Choosing Where To Give Birth In The US

Your medical insurance, location, and finances might play a big role in where you choose to give birth, but there are many options available for most parents-to-be who are living in the United States.

The majority of American women currently choose to give birth in a hospital.

If you’re planning a hospital birth, you still have options. While the location might be the same, choosing either a private practice or a clinic can have an impact on how your prenatal and birth experience unfold.

Some women choose to give birth at a freestanding birth center, or a birth center within a hospital.

Others choose to give birth at home, with the help of a skilled midwife.

Private Practice, Prenatal Care, And Hospital Birth

Private practice doctors or midwifery groups are independent of a hospital; they aren’t hospital employees.

They have privileges to practise at one or more local hospitals where they can attend to their patients in labour and perform medical procedures. They work with the hospital staff, and typically agree to follow a hospital’s policies.

Private practice groups tend to be smaller than large clinics and might have less staff turnover than a larger clinic. You might get to know your doctors’ medical assistants, nurses, and office staff.

Private practice doctors aren’t always in network with your insurance. It’s also possible that even when doctors are in network with your insurance, the hospital where they practise isn’t.

This would mean you would have out of network costs if you choose to work with those doctors, and give birth at their hospital.

Things to keep in mind when considering a private practice:

• Be sure the doctor AND the hospital are in network with your insurance, or calculate your out of pocket expenses
• If there’s more than one doctor or midwife in the practice, be sure you’re comfortable working with all of them, as you won’t always see the provider of your choice for the birth
• Even if you agree with your doctors’ policies, be sure you’re comfortable with their hospital’s policies
• If you’re choosing a practice with both midwives and doctors, find out how their on-call schedule works
• If you’re working with a solo practitioner or a smaller practice, be sure to find out about the other providers in their network. Sometimes smaller practices will partner with other practices to share on-call duties
• Find out their intervention rates, as well as their hospital’s intervention rates. Some practices have c-section rates of around 10% (in line with the World Health Organization’s recommendation of 10-15%), while others are closer to 50%! The same applies to hospitals; their intervention rates vary quite a bit. If your doctor’s rates are low but the hospital’s are quite high, you might still be more likely to experience unwanted interventions.

“My doctor happened to be on call the weekend I went in labor with #6 and it was by far the best birth that I could have ever dreamed of. Baby #5 was with a doctor in my doctor’s network from another practice. She was interested in speed and I was not impressed. So, it’s not just the doctor, it’s their network that matters. My doctor was amazing and exactly what I wanted. Her network, however, had doctors with philosophies that I did NOT like!” – Kelly

“I saw the same physician from my very first OB visit until my birth in our local hospital. It gave me comfort knowing the physician I chose to care for me was who would be at my birth. There were no questions or fears of getting a doctor I didn’t know or trust. I was happy with the entire process and outcome from start to finish.” – Kelly F.

Clinic Prenatal Care And Hospital Birth

For financial or insurance reasons, or for convenience, some women choose to receive prenatal care at a clinic. Many clinics are run by hospitals, some by private organisations; others are military clinics for military families.

For someone who is uninsured and ineligible for Medicaid, prenatal clinic care is often very affordable or even free. However, here’s one thing to consider: it might still be more affordable than you expect to use a private, out-of-hospital midwife if you’re interested in a home or birth center birth.

For some women on Medicaid it is difficult to find a private practice that accepts their insurance  However, in many areas there are private practices that accept Medicaid.

For military families, options are often dependent upon location. If there’s a military hospital with obstetrical care in your area, you’re seen on base (clinic style care) with no out of pocket expenses. For this reason, many will utilise this clinic style care. Occasionally, some choose out of pocket expenses (by switching TRICARE plans) and private care.

If you’re in a large metro area, you might have the option of several different clinics, ranging from smaller clinics, run by organisations, to very large hospital-run clinics.

When deciding on private or clinic care, or choosing between clinics, here are some things to consider:

• How many providers are in the practice? Do they all attend births, or only some?
• Will you have the opportunity to meet the on-call doctors or midwives prior to birth? Alternatively, will your care be provided by the hospital’s on-call employed physician, or midwife, who only attends births?
• Are you comfortable with the policies of the clinic’s affiliated hospital? What are its intervention rates? C-section rates? During labour, much of your care will be provided by the hospital staff.
• Are you actually saving money by utilising clinic care?

