When you're deciding where you would like to give birth, you may think a hospital is your only choice. In fact, you have several options to consider. Where you plan to give birth is an important component of your birth plan, and it is something you need to discuss with your health-care provider.

Birth Center

A birth center is a facility that has some medical equipment but is more comfortable and homey-feeling than a hospital. Birth centers are staffed by midwives, but they also have physicians available. These facilities often offer a wide range of birthing alternatives, such as water birth, birthing balls, birthing chairs, and other choices. Birth centers are often located next to a hospital, yet they do not have that hospital feel.

Birth center rooms are designed to look like real bedrooms. They often have kitchens and living areas for family members to make themselves comfortable in. Birth centers afford more privacy than hospitals and usually allow you to wear your own clothing.

Birth centers have lower C-section and episiotomy rates than hospitals. While this is partially due to the approach taken in birth centers, it is also because higher-risk pregnancies are generally not accepted at birth centers because of the likelihood of complications.

Epidurals are not available at most birth centers. Women who go to birth centers often receive their prenatal care at the center as well. Most insurance companies will cover the cost of a birth center birth.

When considering a birth center, ask the following questions:

• Do they accept your insurance?

• What training and certifications do attendants have?

• How many beds are available?

• Which OB or practice is on standby for complications?

• How long has the center been in operation?

• How many babies are delivered per month at the center?

• What percentage of births are transferred to the hospital?

• What kinds of pain relief are available, if any?

• If a birth is transferred to a hospital, can the midwife go with you?

Hospital

Many women feel most comfortable with a hospital birth. You have access to medical equipment if needed, and your physician or midwife can deliver the baby. When selecting a hospital, talk to your health-care provider about the level of risk you face. If you are at high risk, your health-care provider may recommend you give birth at a hospital such as a children's hospital or perinatal center, where advanced medical care is available for your newborn.

Hospitals that handle obstetrics are designated by levels one through four, with level one approved only for low-risk pregnancies and level four for the highest risk pregnancies. It is important to realize that obstetrical and neonatal care is a highly competitive business. In some instances, hospitals may attempt to market themselves as being capable of managing high-risk pregnancies when in fact the claims may be exaggerated.

Health-care providers may also be partial to a particular hospital, and their decisions on the site of delivery may be based more on political than health-care considerations. If you have a high-risk pregnancy of any kind, you should ask your provider about the level of care appropriate for you. You should also ask about the hospital's capabilities. For example, a level three obstetrical hospital may have the capability to care for a problem pregnancy or premature baby, but it may not have a maternal-fetal medicine specialist or neonatologist on site 24 hours a day. If your baby may require pediatric specialty care, it would be best if the baby were born in a facility where that is available.

If your baby needs to be transferred after birth to a higher-level facility, you may not be able to be transferred with the baby, or if you are transferred, your insurance company may not pay for the transfer or stay at the other facility. This can be particularly problematic if you have undergone a C-section and cannot be discharged earlier.

Most pregnancies can be managed in level-one or level-two facilities. Pregnancies at moderate risk (for example, premature birth over thirty weeks) can usually be managed at a level-three facility. However, the highest risk pregnancies (serious medical complications of pregnancies, birth defects, or extreme prematurity) are best managed in level-four or regional perinatal centers. Do not let community hospital politics or fancy marketing dictate the best place for your delivery.

Some physicians practice in teaching hospitals where residents and medical students are present. Many patients are concerned about having medical students and residents involved in their care. In fact, in a teaching environment where residents and medical students are well supervised, the care is actually better. However, you may have reservations about the number of individuals in the room when you are laboring and delivering or the number of people involved in your care. You should speak to your obstetrical provider about these issues during your prenatal visits. Remember, it is always your right to control these types of issues.

You should also ask your obstetrical caretaker if he has a covering caretaker(s) who will take over care should your original caretaker be on vacation, ill, or unavailable. Some physicians practice out of more than one hospital, which may create a conflict if there is a patient in more than one facility. You should also ask if there is an in-house obstetrician (or “doc in the box,” as they are called). Many hospitals require or provide an obstetrician on-site 24 hours per day, seven days per week. The job of these obstetricians is to act in an emergency if your doctor is not available or to assist your doctor should a complicated situation come up. In many places this individual will assist your physician at a cesarean section if required.

You may also want to ask about the availability of obstetrical anesthesia coverage and epidurals in the hospital you deliver in. Though not absolutely necessary, the ideal is to have on-site 24-hour anesthesia coverage for obstetrics should a problem develop. Many smaller hospitals do not have this.

You should also inquire about the pediatric backup availability and credentials of those available, should the baby develop a problem in the delivery room or after birth. You should make sure that the hospital where you deliver has a transfer agreement with the regional perinatal center should the baby need additional treatment. Ask about the policy of the hospital where you are to deliver. Under what circumstances, and at what gestational age of the baby, is the mother transferred to a regional perinatal center, and which center is it? In some communities you have a choice of one or two centers.

Some obstetrical care providers may make such decisions based on personal bias or convenience. You should insist upon the center that provides the highest level of care both for yourself (if you are transferred) and the baby (if the baby is transferred). Ideally, the center should have board certified neonatologists and maternal-fetal medicine specialists as well as pediatric specialists, and they should be available 24 hours a day, seven days a week.

Home Birth

Giving birth at home offers you the comfort of being able to labor and deliver in surroundings that are comfortable, with family present. Some families choose home birth because they want their existing children to be present. If you give birth at home, you should use a trained midwife.

Home births are a controversial area in obstetrics, and most states have laws governing home deliveries. There are several considerations. First, you should remember that the purpose of the pregnancy is to have a healthy baby and mother. All other considerations must be secondary.

You should also check the regulations in your state governing home births and make sure you are in compliance. Make sure that the midwife is in compliance with state regulations, is complying with safe guidelines to determine pregnancy risk, is licensed in the state where she practices, and has an obstetrical backup and plan should problems arise.