Birth Choices

Hospital, Home or Birth Center?

by Rosemary Romberg

If you are expecting a baby, please make a careful, thought out decision about where and how you wish to give birth. Giving birth in a hospital is not your only choice. Some mothers give birth in alternative birth centers. Others choose to give birth at home.

There are advantages and disadvantages to each choice which you should consider carefully. Please don’t let your personal finances or insurance coverage make the decision for you as many other considerations are of equal or greater importance. (For example, if you have no medical insurance,  giving birth at home may be your least expensive choice. But this is not a good reason to have a baby at home. However, the couple who truly wants a home birth for personal, emotional reasons, even
if they have insurance that would pay for a hospital birth, probably should spend the extra money to hire a qualified home birth attendant and have the kind of birth that they wish to have.)

If you will be having more children in the future, you may decide that different options appeal to you for different births.

I. Birth in the Hospital:

Advantages –

1. Hospitals with maternity departments and qualified birth attendants for hospital birth are readily available practically everywhere in the U.S. and most developed countries. Birth centers and competent attendants for home birth are not readily available in some areas.

2. Hospital birth is more socially acceptable in
the eyes of the general public. If you give birth at home or in a birth center, you may encounter criticism or curious questioning from other people. (However, public attitudes about this, and many other more naturally oriented birth and infant care practices have changed dramatically over the last several years.)

3. Some medical insurance plans will pay for hospital delivery but will not pay for birth at home or in a birth center, especially if the birth is not attended by a doctor or by a midwife who is officially backed up by a doctor.

4. For high risk mothers, hospital birth is usually the only choice. If you will be needing a Cesarean delivery or have any other conditions that strongly indicate that the birth could be complicated, you should give birth in a hospital. Birth center births and home births are only for mothers who are in excellent health with no indications of serious complications.

However, some people’s situations may be unusual but cannot be clearly defined as “high risk.” Some midwives, perhaps out of personal fears or pressure from hospital authorities, have strict, often unfair limitations about what types of conditions they will and will not accept in a home birth or birth center birth client. For example, some midwives will automatically refuse to attend a mother having more than a certain number of previous pregnancies (such as if this is her fifth or sixth baby or more than that). Some midwives will automatically refuse care to a mother over a certain age, such as 38 or 40. Some refuse care to mothers who have lost a previous baby or babies to reasons unrelated to the present pregnancy.

It is frustrating and tragic if a mother has to be pressured into giving birth in a place where she would rather not be out of other people’s fears or arbitrary ideas. A healthy mother who is tuned into herself and her baby will usually have a strong sense of whether or not all is going well with her pregnancy and where she will be most comfortable giving birth. Therefore, if you want to give birth at home or in a birth center, and if one midwife seems overly fearful and full of restrictions, interview other midwives who may be more confident and flexible about your situation.

5. When you give birth at a birth center, usually the mother and baby go home a few hours after delivery. Some hospitals offer this option also. Following a home birth the mother and baby begin their life together at home. Many mothers greatly prefer this. However, some mothers prefer a few days of recuperation in the hospital with nurses in attendance before going home.

6. In the event that a need should arise during labor, at birth, or immediately after birth that the mother and/or baby require emergency services (such as a Cesarean delivery or a blood transfusion) this can usually be handled more quickly and easily if the mother and/or baby are already in the hospital. The necessary equipment, trained professionals, and facilities for some types of emergency treatments are there in the same building. If labor is in progress or the birth has taken place at home or in a birth center that is separate from a hospital, and medical attention becomes necessary that the home birth attendant cannot readily provide, more time and trouble is involved in transporting the mother and/or baby to a hospital.

Occasionally mothers and/or babies do have to be taken from home or a birth center to a hospital for emergency treatment. In almost all cases, while this may be exasperating or even frightening, everything does work out fine, especially if the birth attendant is able to recognize and deal with a complication. In rare cases, however, the extra time involved in getting to a hospital might endanger the life and/or health of the mother and/or baby.

7. Hospital birth is much more convenient for doctors and medical personnel because it is centralized in one place. Home birth (and possibly birth center birth, if the attendant does most of his/her work in the hospital) is much less convenient for birth attendants.

Disadvantages – 

1. The people involved in your birth in the hospital may not be conscious and caring about the emotional and personal aspects of your birth experience. Because they deal with so many people on a regular basis, the experience often becomes “just a job” for them. They may be kind and personable, or they may be cold and grumpy. You do not get a choice about the type of people who attend your birth. While hospital personnel are usually nice and helpful people, they are not usually people who are significantly involved in your life. When you go home they are going to forget all about you.

