A birth center is a middle ground between home birth and a hospital. You get the benefit of natural or non-medicated birth in a home-like setting, with some of the safety nets that you would have in a hospital. Birth centers generally feature midwife-led care, focused on prenatal and postpartum care for low-risk women. The majority of birth centers are freestanding entities. More are popping up in hospitals with the same focus of natural birth with integration into the hospital system in the event resources or care from the hospital are needed. This episode covers what a birth center is, what you can expect during your prenatal care, labor, birth, and the evidence on birth centers’ safety.
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Birth Center vs. Hospital
If you are exploring the idea of a birth center or already know this is the venue where you want to have your baby, this article focuses on how a birth center differs from a hospital setting, what you need to incorporate into your birth plans, and what to expect for a birth at a birth center. The vast majority of births in the United States, about 98%, happen at hospitals. You can visit the article on hospital birth for a rundown of everything you can expect, from walking into the hospital in labor to leaving with your new baby. It is always good to have a backup plan and educate yourself about hospital birth if your plans change during labor and you transfer to a hospital.
What is a Birth Center?
Birth centers are medical facilities that provide prenatal, birth, and postpartum care for low-risk parents. These centers focus on unmedicated births and do not offer epidurals or cesarean birth. Most birth centers are freestanding, although some are incorporated into hospitals. Birth centers are designed to be more like a home setting than a hospital or medical facility.
The Growing Popularity of Birth Centers
Birth Centers are becoming more popular in the U.S. According to CDC data, in 2004, there were 170 birth centers, and a total of .23% of births took place in a freestanding birth center. By 2013 there were 248 birth centers, which accounted for .39% of births. In 2017 that number went up to 0.52%. The number of women giving birth in a birth center is still less than home births. We can expect the number will continue to grow as more birth centers open around the country. According to the American Association of Birth Centers, there are currently 344 birth centers in 39 states and D.C.
Standards and Accreditation
The American Association of Birth Centers sets standards for birth centers to consistently measure the quality of services. The Commission for Accreditation of Birth Centers certifies birth centers that meet the AABC standards. If you want to locate an accredited birth center near you, you can use a search tool on the website for the CABC or the AABC. Even a Google search should pull up results for birth centers in your area.
Birth Center Staff
Typically, birth centers are staffed by midwives. This is the root of what makes birth centers so different from hospitals. Midwife-led care differs significantly from the traditional medical model with OBGYNs. As we discuss how birth centers differ from hospitals, you will see they operate in alignment with the midwifery model. There are three different types of midwives; certified nurse midwives, certified midwives and professional midwives. Each certification has different requirements, and licensing is at the state level.
A Certified Nurse Midwife (CNM) needs a bachelor’s degree in nursing because they are registered, nurses. Then they go through a two to three-year graduate-level training in midwifery. Certified Nurse-Midwives are licensed in all 50 states in the U.S.
A Certified Midwife (CM) has a background in a health-related field other than nursing, then goes through a master’s level midwifery education program. They have similar training to CNMs, conform to the same standards, but C.M.s are not required to have the nursing component. Certified Midwives are licensed in only five states in the U.S.
A Certified Professional Midwife (CPM) does not have college degree requirements and instead gains expertise through clinical training under a midwife’s supervision. CPMs are licensed to practice in 35 states and are the most common type of midwife in the U.S.
Licensing dictates who is legally allowed to attend births based on the setting. Traditionally midwives attend the majority of out-of-hospital births. This report on trends in out-of-hospital births breaks down what type of care provider attended births based on location. CNM/CM midwives attended just over 56% of births at a birth center. 36.7% by non-CNM/CM midwives, and only 2.7% by physicians. If you would like to see licensing details on your state, the Midwives Alliance of North America breaks down each state’s laws. For more information on midwives and the differences between this care provider and an OBGYN, see the article on Choosing or Changing Your Care provider.
Many birth centers will also work closely with other professionals like nurses, acupuncturists, doulas, massage therapists, counselors, chiropractors, childbirth educators, nutritionists, and lactation consultants. Some birth centers will have some of these professionals on staff or have a close working relationship with professionals they can recommend and refer you to.
A birth center focuses on a limited scope of care compared to a hospital with a wide range of services. For this reason, birth centers are much smaller than hospitals, both in size and staff. There are pros and cons to this. A smaller care setting means you get to know more of the staff, and it may be easier to navigate a smaller facility. Since birth centers have a smaller number of patients, they may have more leeway in individualizing care than a hospital with more restrictive policies and procedures. A possible downside is that birth centers limit the number of expecting parents they can treat. They also have fewer rooms to accommodate birthing parents. Hospitals tend to have identical rooms and accommodations. A birth center may offer rooms of different sizes with different amenities. This means you may not be able to choose a specific room if it is in use when you go into labor.
