: NationalCenter forHealthStatistics.2009.

3. National Center for Health Statistics. Vital statistics of the United States,1993,vol1,natality.Hyattsville,MD.1999.

4. AmericanAssociationofBirthCenters.FindABirthCenter.AccessedSeptember14,2009.Available from:http://www.birthcenters.org.

5. Midwives Alliance of North America, North American Registry ofMidwives, Midwifery Education Accreditation Council, and NationalAssociation of Certified Professional Midwives. Certified professionalmidwives in the United States. Issue Brief, June 2008. AccessedSeptember14,2009.Available from:http://mana.org/pdfs/CPMIssueBrief.pdf.

6. Showalter A. Birthing among the Amish. International Journal ofChildbirthEducationvol15no4.2000.

7. StatisticsCanada.Table1024516Livebirthsand fetaldeaths (still-births),byplaceofbirth(hospitalandnon-hospital),Canada,provincesand territories, annual CANSIM database. Accessed April 30, 2009.Available from:http://cansim2.statcan.gc.ca.

8. Midwives Alliance of North America. Direct-entry midwifery state-by-state legal status. Accessed June 22, 2009. Available from:http://mana.org/statechart.html.

9. Declercq ER, Stotland N. Home Birth. In UpToDate, Rose, BD (Ed),UpToDate, Waltham, MA. 2009. Accessed September 15, 2009.Available from:www.uptodate.com.

10. Boucher D, Bennett C, McFarlin B, Freeze R. Staying home to givebirth:WhywomenintheUnitedStateschoosehomebirth.JMidwiferyWomensHealth54:11926.2009.

11. WessonN.Homebirth:Apracticalguide.PinterandMartin:London.2006.

12. American College of Obstetricians and Gynecologists. ACOG State-mentofPolicyasissuedbytheACOGexecutiveboard.HomeBirthsintheUnitedStates.Washington,DC:ACOG.May4,2007.

13. American Medical Association House of Delegates. Resolution: 205(A08).HomeDeliveries.April28,2008.

14. WorldHealthOrganization.Care innormalbirth:Apracticalguide.Depart-ment of Reproductive Health and Research, World Health Organization.Geneva,Switzerland.1996.AccessedSeptember14,2009.Availablefrom:http://whqlibdoc.who.int/hq/1996/WHO_FRH_MSM_96.24.pdf.

15. American College of Nurse Midwives. Position Statement on HomeBirth. Washington, DC: American College of Nurse Midwives.December2005.

16. American Public Health Association. Increasing access to out-of-hospitalmaternitycareservicesthroughstate-regulatedandnationally-certified direct-entry midwives. APHA Policy Statement #20013.January1,2001.

17. EURO-PERISTAT Project, with SCPE, EUROCAT, EURONEOSTAT.European Perinatal Health ReportData from 2004. 2008.AccessedSeptember14,2009.Available from:www.europeristat.com.

18. Office for National Statistics. Birth statistics. Review of the nationalstatistician on births and patterns of family building in England andWales,2007.SeriesFM1no36.2008.

19. New Zealand Health Information Service. Report on maternity:Maternal and newborn information. New Zealand Ministry of Health,Wellington, New Zealand. 2007. Accessed September 14, 2009.Available from: http://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdf.

20. RoyalCollegeofObstetriciansandGynaecologistsandRoyalCollegeofMidwives.Homebirths.RoyalCollegeofObstetriciansandGynae-cologists and Royal College of Midwives Joint Statement No 2.London,England:April2007.
http://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdfhttp://www.nzhis.govt.nz/moh.nsf/pagesns/73/$File/maternityreport04.pdf


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7ationalVitalStatisticsReports,Vol.58,No.11,March3,2010N21. National Center for Health Statistics. 2003 revision of the U.S.

Standard Certificate of Live Birth. 2003. Accessed September 14,2009. Available from: http://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htm.

22. NationalCenter forHealthStatistics.Reportof thePanel toEvaluatetheU.S.StandardCertificatesandReports.NationalCenterforHealthStatistics. 2000. Accessed September 14, 2009. Available from:http://www.cdc.gov/nchs/data/dvs/panelreport_acc.pdf.

23. Osterman MJK, Martin JA, Menacker F. Expanded Health Data fromtheNewBirthCertificate,2006.Nationalvitalstatistics reportsvol58no5.Hyattsville,MD:NationalCenter forHealthStatistics.2009.

