Adriana Lozada goes through the pros and cons of three places where you can give birth: a hospital, a birth center, and at home, and what you should consider when making an informed decision.
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- Maternal outcomes and birth interventions among women who begin labour intending to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses, The Lancet
- Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses, The Lancet
- Report on birth settings in the US: maternal and neonatal outcomes, Journal of Pediatrics
- United States community births increased by 20% from 2019 to 2020, Birth: Issues in Perinatal Care
- How Does Access to Midwifery Care Impact Outcomes? The Birth Place Lab (BPL), in the Faculty of Medicine at the University of British Columbia
- Why Giving Birth Is Safer in Britain Than in the U.S., ProPublica
- Where is best for birth: Hospital or home? Harvard Health Blog
- Home vs Birthing Center vs Hospital: Where to Give Birth, Kopa Birth
- Home Birth or Hospital Birth- How Do I Choose? DC Metro Maternity
- Home Births Became More Popular During the Pandemic. But Many Insurers Still Don’t Cover Them, Time
- As home births rise in popularity, some midwives operate in a legal gray area, NPR
Related Birthful episodes:
Exploring Your Options of Where to Give Birth
Adriana Lozada: Hello Mighty Parent or Parent-to-Be.
Welcome to Birthful, I’m Adriana Lozada and you are listening to another episode in our series on Models and Places of Birth.
Now, so far in this series, we’ve used a very wide-angle lens to explore the ideals and models that lay the foundation, if you will, for how we approach birth, both culturally and institutionally. Today, I thought we’d get a little more granular, a little more detailed, and look at the pros and cons of the three most common places people tend to give birth, which are a hospital, at a freestanding birth center, or at home, and also talk about how these options can shape and influence how your birth unfolds.
If you’ve never thought of giving birth in any other place than in a hospital, you are not alone.
98% of US births happen in a hospital, in part because many people don’t know that they have other options, but mainly because of the limited access to birth centers and homebirth midwives. However, births at freestanding birth centers and homebirths, which are collectively called community births or out-of-hospital births, have been slowly yet steadily increasing since 2004 and that rise has been gaining more momentum since 2020 with the pandemic playing a large part in boosting that nationwide trend.
Figuring out where to give birth is an important decision, because physiological birth flows best when you feel safe, supported, heard, and cared for, and so if you don’t necessarily feel that way in a hospital, it might be worth your while exploring other options.
So I’m going to do a quick rundown of how each birth setting differs. And I want to make sure, you know, I’m not going to talk about safety because that is a very detailed and nuanced conversation for another day. But I will say that the research shows that if you have a low risk, full-term pregnancy, all birth settings carry similar risks.
So, let’s start with the hospital. About 98% of births happen in the hospitals in the U.S., and it’s the most widely-available option, although there are significant holes in rural and urban settings that leave many in health deserts with no good options. Hospitals serve people who are low risk and also high-risk patients because they need to access maternal-fetal medicine specialists and of all hospital births, that’s about 15% that require a higher risk specialist. Also, in hospitals, most of the providers are OBs, so about 86% of them, although there are some mixed practices where there’s OBs and midwives working together. And then even though they’re rare, you can get some full midwifery practices working at hospitals.
Hospitals are not all created equally. Even hospitals across the street can have fluctuating cesarean rates with one having a very low cesarean rate, and the other one, you know, extremely high above average. So that’s something to take into account when you’re evaluating which hospital to go to.
Hospitals are of course the most medicalized option and is the one where you’re also gonna get more interventions and more limits to what you can do, limiting your choices, so you might have to follow protocol and get continuous monitoring, and limit what you drink and eat, maybe limit your movement, have lots of cervical checks, lots of people, and go through triage, which is this limbo between staying and going, and you can’t just cocoon into your birth, because you don’t know what you’re gonna do. So, that is also an interruption. Also, very few of them allow waterbirths as an option.
Also in hospitals, you might find that you have less continuity of care because depending on shift change, you might get shuffled between nurses and providers and even rooms. They may also limit the amount of people that you can have present at your birth. This sometimes is important for parents of more than one kid that want the siblings to be present for the birth.
However, you do have more access to pain medication and it is the only option that offers epidurals.
Now, if there is a full midwifery group at the hospital, then you may receive a hybrid of a birth center care with more flexibilities in policies, and fewer interventions with better outcomes.
Hospital births tend to be covered by insurance and in terms of interventions, you have to then figure out that you are going somewhere. You clearly have to figure out during your labor when to go to the hospital, and usually, you can’t go home before 24 hours, because they want to observe the baby for that long.
Lozada: Now, for birth centers, only about 0.4% of births in the U.S. happen in birth centers, even though they’ve been increasing since 2004, and you can have two types of birth centers. One is a freestanding center, or one that is attached to a hospital, but the ones that are attached to a hospital, be careful that they… What you want is units that are autonomous and run by midwives and not just redecorated OB wings.
