Choosing a Birthplace

The vast majority of births in America take place in hospitals. About 1.5% birth out of hospital. (CDC)

Your birth experience will be profoundly influenced by the environment in which you labor and give birth. Hospitals, out-of-hospital birth centers, and home births can all be beautiful, empowering, and safe, but they are different – each with its own advantages and disadvantages.So, it’s important to think in advance about your goals: what you want your birth to be like and which venue will do the best job of supporting that.

A childbirth educator friend of mine often uses this metaphor: you may have a fabulous Chinese restaurant near your home where other people have had great experiences, but if you really want a good burrito, you shouldn’t go to the Chinese restaurant and expect them to make a good burrito.

Risk Status

It’s important to address up-front: if you are experiencing a low-risk pregnancy (most pregnant people are), and your baby is looking healthy, you can choose any of these birth places. If you or baby have conditions that are potentially high risk, then a hospital is the best place for your birth.

How do you know if you’re a low-risk parent? A health care provider can assess your situation with a complete medical history and exam. An example of a low-risk pregnancy may be someone who’s in general good health without major medical problems or previous uterine surgery, is older than seventeen but younger than thirty-eight, is not obese and is having an uncomplicated pregnancy with a single baby.

Hospital Births

Advantages: Insurance coverage readily available. At most urban hospitals, epidural anesthesia is available 24 hours a day for women who choose to use it. Emergency equipment is available at all times if needed. That is why the hospital is the safest environment for high risk pregnancies. Some low-risk women feel safest in a hospital, and feeling safe helps labor to progress faster and with less pain than when we are fearful.

Disadvantages: Hospital policies often place restrictions on the choices laboring women can make; policies may affect mobility, eating and drinking while in labor, choice of position for birth, etc. Nursing staff may change throughout the labor, and are typically strangers to the family. Interventions such as I.V.’s, electronic fetal monitoring, medical induction, and augmentation may be commonplace routines. Birth is viewed as a medical event, managed with medical interventions to prevent possible complications.

Additional considerations: Note that hospitals vary widely in their services, policies, attitudes about birth, and “homelike” atmospheres. (Check out Consumer Reports article that says your odds of having a C-section are 9 times higher if you pick the wrong hospital.)

Depending on your insurance coverage, and where you live, you may have several hospitals to choose from. Try to learn about your options through tours and online information sources, and choose the hospital which best suits your needs. (Learn more.) Some states have a lot of data available about different hospitals (like California Hospital Compare). To get pointers for your state, check https://www.cesareanrates.org/ or https://www.consumerreports.org/health/hospitals/ratings.

Home Births

Advantages: Parents have more flexibility, control, and choices regarding labor. Moms may feel more relaxed and secure in their own territory. Personalized care: caregivers are guests in the home, and no unfamiliar people are present. Older children can be present for as much of the birth as desired. Mother is able to avoid ‘routine’ interventions, such as I.V.s, monitoring, and augmentation. Intervention rates are minimal, complication rates are typically low. Low risk of infection. Low cost. Birth is viewed as a natural event, and part of the on-going life experience of the family.

Disadvantages: Insurance coverage possible in some states, not in others. Of those who started labor planning a home birth, 11% transferred to a hospital during labor. (7.5% for mothers who have birthed before, 23% for first-time mothers.) (Source) Most transfers (96.6%) are for non-emergency situations.

The most common reasons are a prolonged labor (41% of transfers), desire for pain medication (15%), meconium on amniotic fluid (10%), baby’s position (6%) or maternal exhaustion. (5%) (source)

Additional considerations: Mother should be in good health, and experiencing a low risk pregnancy. Choice of a well-trained and competent caregiver is essential; as is a clear plan for hospital transfer. The home should be within 10-20 minute drive to a hospital.

Birth Center Births

Childbirth centers are a compromise between home and hospital births. They provide a ‘home-like’ setting for active labor, birth, and the first few hours after birth.

Advantages over homebirth: May feel safer than homebirth for some women. (Although in reality, a midwife at a home birth has all the same emergency supplies as she would have at a birth center.) May be closer to hospital than family’s home, in case transfer is needed. Often covered by insurance. (Note that some families choose birth centers because they don’t want to worry about cleaning up their home after the birth. It’s important to know that midwives typically help clean up the birth space after the birth, whether it’s at home or a birth center.)

Advantages over hospital: Less expensive. Fewer restrictive policies. Non-interventive care, with lower chance of cesarean section. May result in a more positive birth experience. Positive environment centered on childbirth, not focused on treating illness. They are similar in philosophy to homebirth, with a focus on birth as a natural event, and on empowering the mother to make choices about how to give birth.

Disadvantages: Early labor may be affected by anxiety over when it will be time to go to the birth center; active labor can be affected by anxiety about whether transfer to the hospital will become necessary. This uncertainty can slow or disrupt labor progress. Most birth centers ask the parents to leave the birth center a few hours after the birth; some parents are ready to leave at that time, some wish they could stay and cocoon.

Finding a birth center: search at https://www.birthcenters.org/search/

Factors in Choosing a Birthplace

Care provider preference

As a general rule (it varies a bit by state), women birthing in a hospital may choose between an obstetrician, a family practice doctor, and a nurse-midwife. Women birthing at home or in a birth center typically see either a nurse-midwife or a direct-entry midwife. Learn more about maternity care providers here.

Cost Comparison

How do costs compare? An uncomplicated home birth might cost $3000-4000, which includes prenatal care costs. A birth center would cost $1000-2000 more than that. A hospital birth might cost $30,000. Note that medical insurance may cover a majority of the costs of hospital birth, and are less likely to cover home birth, depending on the state, so your actual out of pocket cost depends on a lot of factors.

Safety Comparison

When asked why they chose hospital birth, most women say “Safety.” How do birthplaces compare on intervention rates and safety?

Again, a high risk woman should give birth in a hospital which has all available resources. So, let’s look only at low risk women:

On average, they will have fewer interventions if they plan to give birth outside a hospital – less likely to be induced, augmented, receive pain medication, have their mobility and food intake restricted or have second stage interventions, such as episiotomy, vacuum and forceps.

In terms of outcomes – for a planned out-of-hospital birth with a trained caregiver, women and babies can do just as well with out-of-hospital birth as they do with hospital birth.

For more discussion on this, check out these resources. When looking at studies, be sure to look only at planned home births for low-risk women who have well-trained midwives with clear and effective plans to transfer if needed (i.e. don’t look at studies that mix in outcomes from unexpected, unsupported “surprise” home births).

• Outcomes of Care for 16,924 Planned Home Births in the United States https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.12172 (there’s a plain language article about this study here: https://mana.org/blog/home-birth-safety-outcomes)
• ACOG Committee Opinion on Planned Home Birth: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Planned-Home-Birth
• Dueling Statistics: Is Home Birth Safe? https://www.scienceandsensibility.org/p/bl/et/blogid=2&blogaid=817

Researching your options and making a decision:

To learn more about how to research your options, and to get lists of questions to ask at possible birthplaces, go to:  http://www.childbirthconnection.org/healthy-pregnancy/choosing-a-place-of-birth/

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