Birth centers

INTRODUCTION — Birth centers (or birthing centers) provide antepartum and peripartum care for people with low-risk pregnancies who desire birth in a community-based setting. For such people, birth center care can result in greater satisfaction, cost savings, and the same or better outcomes as an in-hospital birth [1]. In the United States, nearly 22,000 of the approximately 3.6 million births (0.61 percent) in 2020 occurred at a freestanding birth center [2].

This topic will provide a description of the birth center model of care and its outcomes. Planned home birth, which is an alternative type of out-of-hospital birth, is reviewed separately. (See "Planned home birth".)

THE BIRTH CENTER MODEL

Definition — A birth center is a medical facility that provides a labor and childbirth experience in a family friendly, homelike environment for healthy, low-risk pregnant people. The facility may be freestanding or part of a hospital, such as a specific floor or set of rooms that are separate from the acute care obstetric unit. Freestanding birth centers provide antepartum, intrapartum, and postpartum care, while those that are part of a hospital generally provide intrapartum, immediate postpartum, and neonatal care. Both types of birth centers are oriented toward care practices that support physiologic labor and birth.

History — As the location for childbirth moved from the home to the hospital in the United States in the 20^th century, the medical model of obstetric care was established. Medicalization of a normal physiologic process was due, in part, to the observation that outcomes of high-risk mothers and babies were improved by specialist care in hospitals. However, over time, increasing use of technological interventions without clear benefits led to a consumer-driven natural childbirth education movement that sought individualized, client-centered care in support of normal, physiologic birth. Although hospitals tried to respond to this consumer demand by relaxing restrictions on family participation, these changes were difficult to implement in the acute care setting.

In 1975, the Maternity Center Association, a voluntary health agency in New York City, established a demonstration birth center (The Childbearing Center) in an affluent urban setting [3]. It was designed and operated to provide professional nurse-midwifery care in collaboration with obstetric specialists for carefully screened people anticipating a normal pregnancy and birth. If that expectation changed, birth center professionals referred or transferred the individual to the collaborating obstetric specialist and hospital for further evaluation and appropriate care. Childbirth education was an integral part of the program. The success of this pilot project prompted expansion of the birth center model of care.

The birth center model has steadily increased in popularity worldwide because of consumer demand and national and international efforts to improve maternal health. In recent years, physicians and hospitals have also recognized the need to avoid unnecessary interventions in people with low-risk pregnancies and the value of facilitating the physiologic labor process in this population [4].

In 2020, the National Academies of Sciences, Engineering, and Medicine (NASEM) emphasized the need to promote research about the birth center model of care, in part to increase awareness about this type of birth setting among consumers and to support informed decision-making about place of birth [5].

Candidates for birth at a birth center — People with low-risk pregnancies are candidates for birth center care. There is no precise definition of low risk, but these individuals are generally healthy with a term singleton pregnancy in vertex presentation, and no medical or obstetric conditions that increase the risk for serious intrapartum, postpartum, or neonatal complications as defined by reasonable and generally accepted criteria.

Birth center care providers and the physicians who collaborate with them develop mutually agreed upon risk criteria for screening candidates for delivery at their birth center and excluding those perceived to be at increased risk. The screening process begins when a pregnant person enrolls in prenatal care to make sure that they are an appropriate candidate. Rescreening occurs at every prenatal visit, at the onset of labor (pre-admit screen), and continues throughout the intrapartum, postpartum, and neonatal course.

Initially low-risk people who go on to develop antepartum, intrapartum, or postpartum complications (eg, preeclampsia, noncephalic presentation, preterm or postterm labor, chorioamnionitis) are required to receive obstetric care and give birth in the acute obstetric care unit of the hospital, where their care is often managed collaboratively by a midwife and obstetric team.

Individuals with high body mass index or previous cesarean birth — High body mass index (BMI) and previous cesarean birth are two common issues in decision-making regarding birth site:

●While pregnant people with prepregnancy BMI ≥30 kg/m² (ie, obese range) historically have been considered inappropriate for birth center care, an analysis of birth outcomes at freestanding birth centers reported no significant differences in complications between people with BMI ≥30 kg/m² and no medical comorbidities compared with those with BMIs 18.5 to 24.9 kg/m² (ie, normal range) [6]. People with BMI ≥30 kg/m² had higher rates of nonemergency intrapartum transfers (30.3 versus 19.9 percent) and primary cesarean birth (11.1 versus 5.8 percent).