24. Walker D, Brooks-Schmunk S, Summers L. Do birth certificate dataaccurately reflect thenumberofCNM-attendedbirths?Anexploratorystudy.JMidwiferyWomensHealth,49(5):44348.2004.

ListofDetailedTables1. Number and percent distribution of births, by place of birth:

United States, 19902006 . . . . . . . . . . . . . . . . . . . . . . . . . . 82. Numberandpercentageofbirths,byplaceofbirthandselected

characteristics: United States, 2006. . . . . . . . . . . . . . . . . . . . 93. Numberofbirths,byplaceofbirth:UnitedStatesandeachstate,

20052006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114. Percentage of births, by place of birth 20052006, and percent

change in homebirths 20032004 to 20052006: United Statesand each state . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

5. Number and percent distribution of births, by place of birth andbirth attendant: United States, 2006 . . . . . . . . . . . . . . . . . . . 13

6. Numberandpercentdistributionofhomebirthsbybirthattendant,and percent distribution of home births by planning status andbirth attendant: 19 states, 2006 . . . . . . . . . . . . . . . . . . . . . . 13
http://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htmhttp://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htm


8/15

8 NationalVitalStatisticsReports,Vol.58,No.11,March3,2010Table1.Numberandpercentdistributionofbirths,byplaceofbirth:UnitedStates,19902006

2006 . .2005

. .2004 . .

2003 . .2002 . .2001 . .2000 . .1999 . .1998 . .1997 . .1996 . .1995 . .1994 . .1993 . .1992 . .1991 . .1990 . .

2006 . .2005 . .2004 . .2003 . .2002 . .2001 . .2000 . .1999 . .1998 . .1997 . .1996 . .1995 . .1994 . .1993 . .1992 . .1991 . .1990 . .

Year

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

Total

. . . . . 4,265,555

. . . . .

4,138,349

. . . . . 4,112,052

. . . . . 4,089,950

. . . . . 4,021,726

. . . . . 4,025,933

. . . . . 4,058,814

. . . . . 3,959,417

. . . . . 3,941,553

. . . . . 3,880,894

. . . . . 3,891,494

. . . . . 3,899,589

. . . . . 3,952,767

. . . . . 4,000,240

. . . . . 4,065,014

. . . . . 4,110,907

. . . . . 4,158,212

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

. . . . . 100.00

Inhospital

4,226,6244,100,608

4,075,7094,053,9873,986,1903,989,6624,020,8773,923,0593,903,7703,843,5063,853,7283,860,5553,912,1953,959,2664,021,6084,064,1534,109,634

99.1099.1099.1399.1399.1299.1199.0799.0999.0699.0699.0599.0298.9899.0098.9498.8898.87

OutofhospitalNot

stated

363339

765240120327302381734867681720453944389919

1,632

...

...

...

...

...

...

...

...

...

...

...

...

...

...

...

...

...

Total

38,56837,402

35,57835,72335,41635,94437,63535,97737,04936,52137,08538,31440,11940,03043,01745,83546,946

0.900.900.870.870.880.890.930.910.940.940.950.981.021.001.061.121.13

BirthingHome center

Number24,970 10,78124,468

10,217

23,150 9,62023,221 9,77922,980 9,68323,245 9,97823,843 10,73823,518 9,64223,232 10,69323,236 10,26423,784 10,27824,276 10,52424,694 11,78725,084 11,23825,923 13,25527,480 14,22827,678 14,759

Percentdistribution10.59 0.250.59 0.250.56 0.230.57 0.240.57 0.240.58 0.250.59 0.260.59 0.240.59 0.270.60 0.260.61 0.260.62 0.270.62 0.300.63 0.280.64 0.330.67 0.350.67 0.36

Clinicordoctors

office

414350

469397385494466464857705778876923977900

1,0101,128

0.010.010.010.010.010.010.010.010.020.020.020.020.020.020.020.020.03

Other

2,4032,367

2,3392,3262,3682,2272,5882,3532,2672,3162,2452,6382,7152,7312,9393,1173,381

0.060.060.060.060.060.060.060.060.060.060.060.070.070.070.070.080.08

. . . Category1Notstateds notapplicable.weresubtracted from totalsbeforepercentageswerecomputed.


