Choosing Where to Give Birth

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By Rebecca Burpo, CNM

For most American women, choosing where to give birth is deceptively simple. Pick up the telephone book and insurance directory or log on to the Internet and find out which physicians and hospitals on your insurance plan are closest to home. Presto, your choice is complete!

Doesn’t this sound overly simple for such a pivotal family event? It certainly should. Most families spend more time and effort choosing an apartment or a church than they do a birthplace. They never consider birthing at home or at a freestanding birth center, usually assuming that hospital births are safest and fearing what might happen if a complication arose during labor or birth. Most families express real fear at the prospect of giving birth outside of a hospital without a physician in attendance.

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Examining the party line

This fear of non-hospital births is the result of a vigorous, long-standing advertising campaign that markets birth as a risky situation. The line of reasoning usually goes something like this:

One hundred years ago, women and babies frequently died during childbirth. When doctors began performing deliveries and birth moved into hospitals, death rates plummeted. Today, almost everybody does well because of the superior resources of hospitals and the skill of obstetricians.

Authorities often follow this proclamation with the ominous comment, “I’ve seen what happens when women try to have babies outside the hospital.” This is a convincing argument, quite frightening when coming from the mouth of an authority figure.

The only problem with this line of reasoning is that the facts and reasoning are not valid.

Several studies show that the transition from midwifery-attended birth to physician-directed birth actually increased the death rate for both mothers and babies. Statistics from the early 1900s show that deaths increased from 60 in 10,000 births to 74 in 10,000 births. Birth injuries increased from 40 percent to 50 percent.

Any improvement in these statistics didn’t come along until the late 1930s, when the first antibiotics hit the scene. At the same time, other factors such as an awareness of the importance of handwashing, improved nutrition, blood transfusions and the ability to space children contributed to lower rates of death and infection — and none of these developments were related to moving birth to hospitals under doctor control!1

A safe, gentle birth

So if hospitals and physicians aren’t clearly the safest choice, how then should you choose where to give birth? Let’s compare a few key factors between hospitals, birth centers and home.

Philosophy of Care

Hospitals
Birth in a hospital is an intense, crisis situation. No birth is labeled uncomplicated until it’s completely finished. Problems are handled with drugs and technology. Physicians deliver babies. Mothers are considered to be patients who need to be treated.

Freestanding Birth Centers
Birth at a birth center is considered to be a normal, healthy event that benefits from professional supervision and care. Most births are considered to be uncomplicated, and difficulties are expected to resolve on their own with time and non-invasive interventions. Mothers give birth and are not considered to be in need of “delivering.”

Home Birth
Birth at home is also a normal, healthy event that benefits from professional supervision and care. Most births are considered to be uncomplicated, and difficulties are expected to resolve on their own with time and non-invasive interventions. Mothers give birth and are not considered to be in need of “delivering.”

Complications

Hospitals
Most hospitals have the necessary diagnostic and treatment equipment for birth complications, although the people trained to operate the equipment may or may not be readily available at the time. Your care during labor is usually provided by nurses, who call your doctor only if there is a problem; therefore, your doctor may or may not be at the hospital during your labor, arriving only when birth is imminent. Your care after birth is provided by nurses and/or nursing assistants. Your baby is usually taken to the nursery for observation for the first few hours after birth. Pediatricians are usually on call. A neonatal intensive care unit may or may not be available.

Freestanding Birth Centers
Medications and equipment to treat or stabilize you and your baby during an emergency are available. Birth attendants are certified in providing emergency support care to both you and your baby. A consulting physician may be called if needed; however, your midwife usually resolves most problems there at your home. Your midwife is present throughout your labor, birth and recovery. Your baby remains with you throughout your stay at the center. Formal arrangements are in place with nearby hospitals to handle necessary emergency transfers. Birth centers meet ACOG recommendations for being able to facilitate emergency Cesarean sections within 30 minutes.

Home Birth
Your midwife brings medications and equipment to treat or stabilize you in case of any emergency. Your midwife is present throughout your labor, birth and recovery. Your baby remains with you after the birth. Midwives are certified to perform emergency care on you and your newborn. There is usually no formal home birth transfer arrangement with the nearest hospital; emergency transfers are processed through the nearest emergency room. Some homes may be too far from hospitals to meet the 30-minute ACOG recommendation for elapsed time before an emergency Cesarean section.