●Some birth centers, particularly those that are part of a hospital, allow a trial of labor after a previous cesarean birth with certain criteria, including no more than one previous cesarean, documented low transverse uterine incision, no history of incision extension or postoperative infection, history of a previous vaginal birth and/or previous vaginal birth after a cesarean birth, and third-trimester ultrasound excluding a placental attachment abnormality [7].

Informed consent — Birth center clinicians provide thorough information with extensive discussion of prenatal and intrapartum care choices. This discussion should include:

●Specific pregnancy complications that would require an antepartum referral to the care of a collaborating physician.

●Specific intrapartum, postpartum, and newborn complications that would require transfer of the mother and/or neonate to a hospital.

●The concept that unforeseen events can occur during any childbirth and how they might be handled at the birth center as compared with a hospital.

●The approximate time it may take to transfer the client to a hospital in emergency situations. Birth centers conduct regular emergency drills, including drills with area emergency teams, and thus can tell clients how an emergency transfer would proceed. All birth centers know their average emergency and nonemergency transport times and how they vary with the time of day, traffic, and weather/road conditions.

After this discussion has been completed, clients are asked to sign a document asserting that they understand the risks and benefits of labor and delivery at a birth center and have chosen to labor and give birth in the birth center. The following form is an example of one such document (form 1A-C).

Antepartum, intrapartum, and postpartum care — The birth center philosophy maintains that, for most people, pregnancy and birth are normal physiologic processes and important psychosocial events within a family. Although hospital-based caregivers may also have this philosophy, birth center providers tend to place greater emphasis on avoiding intervention and providing a relaxed, client- and family-centered atmosphere.

●Antepartum – All of the standard prenatal tests are offered to clients by their birth center providers, as indicated, with discussion of the risks and benefits of each test. (See "Prenatal care: Initial assessment" and "Prenatal care: Second and third trimesters".)

Prenatal care provided at a birth center is generally more time and education intensive than traditional prenatal care. In addition to the usual components, providers at a birth center focus on building their clients' confidence in having a normal birth and caring for their newborn.

Arrangements for access to a specialist and in-hospital care for mother and newborn, if needed, are reviewed periodically during antenatal care.

●Intrapartum – Intrapartum birth center care is a time-intensive, one-on-one approach. Because birth is considered a normal life event, the atmosphere of birth centers is relaxed, with few routines, and an environment that is more like a home than a hospital. For example, clients control who will be with them during labor and birth and generally have more options than in a hospital. They typically wear their own clothes instead of a hospital gown. They eat, drink, shower/bathe, and walk or change positions freely, whereas these choices may be limited on a traditional labor unit.

One hallmark of intrapartum care in birth centers, continuous caregiver support, has been shown to be beneficial in randomized trials. These benefits (eg, increase in spontaneous vaginal births and maternal satisfaction, decrease in use of analgesia/anesthesia) are discussed in detail separately. (See "Continuous labor support by a doula", section on 'Evidence of the effectiveness of continuous labor support'.)

In accordance with a large body of research indicating that intermittent auscultation of the fetal heart rate is appropriate and safe for low-risk pregnancies, birth centers use intermittent auscultation rather than continuous electronic fetal monitoring to monitor fetal status during labor. If a condition in which continuous electronic monitoring is needed occurs, the mother is transferred to a hospital, as they are no longer appropriate for an out-of-hospital birth. (See "Intrapartum fetal heart rate monitoring: Overview".)

The primary approach to labor pain is use of nonpharmacologic interventions. Although some birth centers offer opioid analgesics for pain relief, pharmacologic pain relief is rarely needed and used sparingly only after nonpharmacologic methods have been tried. Many birth centers provide nitrous oxide for labor analgesia [8], and immersion in water during labor is almost universally used. (See "Nonpharmacologic approaches to management of labor pain".)

Oxytocin is not used for induction, as typically only clients in spontaneous labor can receive care in the birth center setting. Oxytocin augmentation also is not used, as true protraction and arrest disorders are indications for hospital transfer.