9/15

9NationalVitalStatisticsReports,Vol.58,No.11,March3,2010Table2.Numberandpercentageofbirths,byplaceofbirthandselectedcharacteristics:UnitedStates,2006

Total1In

hospital

OutofhospitalPercenthomebirths3

PercentbirthingcenterbirthsTotal2 Home

Freestandingbirthingcenter

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RaceandHispanicoriginofmother

Non-Hispanicwhi te. . . . . . . . . . . . . . . . . . . . . . . . . Non-Hispanicblack. . . . . . . . . . . . . . . . . . . . . . . . . American Indian . . . . . . . . . . . . . . . . . . . . . . . . . . AsianorPacific Islander. . . . . . . . . . . . . . . . . . . . . . Hispanic total . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mexican. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PuertoRican. . . . . . . . . . . . . . . . . . . . . . . . . . . Cuban. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CentralorSouthAmerican. . . . . . . . . . . . . . . . . . . OtherandunknownHispanic . . . . . . . . . . . . . . . . .

Originnotstated . . . . . . . . . . . . . . . . . . . . . . . . . . Maternalage(inyears)

Under15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1519 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1517 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1819 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2024 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2529 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3034 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3539 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4044 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45orover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MaritalstatusMarried. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unmarried. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Livebirthorder1st . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2nd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3rd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4th . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5th . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6th . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7th . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8ormorebirths . . . . . . . . . . . . . . . . . . . . . . . . . . Notstated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BirthplaceofmotherBorn in the50statesandD.C.. . . . . . . . . . . . . . . . . . Bornoutside the50statesandD.C. . . . . . . . . . . . . . .

Mexico. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PuertoRico. . . . . . . . . . . . . . . . . . . . . . . . . . . . Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Restof theworld . . . . . . . . . . . . . . . . . . . . . . . .

Notstated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Plurality

Single . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mult iple. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Birthweight (ingrams)2499or less. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2500ormore. . . . . . . . . . . . . . . . . . . . . . . . . . . . Notstated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See footnotesatendof table.

4,265,555

2,308,640617,247

47,721241,045

1,039,077718,146

66,93216,936

165,32171,74230,396

6,396435,436138,943296,493

1,080,4371,181,899

950,258498,616105,539

6,974

2,623,6091,641,946

1,696,9891,354,414

716,670288,768105,832

42,06418,44818,67423,696

3,190,4071,058,706

464,99120,83011,499

561,38616,442

4,121,930143,625

351,9743,908,874

4,707

4,226,624

2,278,520614,307

47,418240,074

1,035,136715,707

66,61416,846

164,58671,38329,619

6,353433,955138,475295,480

1,072,8241,170,014

940,125492,725103,799

6,829

2,592,2871,634,337

1,687,6441,343,884

709,809284,515103,286

40,49317,34816,70622,939

3,157,0661,053,527

463,42420,74911,063

558,29116,031

4,083,344143,280

350,1583,872,166

4,300

38,568

29,8712,898

300966

3,9202,427

31590

731357730

431,463

4669977,573

11,80710,048

5,8071,697

130

31,0707,498

9,25510,453

6,7904,2142,5231,5651,0931,963

712

33,2005,1601,563

81434

3,082208

38,237331

1,78136,401

386

24,970

19,8931,878

150593

2,0061,202

17043

366225525

33835288547

4,4837,4516,6984,0981,274

98

20,2884,682

5,2206,5824,5002,8511,8081,137

8271,438

607

21,9882,866

69645

2711,854

116

24,724246

1,29023,355

325

10,781

8,396534

79242

1,479965117

39262

9678

6432108324

2,3613,5892,7451,309

31623

9,0391,742

3,4923,1691,740

976521312186351

34

8,9991,748

68930

133896

34

10,75823

11410,655

12

0.59

0.860.300.310.250.190.170.250.250.220.31- - -

0.520.190.210.180.410.630.700.821.211.41

0.770.29

0.310.490.630.991.712.704.487.70- - -

0.690.270.150.222.360.33- - -

0.600.17

0.370.60- - -

0.25

0.360.090.170.100.140.130.170.230.160.13- - -

0.090.100.080.110.220.300.290.260.300.33

0.340.11

0.210.230.240.340.490.741.011.88- - -

0.280.170.150.141.160.16- - -

0.260.02

0.030.27- - -


10/15


11/15

NationalVitalStatisticsReports,Vol.58,No.11,March3,2010 11Table3.Numberofbirths,byplaceofbirth:UnitedStatesandeachstate,20052006