Costs and Insurance Coverage
The total cost of prenatal care and birth tends to be less expensive at a birth center than at a hospital. Unfortunately, health insurance tends to cover more of the costs for a hospital birth. The result is you may end up paying more out of pocket for a birth center.
You will need to check with the birth center and your health insurance to determine if a birth center is covered and up to what amount. It could also be a good idea to determine how your insurance coverage will work if you transfer to a hospital. Trying to locate this information online may be challenging, so my recommendation is to get on the phone with your health insurance and ask them. You might be on hold for a little bit before you reach someone, but you will save time and get direct answers to your specific questions in the long run.
Some birth centers may offer assistance or reduced rates if you are low income. If you are concerned about the cost, ask if there are any programs you could qualify for to reduce the fees.
Comparing Birth Center Options
If you have more than one birth center in your area, it is worth exploring all of your options. A tour, if available, will allow you to meet some of the midwives and get a feel for the place to see if it would be the right fit for you. If tours are not available, start with a phone call and learn more about the venue. Birth centers are unique settings, and there can be significant differences between them. If you are looking at multiple options, you may also want to find out the proximity to a hospital is or the procedures in place at each center if a transfer becomes necessary. You also can, and should, have a tour at your backup hospital if possible. If you have multiple hospital options, explore those too.
Some birth centers may offer a centering pregnancy model of care or group appointments. This style of care matches you with other mothers expecting around the same time. Each appointment has a health check where you are one on one with a midwife and then a midwife-led discussion with the group. Group care gives you and your partner a space to meet other expecting parents in your community who are on a similar timeline with their pregnancy. You may meet people who become friends for years to come. This setting also puts you in contact with other expecting parents going through some of the same challenges. Not everyone in your group will be first-time parents, and you may benefit from hearing different perspectives from couples with varying levels of experience. If group appointments are an option, I encourage you to try it out.
Whether you have a group or one-on-one appointments, your prenatal appointments tend to be longer than typical appointments with an OBGYN and focus on education and answering any questions you have. You being an active participant is part of the model of midwife-led care. Many birth centers will involve you in your prenatal care, from taking some tests at home to checking your weight. This is also the case if you see a midwife for your prenatal care and plan a home birth.
Similar to a hospital, you will start your labor at home before coming into the birth center. You should know when your midwife wants you to go in, for example, when your contractions are 5-1-1, or five minutes apart, lasting for one minute, for one hour. You will want to call to let them know you are in labor, especially after hours. Birth centers are generally not open 24 hours like a hospital emergency room would be. You will want to have a birth center bag packed with anything you might want for labor, birth, and your new baby. Depending on the birth center, you may have an assigned midwife who will be present for your birth, or you could end up with the midwife on call. Ensure you know the birth center’s policy to know who you can expect to be present for your birth.
The labor and birth experience at a birth center is similar in setting and policies to home birth. In a birth center, you are encouraged to eat and drink during labor to keep your energy levels up. This differs from a hospital where you are typically discouraged from eating, and IV fluids are often used instead of drinking water.
A birth center is designed like a home setting. There is usually a bed, tools like squatting bars and birthing balls, and often a tub for water births.
Limited Interventions Available
You can expect fewer interventions at a birth center for two main reasons. The first is that many interventions are not routine r simply are not available. This includes interventions like continuous electronic fetal monitoring, inductions, epidurals, or cesarean birth. For these interventions, you would need to be transferred to a hospital. The second reason there are fewer interventions is that birth centers are geared towards physiological birth, and the goal is to labor and birth with little to no intervention.
Focus on Non-Medicated Birth
If you plan to have your baby at a birth center, that means you are planning a non-medicated or “natural” birth. For more information on a non-medicated birth, see this episode. The best way to prepare for labor and birth without an epidural is to have many tools to cope with contractions.
One of the biggest mistakes moms make that results in an unsuccessful natural birth is not preparing. Part of preparing for a non-medicated birth is creating a birth plan. If you want to see an example of what a birth center birth plan might look like, I would be happy to send you a copy of the birth plan I used for my first birth at a birth center, along with my backup birth plan in the event I ended up in a hospital. Click here to get copies of my birth plans. Your preferences may be different from mine, but it may be helpful to see how a birth plan could be structured and worded.
