"Um… I'm not sure I want our neighbors in the apartment next door to hear me giving birth."
I definitely remember saying this to my husband when I was pregnant with our first and we were trying to decide where to give birth. The idea of a home birth was absolutely beautiful, but the reality wasn't super practical for us in that moment of our lives. I knew for sure that I wouldn't feel comfortable just letting everything go and being loud, knowing that our walls were a little thin and our young, bachelor bro neighbors would likely hear everything.
So, like every pregnant person, I had to make two important decisions: where to give birth and what kind of provider I wanted handling my care throughout pregnancy and birth.
To help you figure out your own answers, I've got 5 questions to ask yourself so that you can get a better sense of what you prefer.
As an important reminder, I want to emphasize that birth is unpredictable and it's best to always keep in mind that things can change. For instance, you may plan for a homebirth with a midwife, but you may need to transfer to a hospital during labor and give birth with an attending OB. That being said, it's also completely possible that you wouldn't need Plan B and your location and provider never have to change.
The best course of action is to plan for the birth of your choice in a location and with a provider that both make you feel comfortable, safe, and respected.
Before we get to the questions, let’s all get on the same page with our terms. This may also help you start to figure out your preferences.
Locations:
Hospital
Staffed with nurses. Your birth would be attended by either a Certified Nurse Midwife (CNM) or an OB, depending on the hospital and practice.
Tend to have more restrictions based on hospital policy
All levels of pain relief available, including epidurals
Many have on-site NICUs in case baby needs it
Surgical options available in the event they are needed
Generally 1-3 day postpartum stay depending on delivery method and baby’s health. Lots of staff interruptions during postpartum period to check on vitals.
Birth Center
Staffed with midwives and midwife assistants. These midwives may be CNMs, CPMs, or traditional midwives.
Far fewer restrictions. Follow physiological birth. Eating, drinking, movement all encouraged
Often water birth is supported and available
No epidural and fewer pharmaceutical pain medications available
Privacy before, during, and after birth
Would need to transfer to a hospital in the event of a complication with either mother or baby
Most are independently owned and managed. Some financed by hospitals but located outside main building
Can cost less than hospitals
Usually covered by insurance
Most discharge within 4-6 hours after birth
Home
All of the same as a birth center except you get the comfort and privacy of your own home, so you never have to leave either during labor or after birth
Can rent a birth pool to set up and have a water birth if you choose
Providers:
Obstetrician (OB)
An MD who has gone through medical school and trained in the specialty of obstetrics and (usually) gynecology
Typically going to have a more medicalized approach
May or may not support physiological birth. They tend to focus on the pathology of birth and want to “manage” it as a condition.
May perform interventions “just in case”
Tend to do a lot of testing and scanning throughout pregnancy
Trained in surgical birth and can perform a c-section if needed
Perinatologist or Maternal-Fetal-Medicine Doctor:
A more specialized OB who cares for women with high-risk pregnancies
Family practice physician
Your primary care doctor who you may have been seeing for years
Some regularly deliver babies
Would need to consult with an MFM if anything indicates high risk
Probably not going to jump to surgical birth since not trained in it
Ask about birth facilities and hospital privileges
CNM (Certified Nurse Midwife)
A registered nurse who has pursued advanced training and completed a Masters of Science in Nurse Midwifery program
Licensed and recognized in all 50 states
Insurance typically covers
Can prescribe medications
Scope of practice includes well-woman, birth control, general gynecologic health care throughout a woman’s reproductive years
Can work in any setting, but most often you will find them in a hospital-based practice
Follows the midwifery model of care (an individualized, client-focused, and nurturing model of care that believes in minimal intervention and supports physiologic birth)
CM (Certified Midwife)
Some states (including VA) now recognize this credential
Same scope as a CNM (except some states don’t allow them to prescribe meds)
Usually are not registered nurses, but have gone through the same midwifery master’s programs and training
This credential was created for people who are not RNs and don’t have a BSN (Bachelor of Science in Nursing) but want to become midwives.
Can work in any setting
CPM (Certified Professional Midwife)
Are not RNs and don’t need to have gone through a Master’s in Midwifery program
Must pass a national test and show a certain number of hours/births attended under an apprenticeship model
Many CPMs have gone through some kind of formal midwifery education program in addition to their apprenticeship
Cannot prescribe medications
Some states allow them to carry pharmaceuticals like Pitocin in the case of postpartum hemorrhage
Each state has different rules about CPMs and how they are recognized
Only practice in birth centers or attend homebirths
Lay Midwife
Also called a direct-entry midwife or granny midwife
May or may not be registered with the state
Training and qualifications vary
Some attend births in a birth center. Most are homebirth midwives
Tend to prefer working outside of the medical industrial complex and supporting women as our ancestors did
So what should you ask yourself when thinking about what you'd like your birth to look like?
1) Where would you be most comfortable birthing?
Let's start with birth location, since that can often dictate the type of provider. Think about where you are most comfortable. Where do you feel safest? Where do you feel most supported?