Usually, birth centers only take patients that are healthy, low risk, and that definition can create limits of what can happen at a birth center, so often no twins, no breech, no people with gestational diabetes, no births after 42 weeks, and no VBACs, although that varies from center to center. Birth centers tend to be midwife-led with a nurse, and it does provide for high continuity of family-centered care. You are definitely connected with your provider.
There is medical equipment available at the birth center, but you will experience less interventions and if you are looking to have an epidural at any point, then that would require a transfer to the hospital, although some birth centers may have the option of nitrous oxide, so laughing gas, and in general will focus on non-medicated comfort measures to help you through the process.
A transfer to a hospital from a birth center is easier or tends to be easier than a transfer from home, because they tend to have policies in place for easy continuity of care, and if you’re having a birth center birth, the statistics are that about 16% of them transfer to a hospital. At a birth center birth, you take the lead. You move however you want, eat whatever you want, the monitoring is usually intermittent, and you have access to a waterbirth. You’ll also have more privacy, because it’s more home-like, but you still have to actually leave your home and go somewhere, and figure out when you’re gonna leave, so that is an intervention.
Not all insurances cover birth center births, however, the staff tends to know how to assist you in figuring out what coverage and payments you will end up having. And you get to go home quicker, usually around four to six hours.
And then your third option would be a homebirth, and in the U.S., close to 1% of all births happen at home. The options there are an assisted birth, assisted by homebirth midwives, or an unassisted birth, also known as a freebirth. If you’re having a birth assisted by midwives, usually they can only serve populations that are healthy, low risk, and then that also creates a definition of limits. Like I mentioned, no twins, no previous cesareans, no breech, no going past 42 weeks. You might find that things vary depending on the midwife and depending on the state.
With homebirth midwives, you usually get continuous care by a small group, and they do bring tons of medical equipment with them, including oxygen, including Pitocin if needed, so it’s not like they show up with just their hands and a little bag. They tend to travel in pairs or have an assistant, because one of them will be caring for you, and the other one for the baby. If you are at home and want to have access to pain medications, like an epidural, then you would have to transfer to a hospital. Of homebirths, about 37% transfer to a hospital, but many of those are non-emergent. If you wanted an epidural that would require a transfer. That 37% is for first-time birthing people. If you’ve already had a baby, then that transfer rate tends to be 9%.
At homebirths, you’ll have very few interruptions and complete control of the environment, so you can decide if other kids are around. It’s super comfortable because you’re already home, so after you’ve given birth, you’re already ready to sleep in your bed, and have all your amenities. You don’t need to go anywhere. And you can have a waterbirth if you so desire. The homebirth midwives leave a few hours after the baby has been born, and even though you don’t have around-the-clock care, they will visit you the day after you give birth and then again a few days later, and maybe even more. And finally, homebirths may not be covered by insurance, and the cost does vary by location.
Now, obviously, your choices will be limited to whether you’re able to afford it if it’s not covered by your insurance, or if you don’t have insurance, and what’s actually available around you. But given the numbers, one thing is clear. The U.S. needs more out-of-hospital birth options. With the current health deserts in rural and urban settings, an interconnected web of homebirth midwives, birth centers, and hospitals all working together and providing continuity of care in response to the individual pregnant person’s health needs would be an amazingly wonderful solution and one that other countries have shown works really well.
Lozada: The decision of what place is right for you to give birth in is such a highly personal one, and, as I mentioned before, one of the biggest tools for making that decision can be exploring where you feel safe, supported, and cared for since that’s what’s going to be needed for oxytocin and physiological birth to flow.
However, I also know that often your choices are going to be limited by what’s available where you live, or whether you are able to afford it if it’s not covered by your insurance or you don’t have insurance.
If your first choice is not available to you, it’s gonna be important to figure out how to change the space that you will be birthing at so that you feel safe and well cared for there. For example, you may want to explore ways to cozy up the space by bringing your own pillows, your own labor clothes, images to put around your room to decorate it, have your music, maybe add some battery operated candles –whatever works for you to make the space yours.
And then definitely get a doula! We’re going to talk more about the reasons why you want a doula in an upcoming series on Care Providers and Birth Teams, but before that, we first have to round off this series on Models and Places of Birth. In the next few episodes we’ll dive deeper into what to consider when comparing hospitals, and also helping you decide if a homebirth is right for you, and we’ll also showcase some wonderful birth stories at each place.
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You can find the in-depth show notes and transcript of this episode at birthful.com, where you can also learn more about my small birth preparation classes, and download your free postpartum preparation plan.
Birthful is created and produced by me, Adriana Lozada, with production assistance from Aysia Platte. This episode was produced in part by LWC Studios: Paulina Velasco, Virginia Lora, and Kojin Tashiro.
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Come back for more ways to inform your intuition.
Lozada, Adriana, host. “Exploring Your Options Of Where To Give Birth.” Birthful, Birthful. September 27, 2023. Birthful.com.
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