Standard guidelines for universal screening for group B Streptococcus and intrapartum antibiotic prophylaxis are followed. (See "Prevention of early-onset group B streptococcal disease in neonates".)

Epidural analgesia is not offered in birth centers because additional medical interventions are sometimes or always needed (eg, intravenous infusion of fluids, continuous electronic fetal heart rate monitoring, frequent blood pressure monitoring, medication to treat hypotension, urinary bladder catheterization, oxytocin augmentation). Desire for an epidural indicates the need for transfer to a hospital.

Cesarean and forceps- or vacuum-assisted vaginal births are not performed in birth centers. Need for any of these procedures indicates the need for transfer to a hospital.

Episiotomies are rarely performed because data demonstrate no benefit from routine use. (See "Approach to episiotomy".)

If complications that require medical or surgical intervention arise (eg, labor dystocia, chorioamnionitis, abnormal fetal heart rate, preeclampsia, excessive bleeding), care of the client and newborn is transferred to the collaborating clinician, most often an obstetrician (sometimes a family physician) or neonatologist at the collaborating hospital. Many birth center nurse-midwives also practice in the hospital and thus continue to manage their client's care in collaboration with obstetrician colleagues after transfer. Some birth centers transfer clients to care by hospital-based nurse-midwives. Compliance with strict transfer criteria has resulted in good outcomes for these clients, even when intrapartum complications arise [9-11].

●Postpartum – Physical contact between the mother and newborn is initiated immediately after birth and maintained throughout the postpartum stay. The newborn is examined on the client's bed to enhance parental-newborn bonding, provide an opportunity to explain newborn behavior, and answer questions. Parents and newborns are rarely separated.

Prophylactic uterotonic drugs are not routinely administered, but many birth centers use at least some components of the active management of the third stage (eg, controlled traction of the umbilical cord, administration of a uterotonic medication before the placenta is delivered) for clients with risk factors for postpartum hemorrhage identified on admission, during labor and delivery, or soon after giving birth. If excessive bleeding occurs, then intramuscular oxytocin and rectal misoprostol are the medications given most commonly. Many birth centers also stock methergine, and some stock carboprost tromethamine and tranexamic acid, but if drugs other than oxytocin are needed, transfer to a hospital would be initiated. Intravenous fluids are also available for administration and stabilization during transfer. An increasing number of birth centers have implemented applicable portions of the OB Hemorrhage Toolkit from the California Maternal Quality Care Collaborative, including postpartum hemorrhage (PPH) risk assessment, active third-stage management, simulation drills, and debriefing after a PPH event [12]. (See "Management of the third stage of labor: Prophylactic pharmacotherapy to minimize hemorrhage".)

The midwife or other professional care provider monitors the condition of the mother and newborn closely during the immediate postpartum and neonatal periods, while also providing appropriate privacy. The minimum length of stay is four hours postpartum, and most clients are discharged by eight hours postpartum if maternal and newborn criteria for discharge are met.

Follow-up postpartum and newborn care may include telephone calls and other electronic communication, home visits, and breastfeeding support, as well as an office visit within the first two weeks. All clients have at least a telephone call and one in-person visit. They are required to have a pediatric care provider in place for ongoing follow-up of the newborn. Some birth centers provide well-baby care using pediatric nurse practitioners or family physicians. Clients who were transferred to a hospital during labor may be provided routine birth center follow-up, according to their preference.

Standards

American Association of Birth Centers — The American Association of Birth Centers (AABC) first published the Standards for Birth Centers in 1987 [13], and the regularly updated document continues to be the only comprehensive tool for measuring the quality of services provided to childbearing people in United States birth centers. The AABC standards address all aspects of birth center operations, including evidence-based maternity and neonatal care, midwifery-model approach to care, business operations, facility safety, and continuous quality improvement. The AABC standards are used by the Commission for the Accreditation of Birth Centers (CABC) as the foundation for their Indicators of Compliance with Standards for Birth Centers [14].

Capabilities — In the United States, the American College of Obstetricians and Gynecologists expects birth centers to have the following capabilities [15]:

●Capability and equipment to provide low-risk maternal and newborn care.

●Availability of medical consultation at all times.

