The Delivery Dilemma

Mothers have more birth options today, but their risks are higher

“Where Should Baby Be Born,” by Geraldine and Sharon Youcha. Published in the April 7, 1981 issue of Woman’s Day.

In 1981, my journalist grandmother and my Aunt Sharon, a medical student studying to be an obstetrician, wrote an article for Woman’s Day called “Where Should Baby Be Born?” They were documenting an inflection point in American maternity care.

“In the past,” they wrote, “hospital procedures were designed for patients who were drugged into forgetfulness. But now many women are awake, aware and assertive during childbirth. Hospital maternity units must change or face extinction.”

At the time, “home-style birthing rooms” in hospitals were becoming more popular, growing from one in 1969 to more than a thousand in 1981. That year, there were at least 90 freestanding birth centers throughout the country.

The article listed the pros and cons of each setting: traditional hospital care, hospital birthing rooms, freestanding birth centers, and home births. Grandma and Sharon noted that in the most traditional hospital settings, women had “little chance of varying the uncomfortable flat-on-the-back, legs in-stirrups delivery position,” increased risk of infection for the baby who was put in a nursery, and “increased possibility of delivery by Cesarean section.”

By contrast, standalone birth centers, run by certified nurse midwives, allowed women to labor and deliver in the same room with minimal intervention from staff, and stay with their baby after birth. However, high-risk women were not allowed to deliver there, and insurance coverage was spotty.

These were the facts on the ground 44 years ago. How much has changed today?

The number of birth centers around the country has quadrupled. According to the American Association of Birth Centers, there are now at least 400. But the business model is tough to maintain. The costs associated with a hospital C-section can top $26,000 for an insured woman. Birth centers struggle to pay their bills because natural births are less expensive, and they can’t charge the same facility fees that hospitals do.

Maternity care in hospitals has also morphed. In the 1970s, some hospitals introduced “alternative birth centers,” where a nurse midwife provides care with minimal intervention for low-risk births. This model still exists (there’s one in New Orleans ), but it’s not widely available, and can be hard to identify because so many hospitals advertise their labor and delivery wards as “birth centers.”

Here’s how the National Partnership for Women & Families explains the conundrum:

A birth center within a hospital does not necessarily offer the same type of care as a freestanding birth center. Many hospitals call their regular labor and delivery area their “Birth Center” and while this area may look more home-like than the rest of the hospital (rocking chairs, wallpaper), the care may be more like a routine hospital delivery than you would experience in a freestanding birth center. The organization that accredits out-of-hospital birth centers has also accredited a small number of in-hospital birth centers.

In my experience, midwives still work in hospital maternity wards, but they are often supervised by doctors who design the approach to care. Women are allowed to labor in different position—including a shower or birthing tub—but they’re still exposed to more drugs and surgical interventions.

Their C-section risk is also higher at a hospital. In fact,

Neel Shah, MD

, a leading maternal health researcher, has argued that the biggest factor determining whether or not you have a C-section is the hospital where you deliver. This is important, because the C-section rate has doubled since my grandmother wrote her article. In 1980, C-sections accounted for 16.5 percent of births in this country. That number topped 32.3 percent in 2023.

Put simply: Pregnant women now have more choices, but they also have a much greater chance of dying than they did 45 years ago. America’s maternal mortality rate has soared from 9.2 deaths per 100,000 births in 1980 to 19.6 deaths per 100,000 births in June 2024.

To protect yourself, you must consider: Will your doctor honor your desire to labor naturally in a hospital, or feel inclined to induce when the maternity ward gets too crowded? If you start at a birth center but need to be transferred to a hospital, does the midwife have a good relationship with the attending physicians, or does her power stop at the operating room door?

A good provider will be willing to answer those questions, and discuss the many complications that may arise. No one expects a birth to go as planned, but your doctor should respect your wishes when things go south. As the renowned midwife Ruth Wilf said: “It’s the woman who is giving birth. She’s doing the work. The balance of power should be with the woman.”