For some women, every single answer will be a hospital. For some, it will be at home. And others may find that they answer with a combination of home, hospital, and/or birth center. If you’re somewhere in the middle, birth centers can be a great option because you’re not in your home, but you’re also not in the overly medicalized hospital environment. Know too that if you go into labor spontaneously, you can always labor at home for a while before moving locations to either a birth center or hospital.
The other two questions I’d ask regarding birth location are whether you want high-tech resources or a NICU available. Obviously, these two things are only available in a hospital setting, but they might be important considerations depending on your and your baby’s medical history.
2) What kind of labor support and pain management do you want access to?
If you want any kind of pharmaceutical pain management or an epidural, you’ll have to birth in a hospital setting, since those options aren’t available at your home and usually not at a birth center. If you want someone who will support an unmedicated birth and encourage you to move around, eat and drink, and help you work through surges, then you might want to look for a midwife. At the very least, I’d consider hiring a doula to help support you.
Another thing to think about is how much you’d like to see your care provider during labor. If you have an OB and birth in a hospital, you likely won’t see very much of your provider. You might see them right when you check in and then probably won’t see them again until baby is about to be born. In this scenario, a labor and delivery nurse is the one who would be checking on you periodically. If you want your provider to be there with you through the entire labor, you might consider hiring a midwife with a birth center or a homebirth midwife.
3) How hands-on do you want your provider to be?
The midwifery model of care is rooted in patient autonomy and a strong belief in instinctive, physiological birth. In practice, this looks like presenting the pregnant person with options and giving them the opportunity to accept or decline anything without judgment. In labor, midwives follow the woman’s lead, so if she wants to walk around, eat, turn the lights off, or birth standing up, they support those decisions.
By comparison, many OBs practice what’s called active management of labor, and they tend to be more hands-on in terms of testing and scanning with ultrasounds. They may look for labor to progress along a certain linear progression/path. To assess labor progression, continuous fetal monitoring and regular cervical checks may be used. If labor does not progress along this timetable, the provider might encourage regular augmentation such as the use of pitocin (synthetic oxytocin) and manually breaking the water bag to speed up surges.
In general, the more medicalized the provider, the more hands-on they tend to be. Statistics show that the rates of inductions, labor augmentations, and surgical births are higher with OBs than they are with midwives (even if it’s a hospital-based midwife).
4) What kind of relationship do you want with your provider?
Do you want an intimate relationship in which your care provider knows the names of your spouse, other children, and pets? Do you want to have long prenatal appointments where you talk about all kinds of things? Do you prefer to have quick prenatal visits, where you check to make sure things are going fine and then continue on your merry way?
Because of the way the insurance system works, hospital-based providers usually don’t have time to spend an hour with each patient. Many wish they could, but the system just doesn’t let them. So if you have an OB, you’ll likely have much quicker appointments. This can also be true with hospital-based midwife practices, but not always.
On the flip side, a homebirth midwife or one who works out of a birth center doesn’t have to follow this system, and they often spend much more time in prenatal appointments with their patients. For example, if you have a homebirth midwife, she may even come to your own home for your prenatals, and you might spend an hour chatting about everything from your physical health to your emotional and mental health as well as nutrition.
The other thing I’d add about birth center and homebirth midwives is that your postpartum care is usually more hands-on and compassionate. For instance, if you give birth in a hospital, you might have a 1-3 day stay and then you and baby are discharged home. You’ll have appointments with your baby’s pediatrician after about a week, but you won’t have a physician follow up until you’re 6 weeks postpartum. That can feel like a long time.
Midwives, especially homebirth midwives, will come back to your home to check in on you and baby much more frequently, usually after a couple of days, then a week, then 2 weeks, etc. And this is also included in their overall fee. So if you feel like you want a little more postpartum care, this might be a route to consider.
5) Finally, this brings us to cost and insurance. How much will your birth cost?
This is completely unique to each person and geographic region, so I won’t try to give any numbers. But this is an important thing to consider. What does your insurance cover? Sometimes they will reimburse for homebirths or birth center care. It’s worth looking into if you’re interested in that option. Some people either don’t have insurance or they have a high deductible, so paying out of pocket for a non-hospital-based provider is actually more cost effective. Another thing to think about is if you have really excellent insurance and a hospital-based birth would cost next to nothing, you might consider putting some out-of-pocket money towards a doula who could provide support in the hospital for you.
Final Thoughts:
Pick a birthing location where you feel most comfortable. If you're tense, it's harder for the body to open up and let that baby descend through the birth path.
Regardless of the type of provider you have, you want there to be clear communication between both of you. You should feel comfortable asking any and every question, and you should feel like you are respected and heard.
Finally, the main thing I want to leave you with in this post is that YOU HAVE OPTIONS. ALWAYS. If you started your prenatal care with an OB/GYN, perhaps it’s the person that you’ve been going to for years for well woman checkups, know that you don’t have to stay with them. You can always change providers during your pregnancy. (I did! With each pregnancy actually!)