●Readiness to initiate emergency procedures (eg, maternal and newborn resuscitation and stabilization) at all times to treat unexpected complications within the center and facilitate transport to an acute care setting when necessary.

●Clear understanding of the threshold at which transfer of clients to a facility with a higher level of care should occur.

●An established agreement with a receiving hospital with policies and procedures for timely transport, including risk identification; determination of conditions necessitating consultation, referral, and transfer; and a reliable, accurate, and comprehensive communication system between participating facilities and transport teams. (See "Inter-facility maternal transport".)

●Procedures for data collection, storage, and retrieval.

●Ability to initiate quality improvement programs that include efforts to maximize client safety.

Personnel and staffing — Birth centers are typically staffed by midwives. In the United States, certified nurse-midwives (CNMs) attended 52 percent of births that occurred in birth centers in 2021, other midwives attended 39 percent, physicians attended 3.6 percent, and others or unspecified individuals attended the remainder [16]. At least two professionals with competence in the care of obstetric clients and newborns should attend every birth [15]. In addition, both individuals should be current in adult cardiopulmonary resuscitation training equivalent to American Heart Association (AHA) Basic Life Support [17] and neonatal resuscitation [18] endorsed by the American Academy of Pediatrics (AAP) and the AHA.

Licensure and accreditation — The American Public Health Association (APHA) has published official "Guidelines for Licensing and Regulating Birth Centers" [19] and the AABC provides a toolkit addressing birth center regulation best practices [20]. Both are used by states to write or revise local regulations for licensing birth centers. As of 2023, birth centers were licensed in 41 states and the District of Columbia, either with birth center-specific regulations or licensure as another type of health care facility. Six states did not license or regulate birth centers but allowed them to operate [21].  

Accreditation is a voluntary process that includes self-evaluation of all the essential elements of the organization and management of birth center quality of care. It is designed as an educational process and is similar to the process used to accredit hospitals and other health care facilities. Accredited birth centers are expected to comply with national standards and are held accountable for their care and outcomes by their peers. Three national agencies, the Accreditation Association for Ambulatory Health Care (AAAHC), the Joint Commission, and the CABC, provide accreditation of birth centers. The CABC accreditation process provides birth centers with a benchmark for comparing their own performance with national standards and with other birth centers. Some insurance payers mandate that birth centers maintain CABC accreditation for reimbursement. Some states either require CABC accreditation for licensure or waive site visits by the regulatory agency when CABC site visits are conducted. CABC accredits both freestanding and alongside birth centers. North Carolina, with no birth center licensure, provides deemed status for Medicaid reimbursement to CABC-accredited birth centers.

Medicolegal liability — The AABC works with liability insurance carriers that insure midwives and birth centers to reduce liability risks by reviewing claims that have been filed and offering risk reduction education based on what is learned by those reviews.

The AABC provides its member birth centers a comprehensive Quality Improvement Program. Strategies for risk reduction include ensuring complete documentation of the care provided, the plan for management of care, formal and informal consultations, referrals, and transfers. In addition, emergency simulation drills are performed at least quarterly, ideally with local emergency medical service personnel, to document evaluation of performance and follow up concerning any identified deficiencies.

For CABC-accredited birth centers and alongside midwifery units, the CABC mandates sentinel event reporting that involves reviewing the birth centers' root cause analysis and action plan and the collection of de-identified aggregate data on events, root causes identified, and actions taken by birth centers.

Choosing a specific birth center — We suggest that pregnant people considering birth center care evaluate birth centers based on the following criteria:

●Accreditation by the CABC for freestanding birth centers.

●CABC accreditation as an "Alongside Midwifery Center" for alongside birth centers.

●Midwives who are educated in a nationally accredited midwifery education program (Accreditation Commission for Midwifery Education and Midwifery Education Accreditation Council) and who are credentialed by national certifying agencies (American Midwifery Certification Board and North American Registry of Midwives).

●Current certification in an AAP Neonatal Resuscitation Program and completion of a current AHA Adult Cardio-Pulmonary Resuscitation course for all birth center staff who are in attendance for births.

●Ability to initiate care for common obstetric and neonatal emergencies, including availability of medications for hemorrhage, intravenous equipment and solutions, oxygen, and adult and newborn resuscitation equipment.

