By Stephanie Larson

Have you thought about the day you will give birth to your baby? Where do you see yourself? What's your vision for your birth? Before you make a decision, weigh all of your options. It's important to be informed about the different types of birth places and what they offer, in order to make the best choice for you and your baby. This is a decision that can impact your birth satisfaction and the outcome of your birth, so be sure you stay true to yourself. Many people will have opinions, but no one is going to give birth to your baby except you, so this decision is yours to make. 

You have a lot more choices than you probably realize. The five main choices are: giving birth at home, giving birth at a hospital, giving birth at a freestanding birth center, giving birth at a hospital birth center, and giving birth outdoors. You can’t always control where you are when your baby is ready to be born, but go ahead and plan your ideal birth place, and then be ready for anything, because baby might have other plans.

Home

Home birth can be a great option, especially if you enjoy being in charge. At home you have complete autonomy, you’re not subjected to external protocols, and you’re in comfortable and familiar surroundings. Being in your own space can be more intimate than any of the other options. Birthing at home protects you and your baby from being in a hospital where people go because they’re sick. You can intentionally create a sacred birth space and have full control over who is allowed into your space. Another advantage of home birth is that you don’t need to decide when to go to your birth place—you’re already there. 

Home births tend to be very empowering, because you are used to being in charge in your home. You’re not in a position where you feel like you need anyone’s permission to do what you want to do in the moment. You can eat, drink, go to the bathroom, get in the tub or shower, light candles, play music, dance, sing, sleep, be intimate, invite people over, go outside, be alone—whatever feels right to you. You’ll never have to limit your support people because of a hospital policy, so your partner, your doula, your mother, your children…anyone you want to be there with you will be included. 

Is homebirth safe? In countries that have much better maternal and infant outcomes than the US, home birth is much more common than it is here. According to a landmark study, in low-risk pregnancies, planned home births lower the rate of interventions, without increasing adverse outcomes. (The cesarean birth rate was only 6%, and the epidural rate was only 5%. The vaginal birth after cesarean (VBAC) success rate was 87%). 

Home births are typically attended by a midwife or a physician, and provide a more relaxed and unhurried environment. Your care provider may have an assistant with them as well. You may also decide to hire a birth doula to support you during your birth. As you form your birth team, ask about their training and credentials, their scope of practice, and where they are legally allowed to practice. In the United States it’s legal to have a home birth in every state. However, each state has its own laws governing midwifery and the practice of medicine, and these laws may impact care providers’ ability to attend your birth at home. You also have the freedom and legal right to choose an unassisted home birth, which means there is no midwife or doctor present.

Home births will cost a small fraction of the price of hospital birth. Your only costs will be for the professionals you hire to be on your birth team, for example your midwife and doula, and for your home birth supplies. Check with your insurance company to see if they cover these expenses. Even if they don’t, you're still likely to pay less for a homebirth than you would for a hospital birth that is covered by your insurance, because the deductible, copays, and coinsurance add up for hospital births. 

Some things to think about when considering a home birth

• Who will be on your birth team and when will they plan to join you at home?
• How close are you to the nearest hospital, and how will you get there if you or your baby need to be transferred for hospital care?
• What supplies do you need to have on hand? 
• Who will be there to support you after you give birth, during the postpartum period?
• What is your care provider’s cesarean birth rate, maternal mortality rate and infant mortality rate for planned homebirths?

Hospital

Hospital births are the most common option in the US. One of the main reasons to consider giving birth in a hospital is the level of medical care available. Hospital births are usually attended by obstetricians. Obstetricians are surgeons whose specialty is cesarean surgery (this is why approximately one out of every three babies born in the US is born by cesarean birth, 32.1%).  Hospital births are sometimes attended by Certified Nurse Midwives (CNM’s). CNM’s have a degree in nursing and either a Master's or Doctoral program specializing in midwifery. Hospitals have a wide range of pharmacological pain management options available, this means drugs, like epidurals, and other forms of anesthesia. They also may have a neonatal intensive care unit (NICU) for premature or sick babies. 

Being in the medical environment during birth might sound like a no-brainer, because it seems to imply safety, but it can be a double-edged sword. Hospital births tend to be highly medicalized, and this can lead to interventions such as labor induction or c-section that are unnecessary and bring added risks. A birthing individual is three times more likely to die during a cesarean delivery than during a vaginal birth. 

Is hospital birth safe? Let me tell you the shocking truth. The maternal mortality rate is worse in the US than in 64 other countries. And while other countries’ rates are getting better, ours are getting worse. Approximately 98.4% of pregnant parents in the US give birth in the hospital. These statistics don’t instill a lot of confidence in the safety of hospital birth in the US. For Black parents, there is even more reason to be wary. The mortality rate for Black birthing parents is an atrocious 3 times higher than for White birthing parents. For babies the statistics are also grim. The US infant mortality rate is worse than 54 other countries. For Black babies it is 2.3 times higher than for White babies. This inequity for Black parents and babies is due to systemic racism in the hospital birth system. 

