NOTE: For guiding decisions about care, Childbirth Connection gives priority to systematic reviews. These rigorous summaries of best available studies are the most trustworthy way to know the benefits and harms of specific practices.

What does research say about the pros and cons of different types of birth settings in the United States?

In choosing a place of birth, you will want to find a good match for what is safe and important to you. More rigorous systematic and integrative reviews have clarified that the type of care that women and families get differs greatly between hospitals and birth centers or at home. This section summarizes best available evidence since 2005 on these questions.

Important variation also occurs from hospital to hospital and to some degree from one birth center to another. Once you decide to use one of these settings, it will be important to make a wise choice about the specific facility, as discussed below. Our Resources page has important tools for this purpose.

How does maternity care compare in hospitals versus birth centers?

An integrative reviewAlliman, J. & Phillippi, J.C. (2016). Maternal Outcomes in Birth Centers: An Integrative Review of the Literature. Journal of Midwifery and Women’s Health, 61(1), 21-51. found that the following outcomes are better for women and babies using birth center care than for women using hospital care:

• Less use of pain medicine overall and epidural analgesia in particular.
• Less use of medicine to speed labor (synthetic oxytocin or “Pitocin”).
• Less use of episiotomy (cut just before birth to widen opening of vagina).
• More experience of intact perineum with vaginal birth (no tear or episiotomy).
• Less use of vacuum extraction or forceps.
• More experience of vaginal birth with neither vacuum extraction nor forceps.
• Less use of cesarean birth.
• Greater satisfaction with care.

(Note that many of these interventions are not available in birth centers, but could be used if women are transported for hospital care.)

A structured review found that resource use was generally lower for women with birth center care due to lower rates of intervention, shorter length of stay, or both.Henderson, J. & Petrou, S. (2008). Economic implications of home births and birth centers: a structured review. Birth, 35(2), 136-146.

An integrative reviewAlliman, J. & Phillippi, J.C. (2016). Maternal Outcomes in Birth Centers: An Integrative Review of the Literature. Journal of Midwifery and Women’s Health, 61(1), 21-51. found:

• Women giving birth in birth centers experienced longer labors in comparison with women in hospitals.
• The chance of having a serious tear going into or through the anus during labor does not differ between women giving birth in hospitals and those giving birth in birth centers.
• Rates of transfer of women from birth center care to hospital care are as follows:
• During pregnancy for medical reasons: from 13 percent to 27 percent
• During labor: from 12 percent to 37 percent (from 12 percent to 17 percent when limited to the past five years); transport was “at least five times higher” for first-time mothers than for women who had already given birth)
• After birth: 1 percent to 5 percent

That review reported that the most common reasons for transport were slow or prolonged labor and rupture of membranes without labor. Rates of emergency transport ranged from 2 percent to 4 percent.

How does maternity care compare in regular hospital maternity units versus in-hospital birth centers?

A systematic reviewHodnett, E.D., Downe, S., & Walsh, D. (2012). Alternative versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews, 8, CD000012. found that neither women nor newborns using in-hospital birth centers had worse outcomes than those using regular hospital maternity units. Care was better for women in in-hospital birth centers than for women in regular hospital units due to:

• More experience of no analgesia/anesthesia.
• Less use of epidural analgesia.
• Less use of medicine to speed labor (synthetic oxytocin or “Pitocin”).
• Less use of vacuum extraction or forceps.
• Less use of episiotomy (cut just before birth to widen opening of vagina).
• More experience of a vaginal birth with no vacuum extraction or forceps.
• Less use of cesarean birth.
• More very positive views of their care (just two studies measured this).
• More breastfeeding at 6-8 weeks (just one study measured this).

The same systematic reviewHodnett, E.D., Downe, S., & Walsh, D. (2012). Alternative versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews, 8, CD000012. found that the following outcomes were not different between in-hospital birth centers and regular hospital maternity units:

• Excess maternal bleeding after birth.
• Early condition of newborn.
• Perinatal death.
• Use of newborn intensive care unit.

How does maternity care compare in hospitals versus at home?

A systematic reviewWax, J.R., Lucas, F.L., Lamont, M., Pinette, M.G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. American Journal of Obstetrics and Gynecology, 203(3), 243e1-8. found that the following outcomes are better for women and babies with home birth versus those with hospital birth:

• Less use of electronic fetal heart rate monitoring.
• Less use of epidural analgesia.
• Less use of episiotomy (cut just before birth to widen opening of vagina).
• Less experience of any tear in the perineum (area between opening of vagina and anus).
• Less experience of serious tears into or through the anus, or tears in the vagina.
• Less use of vacuum extraction or forceps.
• Less use of cesarean birth.
• Less experience of excess bleeding.
• Less experience of placenta that does not come out.
• Less experience of infection.
• Less experience of preterm birth.
• Less experience of low birth weight.

