The Birth Book

The Who and the Where

From Birth Center to Hospital in the Middle of the Night

My pager went off at 2 a.m., and I immediately recognized the number. It was a midwife from the local birth center—they had a woman in labor who needed to be transferred to my hospital.

I learned that she’d been in labor for days and was exhausted. Her cervix was 6 centimeters dilated but hadn’t changed over the past ten hours. She was sad at needing to leave her birth center and had a huge fear of hospitals after losing her dad one year prior. Basically, she had zero desire to meet me, and her feelings weren’t subtle.

The midwife and I finished our conversation, and I left my call room to go chat with the labor nurse who would be caring for this patient. When I saw who it would be I smiled, because I knew this was the exact right person to help ease this mom’s transition into a situation that felt scary and unwanted.

I’ve always been proud of how my group has cared for people transferring from home or birth centers, but I’d be lying if I said that my mind didn’t always contemplate the worst-case scenarios before such people arrived. What if she had an infection or hemorrhaged from being in labor so long? How was her baby doing? What if her baby was breech and no one noticed? If she needed a C-section, would she be open to it? How difficult would it be to build rapport?

Our patient arrived an hour later, not ready to talk to me because she was in so much pain and so exhausted. We prioritized comfort, and she received an epidural and slept hard for a few hours. When she (and her partner) woke up, I introduced myself. We talked about her goals, and I clarified that her main one was to avoid a C-section. Her nurse and I discussed why I recommended starting Pitocin to try to help move her labor along, and as a way to actually get her the vaginal birth she so badly wanted. We reviewed risks and alternatives. We acknowledged that we knew this wasn’t her plan, but we would do everything we could to support them as this birth experience took a detour.

There was some crying, but also some laughing as we joked about comparing the hospital décor and linen quality to those of her birth center. At one point she said, “My midwife said you guys were nice, but I didn’t really believe her. You guys are great, though.”

In the end, she birthed a gorgeous baby boy who weighed almost nine pounds and had a ton of hair. There was some extra bleeding, but nothing we couldn’t manage. She went home two days later, healthy and happy—though I am sure still carrying some trauma from not having the experience she had wished for. But I do hope her feeling seen and valued helped, even just a little bit.

Where can I have my baby?

Technically, you can have your baby anywhere you want (well, maybe not anywhere)—but what I mean is that the answer doesn’t always have to be a hospital. You might be surprised that an OB-GYN is starting her book with that statement, but my goal is to go beyond what we’re always told—because that hasn’t really worked well—and to meet people where they’re at so that they can make informed, empowered decisions.

So yes, you can even choose to have your baby without any medical professionals around (Called freebirthing or unassisted birth, this is the practice of having a baby on your own and sometimes includes forgoing prenatal care as well.) That may sound out there, and as a hospital-based OB-GYN of course I have thoughts on it, but at the end of the day where you birth is your choice. However, we need to talk about the risks and benefits of all possible scenarios.

Community birth is a term that refers to a planned birth at home or in a birth center. You’ll see me refer to that often, so I wanted to define it for you.

Here are common places you can choose to give birth, with my thoughts on each:


Hospital.

What it sounds like! This is our most common model of birth in the United States.

• Access to pain medication options like an epidural and IV medications

• Access to emergency care and specialists if needed

• Nothing you need to do to prepare your home

• Often covered by insurance

• Tends to be more socially acceptable to many people

• Requires driving to it (this can be an issue if one isn’t close by)

• Higher rates of interventions like C-sections

• A more medicalized feeling

• You may see providers you don’t know

• Cost concerns are real

Many hospitals employ certified nurse midwives and have access to things like whirlpool baths for labor or even for waterbirths. If you’re interested in this, it’s important to ask early on in pregnancy to make sure your intended hospital has these resources available.


Home

Birthing at home, often with the oversight of a midwife (more on page 11 about the different types of midwives).

• No need to leave the comfort of your own home

• Lower rates of interventions

• Some midwives may offer nitrous oxide for pain relief

• Can be more affordable than hospital birth

• Helpful if you have other children and you don’t have childcare, since you aren’t leaving them

• Often a combination of office and home visits prenatally, and often more postpartum visits than if you delivered with an OB-GYN in a hospital

• Requires preparation, including getting supplies

• Lack of access to IV pain medications or epidurals

• It still may require hospital transfer, which can result in a disjointed-feeling experience

• Some emergencies happen too quickly for a hospital transfer, leading to potential life-threatening outcomes

• May not be covered by insurance in some statesI want to note that a homebirth with an experienced midwife is very different from an unassisted freebirth at home. More on this in the coming pages.


Freestanding birth center

This is a birth center that may be run by a community or by certified nurse midwives. Care, delivery, and postpartum recovery can often happen in the same place. Similar benefits as home birth, but without having to prepare your own home

• Often the same as a homebirth.

• Have to get in a car to go somewhere.

• Same safety profile as with homebirth.

• If you live far from a hospital but a birth center is closer to home, this can be a nice option.


Hospital-based birth center

A birth center that is co-located or nested within, but technically separate from, the hospital’s labor and delivery unit. Feels like a birth center but with access to all emergency care and resources that are on Labor and Delivery.

• Unfortunately, not that common in the United States.

• Can still have some of the medicalized drawbacks of a hospital birth (more interventions). I wish we had this in every hospital!


Transferring into a Hospital

Between 5 and 35 percent of all people who opt for a birth outside the hospital will need to transfer into one either during or after birth, with most situations being non-urgent. This is a huge range, but in general the rate is lower for those who’ve given birth vaginally before. Common reasons to transfer include wanting pain medication and stalled labor. For more, see page 178, “I planned a homebirth and have to transfer in; what should I know?”

I also think having an idea of actual numbers can be helpful in deciding where to have your baby. As you can see below, planned homebirths, birth center births, and hospital births are associated with their own unique risks. It’s up to you—ideally in consultation with a medical provider who understands the intricacies of your own health and pregnancy—to decide which of these risks are more acceptable to you and which are not.