2. Hospital birth involves the inconvenience of transporting the mother during labor and then bringing her and the baby back home afterwards. Some people find that this is a disruption in the natural flow of the pregnancy-birth-new baby process.

3. Potentially dangerous germs abound in hospitals. This is because so many people congregate in hospitals. Also strains of germs tend to develop in hospitals that are resistant to the disinfectants and antibiotics that they commonly use. At home you have a natural immunity to your “own” germs. Some studies have indicated that the chances of the mother or baby developing an infection are much greater in a hospital.

If you do choose to give birth in a hospital, it is a good idea to keep your baby with you in your own room from birth on. The baby is more likely to develop an infection if he/she stays in the central nursery with many other babies than if he/she stays with his/her own mother. Keeping your baby with you is a far more natural and humane way to treat babies as well.

4. Many hospital maternity wards have routine procedures such as pubic shaves, enemas, intravenous solutions, fetal heart monitors, confining the mother to one bed during labor, forbidding food, liquids, or use of the bathroom during labor, moving the mother at the time of delivery, birth on a delivery table, episiotomy, and initial separation of the mother and baby. All of these procedures have medical justifications in some situations. However, their
routine use is highly questionable and in some cases dangerous. Many people have strong feelings about not wanting some or all of the above mentioned procedures used during labor or birth, especially if they are not necessary.

Use of these procedures varies widely from one hospital to another. Some hospitals are quite progressive and accommodating about interfering as little as possible with normal birth. If these matters concern you, you should ask about these procedures if you plan to deliver in a hospital. (Be aware, however, that sometimes mothers are given one answer or are told “we’ll see” by their birth attendant in advance, only to have the unwanted procedure pushed on them anyway during labor or birth.)

Some mothers choose to give birth at home or at birth centers to avoid these procedures entirely.

5. Medication, chemicals for inducing labor, and the option of Cesarean delivery are always available in hospitals. While these things can occasionally be necessary, they are also sources of great controversy as they are often used unnecessarily. Because these things are there they are more likely to be offered in a hospital birth even if a natural birth was planned. Since these things are rarely available in birth centers or at home, birth is more likely to proceed naturally when it does not take place in a hospital.

6. While today, in most hospitals, the father of the baby is usually allowed to be with the mother during labor and birth, in many hospitals other friends or older siblings cannot be present. Some people prefer home birth or birth center birth so that other friends and/or older children can attend as well.

7. During hospital birth the doctor and medical personnel run the show.  While today many certified nurse midwives (CNM’s) attend births in hospitals, a hospital oriented midwife can tend to be more authoritative and controlling in how she handles a birth, while a home birth or birth center oriented midwife who will tend to have more faith in nature and the mother’s resources and will be more likely to be non-interventive in how she treats the mother and/or baby.

Many parents who give birth in hospitals are happy and pleased with their birth experiences. But others have had humiliating experiences which they greatly resent, or have simply found that they are not comfortable with the “medically controlling” philosophy of hospital treatment of a normal physical process (giving birth.) Many mothers who have given birth at home or in birth centers have had previous hospital births that they were unhappy about.

Some people are quite comfortable with accepting all hospital procedures, but for others the element of personal control is most important for their birth experience. Parents giving birth in a hospital have much less control of how their birth will happen, what they will be free to do, what will be done to them, or what will be done to their baby.

8. Some people find that the atmosphere of a hospital seems cold, clinical, impersonal, or “plastic” and prefer the psychological advantages of the home or a home-like environment for giving birth.

In response to such concerns some hospitals have set up birthing rooms, with attractive, comfortable looking furniture and decor. Bear in mind, however, that however home-like one’s surrounding environment may be, there is more to a positive birth experience than attractive wallpaper or bedspreads.

9. The opportunity to have immediate, uninterrupted, skin-to-skin bonding between the mother and baby, or for the baby to have a peaceful, untraumatized beginning in life may not be available, or may be more difficult to achieve when birth takes place in a hospital. A baby born in a hospital is more likely to be separated from his/her mother, and/or subjected to bright light, loud noises, silver nitrate in his/her eyes, being roughly jostled around while he/she is weighed, measured and washed, given a vitamin K shot or circumcised.

The baby born to a peaceful, loving, gentle environment tends to have a calmer, more agreeable disposition which is markedly different from that of a baby born to typical traumatic birthing procedures. There is much evidence that the type of birth and immediate treatment after birth has a long lasting effect on the individual’s life.

