Best Evidence for Choosing A Place of Birth

Best evidence: When making important maternity decisions, women should have information from the best available research about the safety and effectiveness of different choices. In general, we can be most confident about results of systematic reviews that summarize randomized controlled trials (or RCTs, a type of study).

Unfortunately, for many decisions, we must rely on less definitive research; and many important questions - even in the case of widely used drugs, tests, and procedures - have hardly been studied at all. Although this situation is discouraging, an awareness of weak or missing evidence can help you make more informed choices about care.

What is the bottom line for choosing a place of birth?

What is the best evidence about advantages and disadvantages of different types of places of giving birth available in the U.S.?

What factors regarding the place of birth most contribute to women's satisfaction in childbirth?

What is the bottom line for choosing a place of birth?

Neither systematic reviews nor randomized controlled trials are available to compare the relative safety and effectiveness of birth in hospitals with other alternatives in U.S. settings. (The sole exception is a systematic review of observational (less definitive design) research of home versus hospital birth, which includes two U.S. studies.) Because death of mothers and babies is a rare event, requiring very large studies to detect differences, the best available research does not clarify whether hospital or other places of birth might be safer from this perspective for well, low-risk women and their babies. At the present time, we do not have evidence that hospital care offers clear safety benefits for low-risk childbearing families, and studies consistently find that it involves higher rates of intervention than other settings. Places of birth that limit routine use of interventions with low-risk women appear to be more consistent with the best evidence about common interventions.

Despite this overall pattern, specific care environments vary. Characteristics of an individual place of birth, including the attitudes and style of caregivers in that place of birth, have a major impact on the type of care that a woman receives.

What is the best evidence about advantages and disadvantages of different types of places of giving birth available in the U.S.?

This information summarizes the best available evidence about the comparative safety and effectiveness of the following places of birth: hospital, in-hospital "birth center", out of-hospital (freestanding) birth center, and home.

Hospital birth center care compared to usual hospital care.
One systematic review from the Cochrane Collaboration (Hodnett 2004) compares usual hospital settings for birth to hospital birth centers. It summarizes data from nearly 8,000 women in five randomized controlled trials. Unfortunately, the studies are from Europe and Canada, and the reviewer found no relevant high-quality controlled trials from the U.S., which may not be similar. The pooled evidence about home-like settings finds that they involve less use of pain medications, less use of medication to stimulate labor (pitocin), greater mobility in labor, fewer fetal heart abnormalities, and greater satisfaction with care. The babies' rates of death during labor or in the first four weeks after birth were higher, but not statistically different, in the total group using homelike care.

A much earlier study examining care in 25 U.S. in-hospital birth centers (DeVries 1983) found a vague understanding of characteristics distinguishing the birth center from usual hospital care, low levels of administrative and staff support for the alternative birth center concept, and many restrictions on participation. This study may not reflect current conditions in the U.S.

Out-of-hospital birth center care compared to usual hospital care.
For a Cochrane systematic review, Hodnett (2004) looked for, but did not find, any randomized controlled trials comparing care in out-of-hospital birth centers to usual hospital care.

The (U.S.) National Birth Center Study (Rooks and colleagues 1989, 1992a, 1992b, 1992c; Fullerton and Severino 1992) of nearly 12,000 women receiving care in 84 out-of-hospital birth centers, is the largest and most complete source of information about this type of care. As with many smaller studies, the national study found that the birth center group experienced low rates of invasive procedures and restrictions, when compared to similar women in hospitals. One woman in six transferred to hospital care after beginning labor, but just one woman in 42 transferred to hospital care under emergency circumstances. No mothers died. When compared with large studies of low-risk women in hospitals, the birth center group:
  • was half as likely to have a cesarean section
  • had a similar rate of death of babies after 20 weeks of pregnancy or in the first four weeks after birth.