●Established risk criteria that exclude clients with medical or obstetric conditions that increase the chance of an adverse outcome (eg, hypertension or diabetes requiring medication, twins, breech presentation, pregnancy greater than 42 weeks gestation).

●Ready access to laboratory and ultrasound services.

●Transfer procedures that provide for smooth access to hospital and physician care if needed, with positive collaborative relationships with hospitals and obstetric and neonatal specialists.

PREGNANCY OUTCOMES

Overview — No large randomized trial has been conducted to compare birth center outcomes with outcomes of care in hospitals. Most pregnant people have a strong preference for a hospital versus out-of-hospital birth, making such trials unfeasible; however, other research designs have provided data on pregnancy outcomes in various birth settings. In summary:

●The body of this evidence suggests that maternal outcomes for individuals delivering at birth centers are equivalent to or better than those delivering in hospitals or national averages [22].

●Birth centers have met or exceeded national quality benchmarks for outcomes such as elective delivery prior to 39 weeks, incidence of episiotomy, cesarean rate, and exclusive breastfeeding [23].

●No study has reported poorer outcomes among clients cared for in birth centers as compared with hospitals in the United States.

Best available data — The best available data on birth centers are from the National Birth Center Study (NBCS) I [10,24-26] and NBCS II [11], a 2018 meta-analysis [27], and the Strong Start for Mothers and Newborns Initiative [28,29]. NBCS I prospectively followed the pregnancies of almost 18,000 pregnant people who registered for care at 84 birth centers in 35 states from 1985 to 1987 [10,24-26]. NBCS II analyzed data regarding the care and outcomes of over 15,000 pregnant people who were planning and eligible for admission to 79 birth centers in 33 states from 2007 to 2010 [11]. The 2018 meta-analysis included 28 studies meeting strict inclusion criteria and using a validated rating tool to evaluate the quality of included studies [27]. The birth center group of the Strong Start Initiative included data from over 8400 Medicaid and Children's Health Insurance Programs (CHIP) beneficiaries across 47 sites of the American Association of Birth Centers (AABC) who enrolled in the program from 2013 to 2017 [28]. The following is a synopsis of the findings from these studies, and others [1,22,23,30-33], using intent-to-treat data where possible. The pregnancies in these studies qualify for birth center care as described above and supported by the American Association of Birth Centers (AABC) and Commission for the Accreditation of Birth Centers (CABC). (See 'The birth center model' above.)

●Maternal mortality – No maternal deaths were reported [10,11,22,24-26].

●Perinatal mortality – Perinatal mortality rates were not increased in birth center births [10,11,24,27,31].

•In NBCS I, the corrected intrapartum and neonatal mortality rate, excluding deaths due to lethal congenital anomalies, was 0.7/1000 births [10,24]. Studies of low-risk pregnant people delivering in three major United States hospitals during the same time period reported intrapartum plus neonatal mortality rates of 1.0 to 4.3/1000 births. NBCS II reported similar findings [11].

●Transfer out of birth center care [10,11,22,24-26].

•Antepartum transfer rates ranged from 13 to 27 percent and were most often due to a complication (eg, postterm pregnancy, prelabor rupture of membranes, malpresentation) that precluded out-of-hospital birth.

•Intrapartum transfer rates ranged from 12 to 37 percent (but dropped to 12 to 17 percent in recent years) and were usually due to prolonged labor or labor arrest.

•Approximately 2 to 4 percent of mothers and 2 to 4 percent of newborns were transferred to hospitals because of postpartum or newborn complications. The most common reasons for transfer were maternal bleeding, retained placenta, and neonatal respiratory problems.

•Approximately 1 to 2 percent of transfers were emergencies, with intrapartum emergency transfer most commonly for a nonreassuring fetal heart rate. Both emergency and nonemergency postpartum and neonatal transfers were most often for postpartum hemorrhage and respiratory issues, respectively [11].

●Method of birth – Pregnant people planning birth in a birth center consistently have higher rates of spontaneous vaginal birth and lower rates of cesarean birth than those planning birth at a hospital [10,11,22,24-27,30-32,34].

•In NBCS I (1985 to 1987), the cesarean birth rates for low-risk people who planned a birth center birth versus a hospital birth were 4.4 and 24.4 percent, respectively [10,24-26]. This difference was maintained in NBCS II (2007 to 2010), with cesarean rates of 6 versus 26.5 percent in low-risk patients giving birth in birth centers versus hospitals [11].

