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What you need to know about hospital vs. birth center/home birth

I had a proud doula moment earlier this year when my clients told me they had decided to pursue a birth center birth because of helpful info shared during our first consultation. I realized this information needs to be shared more widely, so here is my perspective 6 years into doula work.

Deciding where you will give birth is one of the first big decisions of your parenting journey. This is where you are going to meet your baby and introduce them to the world! So it is prudent to research your options with locations and providers just like you will research school options for your kids down the road. It's not a decision I recommend leaving to the cards.

Here is the first thing I want you to ask yourself...

What does my insurance cover? How does that compare to out of pocket options? What other options are there?

The reality is, many people feel that they don't have much of a choice when it comes to choosing their birth location/provider because of insurance. I was there and wrote another blog about it, What I wish I could tell young pregnant me, addressing the limitations of insurance and the belief that we can only go where our birth is covered. I recommend really looking into the fine print of what your insurance will cover, your deductible, and what a typical vaginal or caesarean birth costs in the area. My story is that I was naively surprised by our hospital bills after an unplanned caesarean in the hospital. I decided to give birth there, solely because of my insurance coverage, despite the fact that I had always dreamed of a water birth (which unfortunately, doesn't happen in hospitals). The amount we ended up paying was around what a homebirth would have cost us out of pocket.

If you receive Medi-Cal, you may have more options than you think as far as out of hospital options. Doulas are usually good people to ask for community resources ;)

Health sharing groups like, Samaritan's and Sedera are alternatives to insurance that have worked well for some families in the childbearing year; however you have to be a member before you get pregnant to be eligible for support with your bills.

The next thing I want you to ask is...

Where do I envision myself giving birth?

Some people absolutely feel comfortable at a hospital, and others are terrified at the thought. I wish I had pursued my own vision of a birth center or home water birth, because a hospital birth was not what I wanted deep down. If you are reading this though, chances are you don't have such strong feelings and are looking for more information.

What does a hospital have to offer? What are the potential down sides?

A hospital, most obviously, has fast access to life saving medical equipment/procedures. It is, after all, where we usually go when we are sick. OBs, unlike midwives, are trained surgeons who can perform life saving caesareans when needed. In the hospital you have access to medicated pain relief, as well as other medications for inducing and augmenting labor.

So what are the down sides? Well, first off let's look at the two basic approaches to birth support/care: The Medical Model and the Midwifery Model. Hospitals operate under the medical model, although some do have midwives and can have a bit of a blend, I would say the Medical Model is still king (pardon 'ye olde patriarchy speaking, which is part of the dark the history of obstetrics). Under this model, birth is viewed as a potentially dangerous event that must be monitored and managed. It is true that there is potential danger in birth, but it is also true that it is a natural physiological process that happens every day outside of hospitals. Because hospitals are built around pathology, there is a general mistrust of the natural, mother and baby led birthing process, so continuous monitoring of mom and baby are the norm. Because the vast majority of people birthing in the hospital have epidurals, many staff have rarely or never witnessed an unmedicated, naturally progressing birth and so are limited in their understanding despite all their years of medical training and experience. Because most women get epidurals, that is the way they know how to support pushing--coached and on your back. For an unmedicated birther, this is probably never the preferred position. And an unmedicated mom usually does not need any coaching in how to push. Because the Medical Model view is generally looking for what could possibly go wrong there is a heightened tendency to want to intervene with things like induction, and augmentation of labor--sometimes for good reason, but oftentimes for questionable reasons.

If you desire an unmedicated birth, the hospital may not be the best place for you. I personally was able to have a successful unmedicated vaginal birth after caesarean in the hospital, so I know it is possible, but it requires a very deep commitment to your goal and ideally a doula to support and help you advocate.

If you know you are going to want an epidural than the hospital is the place for you. If you're undecided about pain relief, I recommend taking a birth class and reading books to get a deeper sense of labor, birth, and what to expect. Actually, I recommend everyone taking a birth class!

If you are experiencing a high risk pregnancy, the hospital may be the best choice but it's worth looking deeper into the relative risks of common concerns, such as advanced maternal age, to make your most informed decision. Evidence Based Birth is a great resource to read all about the latest research and findings on everything pregnancy and birth.

How is Midwifery Care at a birth center or home different from the hospital?

The obvious difference between hospital birth and either of these out of hospital options, is that you are under the care of one or a group of Midwives, rather than a hospital OB or group practice. And of course they are out of the hospital and so don't have access to surgery or anesthesiology for epidurals or other opioid pain relief. This is the downside of these type of births--If a need for any of these things were to arise a hospital transfer would be necessary.

Because the Midwifery Model sees birth as a natural physiological process and anticipates it to work well, there is much less of a culture of managing birth, but rather a culture of supporting birth on its' terms. Ideally, everyone on the team has trust in the process, mom and partner included. Because of this, you won't be constantly monitored (as long as all is well). You will be free and supported in laboring and birthing in whatever position you want, with the rare exception of complications requiring certain positions. Both options typically support water birth, and may offer nitrous oxide (laughing gas) as a pain decreasing option. Additionally, midwives generally spend a lot more time with you prenatally and in your early postpartum transition. Many incorporate herbalism into their practice to support your overall health for pregnancy, labor, and postpartum. It's a lot more personalized care than in a large bureaucratic hospital.

The advantage of homebirth is that you don't have to get in the car when you're in labor. An undisturbed labor is a productive labor and home is where you are naturally relaxed and comfortable. The disadvantage is you will need to store most of the birth gear (not a huge amount) and be prepared for some mess after birth.

The advantage of a birth center is that everything is there waiting for you and after birth you can return to your home in the state you left it. Some people don't feel comfortable birthing at home if they live with shared walls and close neighbors. They may also have nice birth tubs and just feel more luxurious and peaceful to you.

This isn't a comprehensive comparison, but I believe I have outlined the major things to consider as you make this huge decision. It's also important to research the OBs and Midwives you are considering. When meeting with a provider, you can ask them what their transfer and C section rates are. Treat your meeting like an interview. A provider should make you feel heard and respected. Feeling dismissed or even belittled is a huge red flag.

And remember, if during your prenatal care you feel like you made the wrong choice, you can change providers. This will be harder for some than for others, but it is possible. You deserve a provider that you trust, who also trusts you.

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