In a systematic review,Wax, J.R., Lucas, F.L., Lamont, M., Pinette, M.G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. American Journal of Obstetrics and Gynecology, 203(3), 243e1-8. the following outcomes were not different between women and babies in hospitals and with home birth:

• Umbilical cord coming out before birth (cord prolapse, a serious complication).
• Newborn large for gestational age.
• Newborn requiring ventilation.
• Perinatal death (stillbirth from 20 or more weeks plus newborn death in first 28 days).

A systematic reviewWax, J.R., Lucas, F.L., Lamont, M., Pinette, M.G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. American Journal of Obstetrics and Gynecology, 203(3), 243e1-8. found two outcomes that were worse for women giving birth at home:

• More “post-term” births at or beyond 42 weeks.
• More newborn death (in first 28 days).

Note: This finding regarding newborn death risk has been very controversial. It is based on studies that have been criticized (for example, for including high-risk, unplanned, out-of-hospital births) and is based on a relatively small number of births. As the perinatal death rate, which did not differ between home and hospital, was based on 20 times more home births, it is likely to be a more trustworthy result.

A structured review found that resource use was generally lower for women cared for at home due to lower rates of intervention and no facility costs.Henderson, J. & Petrou, S. (2008). Economic implications of home births and birth centers: a structured review. Birth, 35(2), 136-146.

A systematic review reported rates of transport of women or newborns during or after labor from planned home birth care to hospital care. Overall, transport in the various studies ranged from 10 percent to 32 percent, with emergency transport ranging from 0 percent to 5 percent. The most common reason was poor labor progress.Blix, E., Kumle, M., Kjaergaard, H., Oian, P., & Lindgren, H.E. (2014). Transfer to hospital in planned home births: a systematic review. BMC Pregnancy and Childbirth, 14, 179.

How does maternity care compare in birth centers versus at home?

Due to the level of technology available in both places, care practices are similar in both settings. However, we found no rigorous reviews comparing care, including safety, in these two settings.

What is most important to making sure I have a satisfying childbirth experience?

A systematic review of the best available researchHodnett, E.D. (2002). Pain and women’s satisfaction with the experience of childbirth: a systematic review. American Journal of Obstetrics and Gynecology, 186(5), S160-72. finds that the following four factors make the greatest contribution to women’s satisfaction in childbirth:

• Having good support from care providers.
• Having a high-quality relationship with care providers.
• Being involved in decision-making about care.
• Having better-than-expected experiences (or having high expectations).

Choosing a birth setting with care providers that can provide this type of care can make a big difference in your satisfaction!

How can I become familiar with my options before making my decision?

Where you give birth is a big decision, and we encourage you to take the time to visit different care settings before making your choice. It’s also critical that you feel good about the health care professional who will provide your maternity care within your preferred setting.

Many hospitals offer tours for parents who are thinking about giving birth there. Download and print this list of questions you may want to ask when touring a hospital. If you are choosing among hospitals, you may be able to find online sources that compare the quality of different hospitals in your area. See this section’s Resources page for some of the main sources for this information.

Birth centers often have tours and open houses where you can meet the care providers, learn about the facility and ask questions. Here is a list of questions you can use when visiting birth centers.

If you are interested in home birth, you can set up interviews with care providers who may attend your birth at home; we encourage you to print and use this list of guiding questions.

Become informed and follow your instincts. Only you can make the decision that is right for you. If you have concerns, even if you are well into your pregnancy and prenatal care, it may be important to explore other options.

What if I change my mind about where I want to give birth during my pregnancy?

You can always explore other options if you have concerns and have not been able to resolve them through open and respectful communication with the birth setting you originally selected. Even if it is late in your pregnancy, you can switch to a different birth setting (and/or care provider) if:

• You have enough time to explore options and find a situation you believe will work better for you.
• The new care provider or setting has no policies that prevent you from making this change at that time in your pregnancy. (For greatest flexibility, don’t delay exploring other options if you have concerns about your current birth setting and/or care provider.)
• Your insurance will cover the new arrangements or you are willing and able to pay out of pocket.

You may have to change your care provider and/or birth setting to get what you want.