Stateof residence Total Inhospital

OutofhospitalNot

statedTotal HomeFreestanding

birthingcenter

Clinicordoctors

office OtherTotal . . . . . . . . . . . . . . . . . . . . . Alabama . . . . . . . . . . . . . . . . . . . Alaska . . . . . . . . . . . . . . . . . . . . Arizona. . . . . . . . . . . . . . . . . . . . Arkansas. . . . . . . . . . . . . . . . . . . California. . . . . . . . . . . . . . . . . . . Colorado . . . . . . . . . . . . . . . . . . . Connecticut . . . . . . . . . . . . . . . . . Delaware. . . . . . . . . . . . . . . . . . . District of Columbia . . . . . . . . . . . . Florida . . . . . . . . . . . . . . . . . . . . Georgia . . . . . . . . . . . . . . . . . . . Hawaii . . . . . . . . . . . . . . . . . . . . Idaho . . . . . . . . . . . . . . . . . . . . . Illinois . . . . . . . . . . . . . . . . . . . . Indiana . . . . . . . . . . . . . . . . . . . . Iowa . . . . . . . . . . . . . . . . . . . . . Kansas. . . . . . . . . . . . . . . . . . . . Kentucky. . . . . . . . . . . . . . . . . . . Louisiana. . . . . . . . . . . . . . . . . . . Maine. . . . . . . . . . . . . . . . . . . . . Maryland. . . . . . . . . . . . . . . . . . . Massachusetts . . . . . . . . . . . . . . . Michigan . . . . . . . . . . . . . . . . . . . Minnesota . . . . . . . . . . . . . . . . . . Mississippi . . . . . . . . . . . . . . . . . . Missouri . . . . . . . . . . . . . . . . . . . Montana . . . . . . . . . . . . . . . . . . . Nebraska. . . . . . . . . . . . . . . . . . . Nevada. . . . . . . . . . . . . . . . . . . . New Hampshire. . . . . . . . . . . . . . . New Jersey . . . . . . . . . . . . . . . . . New Mexico . . . . . . . . . . . . . . . . . New York . . . . . . . . . . . . . . . . . . North Carolina. . . . . . . . . . . . . . . . North Dakota . . . . . . . . . . . . . . . . Ohio . . . . . . . . . . . . . . . . . . . . . Oklahoma . . . . . . . . . . . . . . . . . . Oregon. . . . . . . . . . . . . . . . . . . . Pennsylvania . . . . . . . . . . . . . . . . Rhode Island . . . . . . . . . . . . . . . . South Carolina . . . . . . . . . . . . . . . South Dakota . . . . . . . . . . . . . . . . Tennessee. . . . . . . . . . . . . . . . . . Texas. . . . . . . . . . . . . . . . . . . . . Utah . . . . . . . . . . . . . . . . . . . . . Vermont . . . . . . . . . . . . . . . . . . . Virginia. . . . . . . . . . . . . . . . . . . . Washington . . . . . . . . . . . . . . . . . West Virginia . . . . . . . . . . . . . . . . Wisconsin . . . . . . . . . . . . . . . . . . Wyoming. . . . . . . . . . . . . . . . . . .