Another drawback is that hospitals can be busy, noisy, and stressful environments. This can make it harder to focus and give birth. Additionally, the hospital environment won’t be as intimate or personal as a birth center or home birth.  You may be limited on who can join you, or even have to choose between your significant other and your birth doula.

Some things to think about when considering a hospital birth

• Who will be on your birth team and when will they join you at the hospital?  Is there a limit on who can be in the room with you?
• When will you go to the hospital, how long will you stay, and how will you get there and back?
• What do you need to bring with you?
• What is your hospital’s cesarean birth rate, maternal mortality rate and infant mortality rate?
• What is your care provider’s cesarean birth rate, maternal mortality rate and infant mortality rate?

Freestanding Birth Center

A freestanding birth center is a great option if you want to have a home-like and holistic environment, but don’t want to give birth at home. There are approximately 400 freestanding birth centers in the US. Freestanding birth centers have fewer interventions and a more personalized approach to care than both hospitals and hospital birth centers. They normally have partnerships with nearby hospitals and doctors, to transfer you in case medical care is needed, or in case you decide you want an epidural. 

Birth centers are typically staffed by midwives. Midwives are highly-trained healthcare professionals. Pregnancy and birth are their core specialities, along with primary care, prenatal and obstetric care, postpartum care, routine gynecological care, and family planning. 

If you give birth in a freestanding birth center, your care providers will typically follow the midwifery model of care. This means that birth will be allowed to follow its normal and natural course, without routine interventions. It won’t be medically induced (forced to start). Nonpharmacological pain relief methods (non-drug) will be the primary methods offered. You’ll typically have continuous support from your midwife and hands-on help to find confidence and comfort. This is different from a hospital setting, where the doctor or midwife is usually only present when it's time to catch the baby. 

Related Article: Understanding the Difference: Midwifery Care and Medical Care, for Pregnancy and Birth

In a freestanding birth center you won’t be pressured to be in bed. You’ll be encouraged to move around your space freely, and to give birth in any position you choose (all the better for dancing your baby out!). You’re unlikely to be hooked up to an IV or to continuous electronic monitoring. Your midwife will listen to your baby’s heartbeat intermittently. There’s often a birth tub or a shower in the room to labor and birth in. You’ll be encouraged to eat and drink if you want to. You will make the decisions for your care and your baby’s care after being fully informed by your midwife. 

Freestanding birth centers are based on family-centered care. You should be able to have as many people join you as you wish. Often the freestanding birth center has a living room and kitchen area where your loved ones can be comfortable while they wait, when they’re not in your birth room with you. You’ll be able to decide on who joins you in your room during labor and who joins you after you give birth. 

Is freestanding birth center birth safe? The rate of transfer to a hospital for cesarean birth is very low at freestanding birth centers. For example, the Farm Midwifery Center has an incredibly low rate of 1.7% (compared to the US cesarean birth rate of 32.8%) and the average rate at freestanding birth centers is only 6%. Since cesareans are three times riskier than vaginal birth, the lower the rate, the better. In a landmark study of 79 midwifery-led birth centers in 33 US states, there were zero maternal deaths (compared to the US national rate of 23.8 maternal deaths per 100,000 births). The neonatal mortality rate was 0.40 per 1000 (compared to the US national rate of 5.3 per 1000). 

Some things to think about when considering a freestanding birth center birth

• Who will be on your birth team and when will they join you at the birth center?
• When will you go to the birth center, how long will you stay, and how will you get there and back?
• What do you need to bring with you?
• What is your freestanding birth center’s transfer for cesarean birth rate, maternal mortality rate and infant mortality rate?
• What is your care provider’s cesarean birth rate, maternal mortality rate and infant mortality rate for planned freestanding birth center births?
• Under what circumstances would you be ‘risked out’ of giving birth at the freestanding birth center?

Hospital Birth Center

A birth center located within or attached to a hospital is a relatively new option in the United States. These centers are designed to provide a more natural birth experience than a traditional hospital setting, while still having the medical resources of a hospital available if needed. Hospital birth centers usually have comfortable birthing rooms and a more relaxed atmosphere than the traditional hospital labor and delivery unit.