Pain management

Hospitals
Drugs are the most common method of pain management used in hospitals, with epidurals being the most seductive delivery method. Showers or whirlpool baths may or may not be available. Position changes and moving around out of bed may or may not be allowed. The stress of numerous strangers, an unfamiliar environment and the crisis atmosphere of a hospital may intensify your perception of pain.

Freestanding Birth Centers
Birth centers may have some narcotics available for injection, but epidurals are not available. A wide variety of non-pharmaceutical methods are used to relieve your pain, including tubs and body activities. The small number of people attending your birth and the more familiar, calm environment creates less stress than a hospital setting.

Home Birth
No drugs are available if you birth at home. Your midwife will help you relieve your pain with a wide variety of non-pharmaceutical techniques and tools. The comfort and familiarity of your home makes it the least stressful place in which to labor; however, the stress of having visitors (the midwife and her assistants) can sometimes increase your perception of pain. If you’ve chosen home as a birth location strictly for financial reasons, you may not feel empowered and confident and may experience increased perceptions of pain.

Social issues

Hospitals
Hospitals are institutional facilities with rules designed to handle people as efficiently and economically as possible. They may not be open to midwifery-model childbirth. Their ambiance varies. Your hospital may be impersonal and lack privacy, with many strangers coming into your room. There may be restrictions on who you can have in your room during labor and births.

Freestanding Birth Centers
Birth centers still feel like someone else’s territory, but at least they do focus on providing individualized, supportive care. Usually midwife-operated, their ambiance varies. Birth centers are usually peaceful, intimate and homelike, offering options for music, aromatic oils and candles. You decide who is present during labor and birth. At a birth center, you will not need to worry about cleaning up afterwards or what the neighbors might say, nor will you be under stress beforehand about preparing for the midwife, having the right supplies available, and preparing basic food and hospitality for the midwife.

Home Birth
At home, your birth is in your territory — everyone else is there as a guest. You set the ambiance. You decide who is to be with you. You may be hassled during your pregnancy by family and friends who disagree with your choices. Your stress may increase if you or your baby needs to be transferred to the hospital for any reason. Prior to your birth, you must ensure that you have the appropriate birth supplies as well as basic food and drink for your midwife and her assistants. You may feel stressed about making sure your home is clean for your midwife, baby and other visitors. You may have to deal with some clean-up and visits by the neighbors
afterwards.

Cost

Hospitals
Hospitals are the most expensive birth option. Costs usually include an obstetrician’s fees, a pediatrician’s hospital fee and a routine visit fee later, an anesthesiologist’s fee, additional physicians’ fees for situations outside the norm (a cold during pregnancy, for instance), lab fees and hospital fees. Hospital births are more likely to be considered “in-network” for insurance purposes, in which case your out-of-pocket expenses are usually less.

Freestanding Birth Centers
Birth center costs usually involve a midwife’s fee, a routine pediatrician visit fee later, lab fees and a birth center facility fee. Most insurance plans cover birth center births, but they are less likely to be considered “in-network”; therefore, your costs will most likely be higher than those for a hospital birth.

Home
Unlike every other service in this country, an individualized birth in your own home actually costs less! Your midwife will probably see you at her office during your pregnancy, due to the costs of covering a large geographical area, although midwives with very limited clientele may be able to manage all your visits at home. Costs usually involve the midwife’s fee, a routine pediatrician visit fee later and lab fees. Some midwives charge less but have you pay for their assistants’ feeds, all lab fees and medication charges. Some insurance plans cover midwife charges for home births, but others prohibit any type of coverage if your birth occurs at
home.

The choice of a lifetime

The place you choose to bring a new life into your family should offer you safety, comfort and an atmosphere that allows your family to savor this once-in-a-lifetime event. Every woman has the right to choose the best birth site for herself and her baby, and every woman has different needs. Be certain you consider all the facts and available choices when planning this key family moment.

1 For more details on the statistics and facts behind this section, please consult “The Thinking Woman’s Guide to a Better Birth” by Henci Goer (Perigee, 1999).

Certified nurse-midwife Becky Burpo has more than 20 years of experience in women’s health.