8,403,904123,685

21,455198,628

80,1691,111,322

139,69583,53823,63216,494

463,042290,833

36,90647,246

359,592175,824

79,91880,856

114,694124,313

28,263152,474154,541255,189144,444

88,451160,003

24,09152,87277,29528,798

228,79658,771

496,455250,955

17,011298,981105,817

94,611294,473

25,069119,882

23,381166,102785,518105,060

12,806212,372169,579

41,767143,324

14,911

8,327,232123,263

20,298196,443

79,5671,105,153

138,17583,10523,30816,231

458,083289,726

36,44545,932

358,088172,983

79,19679,968

113,464123,999

27,882151,036153,507253,320143,504

88,220158,460

23,40452,74976,34628,480

227,93858,089

492,835249,345

16,909295,449104,990

92,430287,339

24,992119,263

23,312164,522779,546103,234

12,492211,059165,813

41,569140,975

14,796

75,970419

1,1472,169

6006,1461,519

432324263

4,9441,075

4611,3011,4802,822

721887956310378

1,4371,0311,855

937230

1,541686122949317781682

3,6011,609

1003,506

8202,1807,114

75619

681,5755,9641,822

3071,3133,763

1502,349

113

49,438318401888471

4,4451,465

2927274

2,196859401708

1,3931,185

674406872227286646564

1,515858206

1,301549103866255576464

2,586840

931,888

5821,5994,750

64429

53914

2,9321,314

3031,0082,284

1142,050

99

20,99819

6801,192

87741

9119165149

2,354187

0589

3941

22426

56

88766463209

31

110121

1205732

192464485

01,483

203482

2,1672

1410

5802,959

4791

2191,406

30136

4

7647

5141

17

1611

20

221114

1663

4119

2262

2641

73821448

5716

713

19

64424

26430043

1450

4,77075154841

95329108540

3721846

378

69022146075

219

2105

722257

81662

1169

18494268

0122

3490

1335

4711556926

38669

31810

7023

1016

223

1100

1532

0132419

11

2744313

143121101

770

1912

2671

20201584703

4802


12/15

12 NationalVitalStatisticsReports,Vol.58,No.11,March3,2010Table4.Percentageofbirths,20052006:UnitedStatesandbyplaceofeachstate birth20052006,andpercentchange inhomebirths20032004 to

StateofresidenceTotal . . . . . . . . . . . . . . . . . . . . . Alabama

. . . . . . . . . . . . . . . . . . .

Alaska . . . . . . . . . . . . . . . . . . . . Arizona. . . . . . . . . . . . . . . . . . . . Arkansas. . . . . . . . . . . . . . . . . . . California. . . . . . . . . . . . . . . . . . . Colorado. . . . . . . . . . . . . . . . . . . Connecticut . . . . . . . . . . . . . . . . . Delaware. . . . . . . . . . . . . . . . . . . DistrictofColumbia . . . . . . . . . . . . Florida . . . . . . . . . . . . . . . . . . . . Georgia . . . . . . . . . . . . . . . . . . . Hawaii . . . . . . . . . . . . . . . . . . . . Idaho. . . . . . . . . . . . . . . . . . . . . Illinois . . . . . . . . . . . . . . . . . . . . Indiana. . . . . . . . . . . . . . . . . . . . Iowa . . . . . . . . . . . . . . . . . . . . . Kansas. . . . . . . . . . . . . . . . . . . . Kentucky

. . . . . . . . . . . . . . . . . . .

Louisiana. . . . . . . . . . . . . . . . . . . Maine. . . . . . . . . . . . . . . . . . . . . Maryland. . . . . . . . . . . . . . . . . . . Massachusetts . . . . . . . . . . . . . . . Michigan. . . . . . . . . . . . . . . . . . . Minnesota . . . . . . . . . . . . . . . . . . Mississippi. . . . . . . . . . . . . . . . . . Missouri . . . . . . . . . . . . . . . . . . . Montana . . . . . . . . . . . . . . . . . . . Nebraska. . . . . . . . . . . . . . . . . . . Nevada. . . . . . . . . . . . . . . . . . . . NewHampshire. . . . . . . . . . . . . . . NewJersey . . . . . . . . . . . . . . . . . NewMexico. . . . . . . . . . . . . . . . . New York . . . . . . . . . . . . . . . . . . NorthCarolina. . . . . . . . . . . . . . . . North

Dakota

. . . . . . . . . . . . . . . .

Ohio . . . . . . . . . . . . . . . . . . . . . Oklahoma . . . . . . . . . . . . . . . . . . Oregon. . . . . . . . . . . . . . . . . . . . Pennsylvania . . . . . . . . . . . . . . . . Rhode Island . . . . . . . . . . . . . . . . SouthCarolina . . . . . . . . . . . . . . . SouthDakota . . . . . . . . . . . . . . . . Tennessee. . . . . . . . . . . . . . . . . . Texas. . . . . . . . . . . . . . . . . . . . . Utah . . . . . . . . . . . . . . . . . . . . . Vermont . . . . . . . . . . . . . . . . . . . Virginia. . . . . . . . . . . . . . . . . . . . Washington . . . . . . . . . . . . . . . . . WestVirginia . . . . . . . . . . . . . . . . Wisconsin . . . . . . . . . . . . . . . . . . Wyoming. . . . . . . . . . . . . . . . . . .