Some hospitals will offer “Leboyer birth” techniques if the parents desire this. This may include putting the baby on the mother’s abdomen immediately after birth, dimming the lights, massaging the baby, or giving him/her a warm bath. Unfortunately this has sometimes been a fad rather than an expression of true consciousness and concern for the baby’s well-being. Often hospitals that “do” Leboyer techniques also follow routine, traumatizing procedures as soon as the baby goes to the nursery.

Also in some hospitals where the staff is progressive enough to allow the mother to hold her baby immediately after birth, they will insist that the baby be wrapped up in blankets rather than allowing skin-to-skin bonding.

10. If you do not have insurance coverage, hospital birth is usually more expensive than birth center birth or home birth.

II. Birth Centers:

In response to the rising popularity of home births and to the objections that some parents have voiced about routine hospital procedures, alternative birth centers have been established in many communities. These may be homes, doctors’ offices, or other buildings which provide rooms with comfortable beds, carpets, curtains, etc. in which to provide a home-like setting for giving birth. Also, some hospitals have set up birthing rooms in place of conventional delivery rooms and have called this a birth center.

As a rule, birth centers which are separate from a hospital are more likely to be truly home-like. Some hospital birthing rooms are merely delivery rooms with wallpaper, and the “birthing bed” may really be a delivery table covered with a flowered bedspread.

Advantages – 

1. In communities where qualified prenatal care and
competent birth attendants are not available for home birth, a birth center may provide a more comfortable, home-like birth opportunity than a traditional hospital setting.

2. Usually birth centers are more liberal than hospitals about such things as allowing children or other friends to participate in birth, allowing the mother to assume different positions during labor and birth, and are less likely to interfere with labor or with the mother/infant bonding immediately after birth.

3. Some people feel more secure about going to an established place such as a birth center rather than giving birth at home.

4. If a birth center is part of a hospital, less time is involved in obtaining emergency services. A birth center that is separate from a hospital may offer no advantage over home birth in this respect. However, free standing birth centers are almost always intentionally located near a hospital, so if you live some distance from the nearest hospital going to a birth center may be advantageous. Also, the birth attendants at a separate birth center may also have privileges to practice at the nearby hospital or will have an openly accepted agreement with the doctors at the hospital for back up care. This may not always be the case with home birth.

5. Like hospital birth, when the mothers giving birth are all brought to one location, this is much easier for the birth attendants. Some former home birth attendants have established birth centers for this reason.

6. Usually a birth center is less expensive than a hospital for giving birth.

Disadvantages –

1. Just as with hospital birth, birth in a birth center requires the mother to travel there during labor and home again after the baby is born. Also, while their rooms may be home-like, they are not your home. Some people find these important considerations.

2. Usually the parents and baby stay only a few hours after giving birth in a birth center. Some people greatly prefer this and consider this an advantage. But other mothers prefer the longer stay in a conventional hospital.

3. With a free standing birth center, should need for hospital services arise extra time and inconvenience is involved in transporting the mother and/or baby to another place. While true time pinch emergencies are rare, it can be more inconvenient and troublesome to have to be moved from one place to another.

4. Infection rates in birth centers have sometimes been found to be greater than either hospitals or home births. Many people congregate in birth centers, while the sterility of the hospital environment is rarely possible.

5. While birth centers tend to be less intervening than hospitals, many do offer fetal heart monitors, pubic shaves, enemas, induction of labor, episiotomies, etc., which some people question or find objectionable. You are more likely to encounter such things in a birth center than if you choose home birth. You should inquire about such practices if you are considering giving birth in a birth center.

6. Some birth centers, either in an attempt to keep their records looking good or because they get more applicants than they can serve, can be overly quick to label a mother high risk and refuse to allow her to deliver there, or make a hasty, unnecessary decision to transport her to the hospital during labor. Some high risk situations such as abnormal bleeding during labor, or a dangerous drop in the baby’s heart rate almost always require immediate emergency procedures. But other conditions such as maternal age, number of previous pregnancies, previous miscarriages, previous Cesarean delivery, minor fluctuations in fetal heart tones or the mother’s blood pressure, or a long, slow labor are gray areas. Usually mothers with conditions such as these will give birth normally to healthy babies. But some birth attendants are more cautious than others in labeling certain situations as high risk. This can sometimes unfairly deprive some mothers of the type of uninterfered with birth that they would like.