These centers are typically staffed by certified nurse-midwives and nurses, who provide care and support during labor and birth. When researching  hospital birth centers, find out if they follow the midwifery model of care or the medical model of care. Sometimes looks may be deceiving. You don’t want to choose a hospital birth center birth only to find out during labor that it only looks like a birth center, but it functions just like a hospital birth and doesn’t practice the midwifery model of care. Also be aware that a hospital birth center might redirect you to the regular labor and delivery unit if the birth center is full or understaffed when you come in in labor.

Some things to think about when considering a hospital birth center birth

• Who will be on your birth team and when will they join you at the birth center?
• When will you go to the birth center, how long will you stay, and how will you get there and back?
• What do you need to bring with you?
• What is your birth center’s cesarean birth rate, maternal mortality rate and infant mortality rate?
• What is your care provider’s cesarean birth rate, maternal mortality rate and infant mortality rate?
• Under what circumstances would you be ‘risked out’ of giving birth at the hospital birth center?
• What will happen if the birth center is full or understaffed during your labor?

Outdoors

Since birth is a normal, healthy, life event, some birthing individuals and families gravitate towards natural environments to give birth. This may seem unusual, but mammals give birth in nature all the time, and humans are mammals too. Giving birth in nature can be very calming and can help you access your primal birth instincts. Birthing under the stars, or in water, or against a tree, or amongst flowers can help you connect with the earth. Nature can highlight the sacred aspects of birthing, and birth as a transformative rite of passage.

Outdoor births are typically attended by homebirth care providers like midwives or doctors. You’ll need to specifically discuss your plans to be outside with them. As with homebirth, you can also choose to give birth without a care provider present. This is sometimes called freebirth or unassisted birth. Being outside you’ll have a lot of autonomy, but you may not have total privacy, depending on the setting you choose. 

Are outdoor births safe? While there aren’t any statistics specifically about outdoor births, they should be somewhat similar to the statistics for planned homebirth. 

Some things to think about when considering birthing outdoors.

• Who will be on your birth team and when will they join you outside?
• How close are you to the nearest hospital, and how will you get there if you or your baby need to be transferred for hospital care?
• When will you go to the location, how long will you stay, and how will you get there and back?
• What do you need to bring with you? 
• How will the weather impact your birth? Will it be warm enough for you and for your baby?
• What is your care provider’s cesarean birth rate, maternal mortality rate and infant mortality rate?

Now you know the five main choices of birth places. As you decide where you want to give birth, consider all of your choices and which one will best suit your birth philosophy, your vision for your birth, and your unique needs. You are free to change your mind at any time (even during labor) as you gain more clarity on what will work best for you. Your birth will proceed best when you feel centered, connected to your body and your baby, and safe on every level, including physically and emotionally. 

Sources:

The Journal of Midwifery and Women's Heath. Cheyney, M et al 'Outcomes of care for 16,924 Planned Home Birth in the United States: The Midwives Alliance of North America Statistics Project 2004-2009. 30 January 2014. https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.12172 

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention ‘Changes in Primary and Repeat Cesarean Delivery 2016-2021’ July 2022 https://www.cdc.gov/nchs/data/vsrr/vsrr021.pdf 

Deneux-Tharaux, C et al. ‘Postpartum Maternal Mortality and Cesarean Delivery’. Obstetrics & Gynecology 108(3 Part 1):p 541-548, September 2006. | DOI: 10.1097/01.AOG.0000233154.62729.24 https://journals.lww.com/greenjournal/Abstract/2006/09000/Postpartum_Maternal_Mortality_and_Cesarean.12.aspx 

​​National Academies of Sciences, Engineering, and Medicine; Committee on Assessing Health Outcomes by Birth Settings; Backes EP, Scrimshaw SC, editors. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington (DC): National Academies Press (US); 2020 Feb 6. 2, Maternal and Newborn Care in the United States. https://www.ncbi.nlm.nih.gov/books/NBK555484/ 

Hoyert DL. Maternal mortality rates in the United States, 2020. NCHS Health E-Stats. 2022. DOI: https://dx.doi.org/10.15620/cdc:113967 https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm#Suggested_citation 

List of countries by maternal mortality ratio https://en.wikipedia.org/wiki/List_of_countries_by_maternal_mortality_ratio 

List of countries by infant mortality rates https://en.wikipedia.org/wiki/List_of_countries_by_infant_and_under-five_mortality_rates 

Infant Mortality Rates by Race and Ethnicity, 2019 CDC Centers for Disease Control and Prevention https;//www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm  

The Farm Midwifery Center, ‘Preliminary Report of 2,844 Pregnancies: 1970-2010’ https://thefarmmidwives.org/preliminary-statistics/ 

Journal of Midwifery and Women’s Health ‘Outcomes of Care in Birth Centers: Demonstration of a Durable Model’ Rutledge Stapleton, S et al 30 January 2013 https://doi.org/10.1111/jmwh.12003 https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.12003