Non-hospital birth center care compared to hospital-sponsored birth center care.
The National Survey of Women's Health Centers, conducted in 1994, provides an opportunity to compare 37 non-hospital birth centers with 32 hospital-sponsored birth centers in the U.S. (Khoury and colleagues 1997). Most hospital-sponsored centers were physically located in the hospital. Compared to the hospital-sponsored centers, non-hospital centers were more likely to
  • be led by a midwife
  • employ midwives and emphasize woman-provided care
  • provide a broader range of services
  • be accredited by the National Association of Childbearing Centers
  • emphasize shared decision-making between women and caregivers
  • emphasize women's empowerment and express a feminist ideology.
The non-hospital centers were less likely to view the center as a way to attract women to the sponsoring organization and to aggressively market their services. This national survey did not examine specific maternity practices and health outcomes.

Home birth compared to hospital birth.
One systematic review from the Cochrane Collaboration (Olsen and Jewell 2004) found just one randomized controlled trial comparing home to hospital birth. That study showed that women could be randomized to home birth, but included too few women to interpret the results.

Another review pools the experiences of over 24,000 women from six controlled observational studies comparing planned home birth with modern hospital back-up to planned hospital birth (Olsen 1997). Observational study designs are less definitive than controlled trials. Two of the six included studies were done in the U.S. The pooled home and hospital groups had a similar rate of death for babies after 20 weeks of pregnancy or in the first four weeks after birth. No maternal deaths occurred in either group. The following outcomes favored the home birth group:
  • fewer low Apgar scores (rating newborn well-being)
  • fewer severe tears in the mother's perineum (tissue around the opening of the vagina).

Because of important differences in conditions of the studies, the reviewer did not pool data on rates of interventions. Individual included studies found that women in the hospital groups had higher rates of artificially induced labor, artificially stimulated labor, episiotomy, cesarean section, use of forceps or vacuum extractor, and other interventions.

The author concludes that (1) no good evidence exists to support the view that planned home birth with an experienced caregiver and hospital back-up is less safe than planned hospital birth, and (2) planned home birth may have advantages.

What factors regarding the place of birth most contribute to women's satisfaction in childbirth?

In choosing your place of birth, it may be helpful to consider results of research about satisfaction in childbirth. A systematic review of the best available research (Hodnett 2002) finds that the following four factors make the greatest contribution to women's satisfaction in childbirth:
  • having good support from caregivers
  • having a high-quality relationship with caregivers
  • being involved in decision-making about care
  • having better-than-expected experiences (or having high expectations).

Choosing a place of birth where you can receive this type of care make a big difference in your satisfaction!


DeVries RG. Image and reality: an evaluation of hospital alternative birth centers. Journal of Nurse-Midwifery 28,3 (1983) 3-9.

Fullerton JT and Severino R. In-hospital care for low-risk childbirth: comparison with results from the National Birth Center Study. Journal of Nurse-Midwifery 37,5 (1992) 331-40.

Hodnett ED. Home-like versus conventional institutional settings for birth (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.

Hodnett ED. Pain and women's satisfaction with the experience of childbirth: a systematic review. American Journal of Obstetrics and Gynecology 186,5 (2002) S160-72.

Khoury AJ, Summers L and Weisman CS. Characteristics of current hospital-sponsored and nonhospital birth centers. Maternal and Child Health Journal 1,2 (1997) 89-99.

Olsen O. Meta-analysis of the safety of home birth. Birth 24,1 (1997) 4-13.

Olsen O and Jewell MD. Home versus hospital birth (Cochrane Review). In: The Cochrane Library, Issue 4, 2001. Chichester, UK: John Wiley & Sons, Ltd.

Rooks JP and colleagues. Outcomes of care in care in birth centers: the National Birth Center Study. New England Journal of Medicine 321,26 (December 29, 1989) 1804-1811. [See also: "Birth-day choices" editorial in the same issue.]

Rooks JP and colleagues. The National Birth Center Study. Part I. Methodology and prenatal care and referrals. Journal of Nurse-Midwifery 37,4 (1992a) 222-53.

Rooks JP and colleagues. The National Birth Center Study. Part II. Intrapartum and immediate postpartum and neonatal care. Journal of Nurse-Midwifery 37,5 (1992b) 301-30.

Rooks JP and colleagues. The National Birth Center Study. Part III. Intrapartum and immediate postpartum and neonatal complications and transfers, postpartum and neonatal care, outcomes, and client satisfaction. Journal of Nurse-Midwifery 37,6 (1992c) 361-97.

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Tips & Tools for Choosing Your Place of Birth

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Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Our mission is to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families.
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