“I saw the same midwife my entire pregnancy (however, she was not there for the birth… I couldn’t even tell you the name of the doctor who was there for Tyler’s birth!); with the twins, I saw a different provider at every appointment and again, don’t remember the name of the doctor who did the c-section. However, giving birth in military hospitals was a blessing on the wallet.” – Amanda

“My OB care was through the hospital clinic. I only saw my midwife unless she was on vacation or I required a visit on a day she wasn’t scheduled in the clinic. She wasn’t at the birth of either of my children though. With J, I was induced and had a FTP. So I had the c-section with a different doctor and follow up with my midwife. With T, I had the same Midwife who fully supported my choice of VBAC. I also had a doula and a completely different experience. My midwife missed the birth by 5 minutes because they called her and said I was only 6 cm and then 15 minutes later I had given birth. My doula made a HUGE difference by not allowing them to bully me into a repeat c-section, pain medicine, etc.” – Kristina

Birth Center Birth With A Midwife

For low-risk women, using a low-risk provider and birth facility often means an intervention free birth, or a birth where interventions only occur when necessary.

A birth center midwife is more likely than an obstetrician to discuss your diet, your emotional health, and your birth preferences. The average midwifery appointment is 30-60 minutes, compared with an average obstetrician appointment of 15 minutes.

A birth center can freestanding, which means it is often near, but not part of, a hospital. A birth center can also be located inside or next to a hospital, and considered to be part of the hospital.

Freestanding birth centers typically have their own policies and practices. They are still required to follow any state, licensing, or insurance regulations, but generally have lot more freedom to practise than centers associated with a hospital.

Freestanding centers, and some in-hospital centers, have significantly reduced intervention rates. C-section, epidurals, and instrument assisted births don’t occur in out-of-hospital settings. And even when patients are transferred to a hospital, their rate of intervention remains lower than that of patients planning a hospital birth.

Many birth centers accept insurance; some accept Medicaid. If you’re using a freestanding birth center, it’s likely to be less expensive than a hospital birth in terms of deductibles, and copays, and if you’re paying completely out of pocket.

For a hospital birth, you pay your obstetrician/midwife for prenatal and labour care. The hospital bill is  paid separately, and might include costs for medical supplies, medications, the room, nursing care, nutrition and, sometimes, nursery fees. You might also receive a bill from other providers, such as an anaesthesiologist or paediatrician.

Some things you might want to consider, when choosing between a hospital and a birth center, are:

• Does the center accept your insurance? What, if any, will be your out of pocket expenses, compared with those at the hospital?
• Will you meet all of the midwives prior to birth?
• How long after birth do you stay at the center?
• To what hospital would you be transferred, if necessary?
• How does the on-call schedule work? Who is the back up physician?
• What medical conditions, labour situations, and so on, would risk you out of their care, and require your transfer to another provider?

“I saw the same two midwives for my prenatal care and felt truly confident in my ability to have a natural birth. When it came time for birth, my water broke but it wasn’t a rush or emergency. I relaxed at home until labor began. I arrived shortly before transition where the midwives provided space as desired, but also ongoing support when needed. The tub to labor in was also amazing.

The immediate postpartum period was so relaxed! They helped establish breastfeeding, made sure baby and I were good and then about 6 hours after birth we headed home. They came two days later to check on baby and I (they were on call for any concerns), we saw them again a week later and at our 6 follow up.

My co-pay was hundreds less than had I given birth at the hospital. Not a deciding factor, but a nice bonus.” – anonymous

Home Birth With A Midwife

Home birth options vary quite a bit from state to state. In some states Medicaid will cover a home birth with a midwife, while in other states midwives aren’t even legally allowed to attend home births.

Home births, like freestanding birth centers, are a safe option for low-risk women, and almost always lead to an intervention free, natural birth.

Even when transfers to a hospital occur, the rate of intervention still remains lower when compared with planned hospital births. In the event of a transfer that includes an undesired intervention (such as a c-section), many take comfort in knowing it was a necessary intervention, rather question the need for it, if they had been in the hospital from the start.

Home births are comparable to freestanding centers in terms of overall cost. However, your out of pocket expenses will depend upon your state, and your insurance cover. If your state allows for midwives to attend home births, and your midwife is in network with your insurance, you will probably have little out of pocket expense.

Even if you have to pay out of pocket for home birth care, sometimes that cost is still lower than a hospital birth co-pay or deductible.

For a home birth, many of the things to consider are similar to those for a birth center birth.

There are a few additional things to think about:

• At what stage does the midwife typically come to your home when you’re in labour?
• Who is her back up midwife? Back up physician?
• Under what circumstances would you risk out of a home birth, and what does transferring care entail?
• How long does the midwife stay after the birth? How many follow up appointments will you have?

“I really got to know my midwife and was so comfortable around her. When I was in active labor, she came to the house. Unlike my previous hospital births, there wasn’t a moment to fear. I was confident I’d have a natural birth, but felt secure in knowing she could handle any unexpected complications.

After she was born, I got to just relax in my own bed. No extra staff, no interruptions, no traveling home. I was already home and my baby just fell right into place in our family.” – Amy

Recommended Reading: Learn more about your options for birth in the US in BellyBelly’s article Who Cares In The US? Choosing A Maternity Care Provider.