Inhospital

99.1099.66

94.6598.9199.2599.4598.9199.4898.6398.4198.9399.6398.7597.2599.5998.3999.1098.9099.16

99.7598.6699.0699.3399.2799.3599.7499.0497.1599.7798.7798.9099.6698.8499.2799.3699.41

98.8399.2397.7097.5899.7099.4899.7199.0599.2498.2797.6099.3897.7899.6498.3699.24

Outofhospital Percentagechange in

homebirths20032004

to200520063.5

18.2

0.52.2

14.55.3

2.912.9

21.12.3

6.06.3

1.92.64.9

21.26.3

16.326.7

10.0

5.635.5

9.11.7

25.50.02.5

10.117.4

10.421.9

3.80.02.0

32.027.9

37.0

5.26.32.5

36.87.7

23.35.82.83.3

7.820.5

4.717.47.5

25.8

Total1

0.900.34

5.351.090.750.551.090.521.371.591.070.371.252.750.411.610.901.100.84

0.251.340.940.670.730.650.260.962.850.231.231.100.341.160.730.640.59

1.170.772.302.420.300.520.290.950.761.732.400.622.220.361.640.76

Home0.590.26

1.870.450.590.401.050.350.300.450.470.301.091.500.390.670.840.500.76

0.181.010.420.360.590.590.230.812.280.191.120.890.250.790.520.330.55

0.630.551.691.610.260.360.230.550.371.252.370.471.350.271.430.66

Freestandingbirthingcenter0.250.02

3.170.600.110.070.010.140.700.900.510.060.001.250.000.540.030.530.00

0.000.310.500.300.080.000.000.070.500.000.030.200.010.330.090.190.00

0.500.190.510.740.010.120.000.350.380.460.010.100.830.070.090.03

Indicatesstatisticallysignificant1Includesbirths ina freestandingNOTE:Notstatedsareexcluded

changeat thep


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NationalVitalStatisticsReports,Vol.58,No.11,March3,2010 13Table5.Numberandpercentdistributionofbirths,byplaceofbirthandbirthattendant:UnitedStates,2006

Placeofbirth Total1

BirthattendantPhysician

Certifiednurse

midwife OtherMidwife OtherTotal Medicaldoctor Doctorofosteopathy

Total2. . . . . . . . . . . . . . . . . . . . . Hospital . . . . . . . . . . . . . . . . . . . Outofhospital . . . . . . . . . . . . . .

Home . . . . . . . . . . . . . . . . . . . Freestandingbirthingcenter . . . . . Clinicordoctorsoffice . . . . . . . . Other . . . . . . . . . . . . . . . . . . .

4,265,5554,226,624

38,568 24,970 10,781

414 2,403

3,905,1463,901,518

3,565 1,849

882 273 561

3,698,6413,695,492

3,090

1,682

620

252

536

Number

206,505206,026

475 167 262

21 25

317,168306,629

10,502 3,951 6,244

58 249

19,1794,735

14,435 10,823

3,397 31

184

21,79812,469

9,112 7,623

218 50

1,221 Percentdistribution3

Total . . . . . . . . . . . . . . . . . . . . . Hospital . . . . . . . . . . . . . . . . . . . Out of hospital . . . . . . . . . . . . . .

Home . . . . . . . . . . . . . . . . . . . Freestandingbirthingcenter . . . . . Clinicordoctorsoffice . . . . . . . . Other . . . . . . . . . . . . . . . . . . .

100.0099.10

0.90 0.59 0.25 0.01 0.06

100.0099.91

0.09 0.05 0.02 0.01 0.01

100.0099.92

0.08

0.05

0.02

0.01

0.01

100.0099.77

0.23 0.08 0.13 0.01 0.01

100.0096.69

3.31 1.25 1.97 0.02 0.08

100.0024.70 75.30 56.46 17.72

0.16 0.96

100.0057.78 42.22 35.32

1.01 0.23 5.66

1Notstatedbirthattendant included in totalsbutnotshownseparately.2Notstatedplaceofdelivery included in totalsbutnotshownseparately. 3Notstatedplaceofdeliverywassubtracted from totalsbeforepercentageswerecomputed.

Table6.Numberandpercentdistributionofhomebirthsplanningstatusandbirthattendant:19states,2006 bybirthattendant,andpercentdistributionofhomebirthsby

Total1

BirthattendantPhysician

Certifiednurse

midwife OtherMidwife OtherTotal Medicaldoctor DoctorofosteopathyNumber

Percentof

ofhome births. . . . . . . . . . totalbirths. . . . . . . . . . .

12,475 0.61

592 0.03

515 0.03

77 0.08

2,411 1.64

5,283 57.64

3,660 30.25

Homebirths2 . . . . . . . . . . . . . . . . Plannedhomebirths . . . . . . . . . . . Unplannedhomebirths . . . . . . . . .

