Where to give birth in the US: hospital, birth center or home

The order of operations is different here

In most countries the conversation about where to give birth starts with risk. In the United States it starts with money. The federal Office on Women's Health puts it in one sentence: women can choose to deliver at a hospital, birth center or at home, and you will need to contact your health insurance provider to find out what options are available to you.

Do that call before you fall in love with a setting. Then ask the second question that trips people up: whether the doctor or midwife you are considering can actually deliver your baby in the place you want to give birth. Providers have admitting privileges at specific facilities, and a provider you like who cannot deliver where you want is a problem you want to find in month two, not month eight.

Hospitals

Hospitals are the recommended choice for women with health problems, pregnancy complications, or those at risk of problems during labour and delivery. They offer the most advanced medical equipment, and doctors who can perform a cesarean delivery if you or your baby is in danger during labour. Epidurals and the full range of pain relief options are available.

Increasingly, hospitals also run on-site birth centers that aim to offer a style of care similar to a standalone center, which is worth asking about if you want the atmosphere without leaving the building.

What to ask a hospital

How close is it to home? What is the policy on monitoring and movement in labour? Who will be with you? And, specific to the US, confirm in writing that the hospital is in-network for your plan, because an in-network hospital can still bill you for out-of-network anesthesiology or neonatology.

Birth centers

A birth center gives you a home-like environment and does away with most high-tech equipment and routine procedures. You are not automatically hooked up to an IV, and you do not wear a continuous electronic fetal monitor; a midwife or nurse checks your baby periodically with a handheld device. Once the baby is born, exams and care happen in your room. Usually certified nurse-midwives, not obstetricians, deliver babies at birth centers.

Two limits are firm. You cannot receive an epidural at a birth center, although some pain medicines may be available, and if a cesarean becomes necessary you must be moved to a hospital.

Accreditation is the thing to check

The Office on Women's Health names three bodies: the Accreditation Association for Ambulatory Health Care, The Joint Commission, and the American Association of Birth Centers. Accredited birth centers must have doctors who can work at a nearby hospital in case of problems with the mother or the baby. Ask which hospital, and how far.

Birth centers can sit inside a hospital, be attached to one, or be completely separate facilities. That distinction changes your transfer time and often your billing, so ask which one you are looking at.

Home birth

Home birth in the US is a different proposition from home birth in a country with a single national midwifery service. The federal guidance is explicit about what you must have in place: a highly trained and experienced midwife, a fail-safe back-up plan, and fast, reliable transportation to a hospital. If you live far from a hospital, home birth may not be the best choice.

Your midwife must have the skills and supplies to start emergency care for you and your baby, and should have access to a doctor 24 hours a day.

The part that varies by state, and we are not going to fudge it

Midwifery licensure, which credentials may legally attend a home birth, and whether Medicaid or your commercial plan pays for a freestanding birth center or a home birth are all set state by state. There are more than fifty different answers and they change. We are not going to generalise from one state and let you plan around it.

The two calls that give you your actual answer are your state health department and your insurer's member services line. Federal law helps in one place worth knowing: maternity and newborn care is an essential health benefit, so every qualified health plan sold on the Marketplace covers pregnancy and childbirth. That tells you the care is covered. It does not tell you which setting your particular plan covers.

Certified nurse-midwife or certified professional midwife

The letters change where the person usually works. A certified nurse-midwife is educated in both nursing and midwifery, and most practise in hospitals and birth centers. A certified professional midwife is required to have experience delivering babies in home settings, because most CPMs practise in homes and birthing centers. Federal guidance says all midwives should have a back-up plan with an obstetrician in case of a problem or emergency. Ask to see it.

A short checklist before you decide

Call your insurer and ask which facilities and which provider types are covered. Confirm your provider delivers where you want to give birth. If it is a birth center, check the accreditation and the named back-up hospital. If it is home, check the transfer plan and the distance. And if you have a health problem or a complication, take the federal advice at face value: that is what hospitals are for.

What a transfer looks like from a birth center or home

Every out-of-hospital plan needs a written transfer plan, and it is fair to ask to see it. From an accredited birth center, the accrediting bodies require doctors who can work at a nearby hospital in case of problems with the mother or baby. After delivery, babies with problems can receive basic emergency care at the center while being moved to a hospital.

From home, the requirement is a fail-safe back-up plan, fast and reliable transportation, and a midwife with the skills and supplies to start emergency care and access to a doctor 24 hours a day. Ask which hospital, how far, who calls ahead, and who travels with you.

The other thing to check at a birth center

Ask whether the center has the staff and set-up to support successful breastfeeding, which federal guidance names specifically. Many birthing centers have showers or tubs in their rooms, large beds and rocking chairs, and in general allow more people in the delivery room than hospitals do.