(*I gave birth in a hospital to my fifth baby at age 38, against my wishes but out of pressure from others that I was “too old, with “too many previous pregnancies”, “too many previous miscarriages” and “too high risk” to consider a home birth. Later, at age 42, I gave birth to my sixth baby at home. Both were totally normal births. – R.R.)

7. Some birth centers, especially hospitals that have only one or two birthing rooms alongside conventional labor rooms and delivery rooms, work on an availability basis. Parents who may have planned for months to deliver in a birthing room sometimes arrive at the hospital to find that someone else is using it and that they must settle for the labor room and delivery room instead. Even a free standing birth center with only birthing rooms may be full at any given time. Occasionally hospitals are full of mothers in labor and some women are left to labor on gurneys in the hall. At home no one is going to take your birthing room away from you

III.  Home Birth:

Advantages –

1.  You do not (normally) have to travel somewhere during labor, give birth in an unfamiliar environment, or go back home with the new baby.  The entire birth process normally takes place in the same environment.  For this reason, many people find that labor, birth, and life with the new baby proceeds much more smoothly when it takes place at home.

2.  You are free to choose just who will and will not be present for your birth.  Your older children and other friends may participate if you wish.

3.  Introduction of a new sibling into the family is often easier for older children when the baby is born at home.  Some children find it quite disrupting to be left behind while the mother is away somewhere else giving birth.  For some children the arrival of a new baby brought home from a hospital or birth center can seem like an intrusion, as if the baby came from some place else.  This can result in jealousy and lack of acceptance of the new sibling for some children.

4.  You are free to do whatever you want during labor – eat, drink liquids, use the bathroom, shower, walk around, talk to people, do simple comfortable tasks, and assume any position that you want for labor and birth with no interference or control from other people when you give birth at home.

5.  Usually you will not be moved at the time of birth or made to deliver in an unnatural or uncomfortable position.

6.  Medical paraphernalia and routines, such as electronic fetal heart monitors, intravenous feedings, means of inducing labor and performing Cesareans are rarely available during home birth.  Many people find such things to be questionable, cumbersome, and over-used in hospitals and are glad to be free of such interferences during home birth.

7. Immediate skin-to-skin bonding with the baby, and a totally peaceful, untraumatized beginning for the baby’s life is possible. No one is going to take the baby away from you or subject him/her to numerous traumatic procedures.

8. You are in control of what happens during your birth, who is there, what you can do, how you will deliver, and what will and will not be done to your baby. For some people it is very important that this control not be turned over to someone else.

9. Usually home birth is less expensive than birth center or hospital birth.

Disadvantages –

1. Going to a hospital or established place to give birth is the normal thing to do in this society. Therefore, if you give birth at home some people may object and criticize your decision. (Perhaps it helps to remember that until around the 1930’s and 40’s manybirths in this country took place at home. In most parts of the world today, birth still takes place at home.)

2. If you have a great deal of fears about birth in general, or if you simply feel more secure about the idea of being in an established place that is set up for birth, you will probably not feel comfortable about giving birth at home. (Occasionally mother have attempted home birth, labored for many hours or even days without progress, and then have given birth easily once they got to a hospital. This is caused by psychological factors based on uneasiness with home birth.)

3. If you like the idea of staying in the hospital for several days following birth, then obviously home birth is not for you.

4. In some communities prenatal care and qualified birth attendants for home birth may be difficult to find. Sometimes finding a home birth attendant may be an underground type of connection involving knowing the right people. It is not illegal for parents to have their babies at home, but in some areas it may not be legal for midwives to attend home births, especially if they are not Certified Nurse Midwives, and/or are not backed up by a doctor. More often there is no problem with true legality, but political pressures from local medical communities may force sympathetic medical professionals to avoid home birth, or at least be extremely secretive about attending any.

Any medical doctor can attend a home birth, but for political and personal reasons very few do. Any medical doctor can attend a home birth, but for political and personal reasons very few do. Occasionally home birth attendants are chiropractors or naturopaths. But most home birth attendants are midwives. Some midwives are Certified Nurse Midwives (CNM’s). A CNM has an RN degree and a CNM degree in addition to that (somewhat like having a master’s degree after obtaining a B.A. degree.) A CNM is qualified to practice independently in a hospital and set up a practice on her own. She is qualified and medically equipped to handle all normal, vaginal birth needs including minor complications. A CNM usually works in cooperation with local doctors. If need for a Cesarean delivery or other unusual complications should arise a CNM will refer the patient to a medical doctor (at least in the United States and most Western countries.)