100.083.2 16.8

100.037.3 62.7

100.031.0 69.0

100.078.6 21.4

100.097.8

2.2 100.0

98.9 1.1

100.064.9 35.1

1Notstatedbirthattendant included in totalsbutnotshownseparately.2Notstatedplanningstatuswassubtracted from totalsbeforepercentswerecomputed.NOTE:Data from the2003Revisionof theU.S.StandardCertificateofBirth. Includesdata fromCalifornia,Delaware,Florida, Idaho,Kansas,Kentucky,(excludingNewYorkCity),NorthDakota,Ohio,Pennsylvania,SouthCarolina,SouthDakota,Tennessee,Texas,Vermont,Washington,andWyoming. Nebraska,NewHampshire,NewYork


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14 NationalVitalStatisticsReports,Vol.58,No.11,March3,2010TechnicalNotesSourcesofdata

This report contains 2006 data on items that are collected onboth the 1989 Revision of U.S. Standard Certificate of Live Birth(unrevised) and the 2003 Revision of U.S. Standard Certificate ofLive

Birth

(revised).

The

2003

revision

is

described

in

detail

else-where (21, 22). The 2003 revision was seen as an important

opportunitytoimprovedataquality,primarilythroughthedevelopmentofdetailed,standardizeddatacollection techniques (23).Placeofbirth

Theplaceofbirthvariableiscomparablebetweenthe1989and2003revisionsoftheU.S.StandardCertificateofBirth.Thisvariableincludesseparatecategoriesforhospital,freestandingbirthingcenter,home, clinic or doctors office, other, and unknown.Hospital birthsmay include births occurring en-route or upon arrival at a hospital(24).Placeofbirth,a legal itemon thebirthcertificate, isverywellreported.

In

2006,

this

information

was

not

reported

for

only

363

out

4,265,555births (0.01%ofbirths) (2).

The2003revisionofthebirthcertificateaddedanitemforhomebirths:Plannedtodeliverathome?(yes,no).Dataonwhetherahomebirthwasplannedorunplannedareavailable for the19states thatimplementedthe2003RevisionoftheU.S.StandardCertificateofBirthon or before January1,2006:California,Delaware,Florida, Idaho,Kansas,Kentucky,Nebraska,NewHampshire,NewYork (excludingNewYorkCity),NorthDakota,Ohio,Pennsylvania,SouthCarolina,SouthDakota,Tennessee,Texas,Vermont,Washington,andWyoming.The2,073,368birthstoresidentsofthe19statescomprise49percentofallU.S.birthsin2006.ResultsforthislimitedreportingareaarenotgeneralizabletotheUnitedStatesasawholebecausetheyarenotarandomsampleofbirths.BecauseCaliforniaandTexasare includedinthe19-statearea,thisareahasahigherpercentageofMexican(andoverallHispanic)births than theUnitedStatesasawholeand thisHispanicpopulationmaynotberepresentativeofallHispanicsintheUnitedStates;see ExpandedHealthData from theNewBirthCer-tificate,2006for further information(23).

Planningstatusofhomebirthisarelativelynewvariableonthebirthcertificate,solessisknownaboutthequalityofthesedatawhencomparedwithmostotherbirthcertificatevariables.Forhomebirthsinthe19revisedstates,theplanningstatuswasunknownfor5.5%ofbirths.However,424ofa totalof688birthswithunknownplanningstatuswere fromasinglestate (Pennsylvania);whendata from thisstatewereexcluded,thepercentageofbirthswithunknownplanningstatusdroppedto2.6%.Severalstates(Idaho,NewHampshire,Ohio,Vermont,andWyoming)hadnohomebirthswithunknownplanningstatus.Incontrast,17.4%ofhomebirthsinPennsylvania,and20.4%ofhomebirthsinNorthDakotahadunknownplanningstatus,althoughthe latter figurewasbasedononly10birthswithunknownplanningstatus.PatternsofhomebirthsbyplanningstatusweresimilarwhendatafromPennsylvaniaandNorthDakotawereexcluded,with81%ofhome births being planned, compared with 83% when data fromPennsylvaniaandNorthDakotawere included in theestimates (seeTable6).Although2006marksthefirstyearofimplementationofthenewcertificateforsevenofthestatesincludedinthisreport,theuseofthenewcertificateisrelativelynewforallstates(23)anddataquality

mayimproveovertimeashomebirthattendantsbecomemorefamiliarwiththenewdataitems.Moreassessmentisneededoftheaccuracyofreportingofplanningstatus forhomebirths,as thepercentageofunknowns isjustonemeasureofdataquality.Attendantatbirth