•In the 2018 meta-analysis, the cesarean birth rates for low-risk people who planned a birth center birth versus a hospital were approximately 5 and 18 percent, respectively [27].

•In the Strong Start Initiative (2013 to 2017), mothers who gave birth in birth centers had a primary cesarean rate of 8.56 percent, compared with the contemporaneous United States national average of 21.9 percent [34].

•In a study of the impact of birth setting preferences that compared medically low-risk people choosing to give birth in birth centers with those from the same practices choosing hospital birth in the absence of any medical indication, electing to have a hospital birth was an independent driver of cesarean birth for both nulliparous and multiparous people, with multiparas electively admitted to hospitals having five times greater odds of cesarean birth [35].  

●Maternal and neonatal morbidity rates are not increased in birth centers and may be decreased; serious maternal complications, including postpartum hemorrhage and severe perineal trauma (third- or fourth-degree lacerations), are rare [22,27,34]. Of note, racial disparities in perinatal indicators (preterm birth, low birth weight, cesarean birth) were observed among participants in the Strong Start Initiative mentioned above but were narrower than in national data [34].

●Rates of maternal intervention (particularly episiotomy) are lower [22,27,30]. Pregnant people who planned a birth center delivery but delivered in a hospital still appear to have lower rates of intervention (eg, pharmacologic pain relief, epidural anesthesia, oxytocin induction or augmentation, forceps- or vacuum-assisted vaginal delivery) than those who planned a hospital birth.

Following vaginal birth, people who deliver at a birth center are probably more likely to have an intact perineum than those delivering in a hospital and a lower frequency of third- and fourth-degree lacerations [27,36,37].

●Length of labor appears to be longer in birth centers [22].

●Maternal satisfaction is high in birth centers [22,28]. Clients describe satisfaction with their care and the birth center environment, positive relationships with caregivers, greater engagement, and increased confidence in themselves as parturients and as parents.

•In NBCS I, almost 99 percent of birth center mothers said they would recommend the birth center to a friend [10,24-26].

•In the Strong Start Initiative, clients acknowledged the value of extra time, support, and education and were more likely to report being "very satisfied" with their care experience when compared with the medical home or traditional medical models [28].

•In an analysis of birth center client experience data from a survey piloted during Strong Start, clients reported being treated with respect, spoken to in ways that they understood, involved in decision-making, feeling listened to, and having time for questions [38]. There were no variations in the clients' experience of care by race.

Limitations of these data — There are several limitations to these data. Although all people who deliver at birth centers have low-risk pregnancies, they have self-selected this model of pregnancy care; if low-risk people are required to accept this model of care, they may not have similar outcomes. The study population for the AABC Strong Start Initiative was comparable to national childbearing demographics, with sociobehavioral risk factors similar to the national profile and with slightly higher rates of tobacco and drug use, domestic violence, and chronic stress [34]. In spite of this risk profile, birth centers demonstrated lower rates of labor induction, low birth weight, preterm birth, and cesarean birth compared with the other Strong Start Initiative models and national rates.

The birth centers that participated in major studies, such as NBCS I and II, may not be representative of all birth centers operating in the United States. For example, only 53 percent of known birth centers participated in NBCS I, and birth centers providing data for NBCS II represented 32 percent of all United States birth centers. The birth centers participating in these studies may have a high level of organization, adherence to standards, and quality assurance that may not exist in all birth centers. Birth center providers in these studies varied; outcomes by type of attendant (eg, certified nurse-midwife, certified professional midwife, licensed midwife) were not evaluated. In addition, the impact of birth centers operating outside of an infrastructure of licensure, national standards, and an accreditation mechanism may be different from those reported in NBCS I and II.

In literature reviews, definitions in studies varied (eg, "antepartum" versus "intrapartum" versus "pre-admit intrapartum" transfer), and variations in birth center populations and practices limited generalizability. Furthermore, the data were collected over several decades during which frequencies of some pregnancy outcomes changed: baseline rates of episiotomy decreased in hospital settings, while epidural anesthesia and cesarean rates increased, making between-study comparisons difficult.