Some midwives are RN’s who have had special training in maternity care.  An RN may be more dependent on back up from a doctor in order to be legally qualified to attend home births. Or she may be simply attending home births on her own regardless of officiality.

There are also lay midwives. A lay midwife is a self-taught midwife who may (or may not) have considerable knowledge and experience with birth, but lacks formal training or officiality in the eyes of the medical community. A lay midwife may be a childbirth instructor, or may have had some medical education such as an LVN degree. She may simply be a mother who has had her own babies at home and/or has happened to be present at the home births of a few friends and began her experience in this way. The lay midwife may have read many books about birth. She may have attended various midwifery training workshops (which can be highly informative although not officially recognized in the medical world.) Many lay midwives are enrolled in classes towards an RN or CNM degree.

In communities where birth alternatives have been difficult to find and home birth has been actively discouraged by the medical community, people who desire home births have been more likely to turn to lay midwives due to lack of any more officially qualified birth attendant. Someone who has been present at even a few home births is going to know more about birth than someone who has never been to one.  Also some people prefer that their birth attendant be a lay midwife, feeling that she will have a more wholistic approach to birth if she is not formally trained in the medical way of thinking.

Some lay midwives are extremely knowledgeable and competent, while others have little experience and may make dangerous mistakes. A lay midwife is less likely to have certain types of equipment (for example the suturing equipment necessary for repairing a perineal tear) since some medical equipment can often only be purchased by medical personnel. Also a lay midwife is less likely to have official physician back up at a hospital should an emergency arise. Some lay midwives and parents have been treated quite poorly by hospital personnel when they have had to go there in the event of an emergency.

Finally, some parents choose to have their babies at home entirely by themselves, either because they cannot find a birth attendant at all or one that they like, or because they prefer not to have any outsider present for their birth. Occasionally there are fathers who want to play obstetrician for seemingly questionable reasons. A father’s true role should be one of loving and supporting the mother during labor and birth.

Birth is a normal, physiological process. Therefore, the vast majority of people who give birth at home by themselves or with an inexperienced midwife have perfectly satisfactory experiences. However, this is somewhat riskier than giving birth with a more experienced, well-trained and equipped midwife.

5. The legality of lay midwifery and/or unattended home birth varies widely in different locations. In some areas authorities have hassled home birth parents, home birth attendants, and even instructors of prenatal classes that are geared for home birth, especially if a complication arises with the mother or baby.

Although many complications arise in hospitals and birth centers, some of which are caused by medical procedures, parents and birth attendants in official places such as this are not likely to encounter legal hassling about it the way they might at home. (The situation here often becomes one of politics rather than the true safety of the mother or baby.)

Attitudes are rapidly changing however, and laws along with it. There is a growing trend for the general public to recognize birth at home as a valid and desirable option for some people.

6. With a home birth there is a small risk that your birth attendant may not arrive on time. In a hospital or birth center there will always be someone there (if not your own birth attendant) who will know how to assist with the birth. (On the other hand, going to a hospital or birth center presents the small risk that the baby might arrive on the way!)

7. Sometimes insurance will not cover the expenses of home birth, but will for a hospital or birth center birth.

8. Greater time and effort is involved in transporting the mother and/or baby to a hospital if the need for emergency services should arise. This is people’s greatest fear about home birth. In actuality when the mother is healthy, well-nourished, and free of high risk factors, the chances of serious complications are quite small.

(Four important concerns are 1.) One baby – twins or triplets are more likely to have complicated births although sometimes twins have been born at home with no problems.

2.) Full term – a premature baby needs expert medical care that only a hospital can provide.

3.) Head down – a breech birth can be complicated although some breech births have taken place at home with no problems.

4.) Good heart tones during labor – a knowledgeable birth attendant knows how to check for this and will probably transport the mother to a hospital if the baby seems to be in distress.)

Detailed studies involving thousands of births have shown extremely low complication rates for home births. Also, the vast majority of complications are not time pinch emergencies. And many complications can occur with the same results regardless of the place of delivery. All of this must be carefully weighed against the possibility of complications that are caused by hospital procedures (for example infections of the mother or baby caused by the hospital environment.)

There is no evidence that hospital birth is any safer for the mother who is healthy and low risk. Therefore, your choice for where and how to give birth should be based on where and how you feel most comfortable – not out of fear, pressure from others, financial concerns alone, or medical politics.

c. 1981 (Revised – 2012)