Forboth therevisedandunrevisedcertificates,birthattendantsareclassifiedtooneofthefollowingcategories:medicaldoctor(MD),doctor of osteopathy (DO), certified nursemidwife/certifiedmidwife(CNM/CM), othermidwife, other, and unknown. There is evidencethatthenumberofbirthsbyCNMsisunderstated(24),largelyduetodifficulty in correctly identifying the birth attendantwhenmore thanoneproviderispresentatthebirth.Anecdotalevidencesuggeststhatsome hospitals require that a physician be reported as the birthattendantevenwhennophysicianisphysicallypresentatamidwife-attendedbirth (24).Randomvariation innatalitydata

The number of births reported for an area is essentially acomplete count because more than 99percent of all births areregistered.Although thisnumber isnotsubject to samplingerror, itmaybeaffectedbynonsamplingerrorssuchasmistakesinrecordingthemothersresidenceorageduringtheregistrationprocess.Whenthe number of births is used for analytic purposes (that is, thecomparison of numbers, rates, and percentages over time, fordifferent areas, or between different groups), thenumberof eventsthatactuallyoccurredcanbe thoughtofasoneoutcome ina largeseriesofpossible results thatcouldhaveoccurredunder thesame(orsimilar)circumstances.Whenconsidered inthisway,thenumberofbirthsissubjecttorandomvariationaccordingtocertainstatisticalassumptions. For further information see the Technical Notes ofBirths:FinalData for2006(2).Statements in the text thatagivennumberorpercentage ishigheror lower thananother indicate thatthedifference isstatisticallysignificant.


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16 NationalVitalStatisticsReports,Vol.58,No.11,March3,2010

ContentsAbstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Trends inhomeandout-of-hospitalbirths. . . . . . . . . . . . . . . 2Variations inhomebirthsbymaternaland infant

characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Geographic differences . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Attendant at birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Planned and unplanned home births . . . . . . . . . . . . . . . . . . 4

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6List of Detailed Tables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Technical Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

AcknowledgmentsThisreportwaspreparedunder thegeneraldirectionofCharlesJ.Rothwell,Director of the Division of Vital Statistics (DVS), and Stephanie J. Ventura,Chief of the Reproductive Statistics Branch (RSB). Steve Steimel of theSystems,Programming,andStatisticalResourcesBranch(SPSRB)preparedthe natality file under the general direction of Nicholas F. Pace, Chief ofSPSRB. Yashodhara Patel and Michelle J.K. Osterman of RSB providedcontent review.Staffof theDataAcquisistionandEvaluationBranchcarriedoutqualityevaluationandacceptanceprocedures for thestatedata filesonwhich thisreport isbased.TheRegistrationMethodsstaffofDVSconsultedwithstatevitalstatisticsofficesregarding thecollectionofbirthcertificatedata.ThisreportwaseditedbyDemariusV.Miller,CDC/NCHM/DivisionofCreativeServices,Writer-EditorServicesBranch;typesetbyJacquelineM.Davis,CDC/NCHM/Divisionof Creative Services, Graphics Services Branch; and graphics were produced byKyungPark,CDC/NCHM/DivisionofCreativeServices,NOVAcontractor.

SuggestedcitationMacDormanM,MenackerF,DeclercqE.Trendsandcharacteristicsofhomeandotherout-of-hospitalbirths in theUnitedStates,19902006.Nationalvitalstatisticsreports;vol58no11.Hyattsville,MD:NationalCenter forHealthStatistics.2010.

Copyright informationAllmaterialappearing in thisreport is in thepublicdomainandmaybereproducedorcopiedwithoutpermission;citationas tosource,however,isappreciated.

NationalCenterforHealthStatisticsEdwardJ.Sondik,Ph.D.,Director

JenniferH.Madans,Ph.D.,AssociateDirector forScienceDivisionofVitalStatistics

CharlesJ.Rothwell,M.S.,Director

U.S.DEPARTMENTOFHEALTH&HUMANSERVICESCenters forDiseaseControlandPreventionNationalCenter forHealthStatistics3311ToledoRoadHyattsville,MD20782

FIRSTCLASSMAILPOSTAGE&FEESPAID

CDC/NCHSPERMITNO.G-284

OFFICIALBUSINESSPENALTYFORPRIVATEUSE,$300Toreceive thispublicationregularly,contacttheNationalCenter forHealthStatisticsbycalling1-800-232-4636E-mail:[email protected]:www.cdc.gov/nchsCS209015T35799(03/2010)DHHSPublicationNo.(PHS)20101120

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