Birth centers should have procedures in place in the event you transfer to a hospital. No matter how prepared you are, there is always the possibility you will need to transfer to a hospital. The most extensive study on birth centers gives useful statistics on hospital transfers. Of over 15,000 participants, 84% were able to give birth at the birth center. 4.5% were referred to a hospital before being admitted to the birth center, 11.9% transferred to the hospital during labor, 2.0% transferred after giving birth, and 2.2% had their babies transferred after birth. Of the women who transferred to a hospital during labor, 54% ended up with a vaginal birth, 8% had a forceps or vacuum-assisted vaginal birth, and 38% had a C-section. The majority of the in-labor transfers were for non-emergency reasons, such as prolonged labor. 0.9% of the total participants transferred to the hospital during labor for emergency reasons, 0.4% of mothers, and 0.6% of newborns transferred after birth for emergency reasons.
You should discuss how a hospital transfer works and whether your midwife would be able to continue your care in a hospital or whether they would transfer you to an OBGYN. Ideally, the birth center should have OBGYNs they work with regularly and have a relationship with a nearby hospital.
High Rate of Vaginal Delivery
Many women choose a birth center over a hospital because of the high rate of vaginal births. In one study, 94% of over 15,000 participants had a vaginal birth. This means that the C-section rate for low-risk women who chose to give birth at a birth center was only 6%. If you want to reduce your risk for cesarean, a birth center is worth exploring.
After the birth of your baby, you can expect to be able to focus on your little one. Your midwife will, of course, be checking to make sure both you and your baby are healthy. Birth centers are very baby-friendly and will support skin-to-skin contact. Often they will delay some routine procedures, like weighing your baby. Or perform some procedures with your baby on your chest.
Your stay after birth at a birth center is shorter than a hospital stay, and often, you can expect to go home the same day. Talk to your midwife ahead of time so you know how long you can expect to be there.
Evidence on Safety
Now that you have an overview of what a birth center is and how it works let’s talk about some of the statistics and the safety concerns at birth centers. There is not a lot of research on birth centers, and as more open up around the country, hopefully, we will see more published data.
The most extensive study was the National Birth Center Study II was published in 2013. This included data on 15,574 mothers in 33 states. 93% of participants had a spontaneous vaginal birth, 1% an assisted vaginal birth, and 6% a cesarean. These rates are far lower than you would typically see in a hospital. According to CDC data, the cesarean rate for low-risk women was 26.9% in 2013, and this is roughly the same time frame as the National Birth Center Study reported a cesarean rate of 6%.
There were no maternal deaths among participants. The study found the stillbirth rate was 0.47 per 1,000 women. You can compare this to a national stillbirth rate of 0.6 per 1,000 births in low-risk women in the U.S. The study also reported 0.4 newborn deaths per 1,000 women. This is also lower than you would expect to see in a low-risk population in a hospital.
An integrative review published in 2016 gives a good summary of the literature on birth centers. This review included 32 papers covering over 84,000 women in the U.S., Sweden, Denmark, Australia, Canada, Scotland, and Germany. Spontaneous vaginal birth rates were higher for women beginning care in a birth center than women receiving care in hospitals in all studies. Three studies found significantly lower rates of episiotomy in birth center groups as compared to hospital groups. In 3 studies, rates of women with an intact perineum following vaginal birth were significantly higher in the birth center group than in the hospital group. Intact perineum rates in the birth centers, when reported, ranged from 25% to 61.3%.
Three sources measured the length of labor and found that women beginning labor in birth centers had significantly longer labors than women starting labor in the hospital. Overall, women had a positive satisfaction with their birth center experience in the studies that looked at this outcome.
The research available does support that birth centers are a good option for low-risk women. There is not a standard definition of “low-risk” across all birth centers. Typically, the criteria for birth at a birth center are that you are pregnant with a single baby, in a head-down position, and go into labor between 37-42 weeks. The particular requirements may vary by birth center.
Questions to Ask
If you are exploring a birth center, there are a lot of questions you can ask to gather information to help you decide whether this could be a good option for you. Some questions you may want to ask are:
- Are you accredited?
- What certifications do the midwives at the birth center have? (CNM, CM, CPM)
- Are prenatal care appointments individual or in groups?
- Will a specific midwife attend my birth, or will it be the midwife on call?
- What are the requirements to remain eligible to have your birth there?
- How does a hospital transfer work?
- What percentage of your patients transfer to a hospital?
- What percentage of hospital transfers are emergency transfers in labor?
- What percentage of your patients have an episiotomy or vaginal tear?
- Have you had any maternal or infant deaths?
- What is the cost of prenatal care and birth, and what does that include?
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