COST-EFFECTIVENESS — Older studies that have examined the cost of care provided in birth centers compared with hospitals, including costs associated with transfer for a hospital delivery, have consistently found cost savings of 20 to 50 percent [28,39-41]. A major structural reason for this lower cost is that birth centers are paid far less than hospitals for the same services. There are no national standards for contracting and coding for birth centers; payments are often inadequate to cover the costs of providing midwifery care and facility services; newborn facility fees are included in maternal payment instead of being billed separately; and timing of payments is mismatched with the program of time-intensive, relationship-based care provided prenatally in birth centers [42]. Process of care and clinical outcomes also impact the cost effectiveness of birth centers and include lower rates of preterm and low birthweight infants, lower rates of cesarean birth, and less use of some procedures, such as epidural analgesia and induction of labor.

The birth centers in the Strong Start Initiative for Mothers and Newborns had better outcomes at lower cost relative to other Medicaid participants with similar characteristics in the other models of care studied, with costs USD $2010 lower through birth and the following year for each mother-infant pair. Some of this cost savings resulted from fewer infant emergency department visits and hospitalizations [43,44]. In one study reporting these findings, the authors noted the potential for the birth center model to lower maternity care costs and improve outcomes and commented that increasing the use of birth centers would require broadening Medicaid-managed care networks, increasing payments, reducing state licensing barriers, and revising scope of practice regulations that limit how midwives can practice in some states.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Labor".)

SUMMARY AND RECOMMENDATIONS

●Overview – A birth center provides a labor and childbirth experience in a family friendly, homelike environment for healthy, low-risk pregnant people. It may be freestanding or alongside a hospital (eg, a specific floor or set of rooms) but separate from the acute care obstetric unit. Freestanding birth centers provide prenatal, intrapartum, and postpartum care, while alongside birth centers generally provide intrapartum and immediate postpartum and neonatal care. (See 'Definition' above.)

●Philosophy – The birth center philosophy maintains that pregnancy and birth are usually normal and physiologic events and are important psychosocial milestones within a family. The approach to care in birth centers is based on this philosophy and highly individualized. (See 'Antepartum, intrapartum, and postpartum care' above.)

●Staffing – Birth centers are typically staffed by midwives. Accreditation is not required to operate in all jurisdictions but indicates that a birth center has met a high standard of evidence-based and widely recognized benchmarks for maternity care, neonatal care, business operations, and safety. (See 'Standards' above and 'Choosing a specific birth center' above.)

●Care – Prenatal care is similar to that for pregnant people planning to give birth in a hospital but is usually more time and education intensive. Continuous caregiver support during labor is a hallmark of birth center intrapartum care. Oxytocin is not used for induction or augmentation of labor or routinely in the third stage as prophylaxis against hemorrhage. The primary approach to labor pain is use of nonpharmacologic interventions. The minimum postpartum length of stay is four hours, and most clients are discharged by eight hours. (See 'Antepartum, intrapartum, and postpartum care' above.)

●Candidates for birth at a birth center – Birth center care providers and the physicians who collaborate with them develop mutually agreed upon risk criteria for screening candidates for delivery at their birth center and excluding those perceived to be at increased risk. (See 'Candidates for birth at a birth center' above.)

Candidates for birth center care should have low-risk pregnancies. These individuals are generally healthy with a term singleton pregnancy in vertex presentation, and no medical or obstetric conditions that increase the risk for serious intrapartum, postpartum, or neonatal complications as defined by reasonable and generally accepted criteria. (See 'Candidates for birth at a birth center' above.)

Initially low-risk pregnant people who go on to develop antepartum, intrapartum, or postpartum complications (eg, preeclampsia, noncephalic presentation, preterm or postterm labor, chorioamnionitis) are required to transfer their obstetric care and give birth in the hospital, where their care is often managed collaboratively by a midwife and obstetric team. (See 'Candidates for birth at a birth center' above.)

●Birth outcomes – The body of evidence from observational studies suggests that maternal and newborn outcomes for individuals planning to deliver at a birth center are equivalent to or better than those giving birth in hospitals or national averages. (See 'Pregnancy outcomes' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Judith P Rooks, CNM, MPH, MSc, who contributed to an earlier version of this topic review.