For many expecting parents, one of the most significant decisions they will make during pregnancy is where to give birth. In the United States, families choose to give birth in hospitals, freestanding birth centers, or at home with a qualified midwife.
In many countries, the maternity care system is more straightforward and cohesive. In the US, birthing options vary greatly regionally. Regulations around care providers also vary significantly state to state. These differences can make it difficult for parents to understand all their options.
As doulas, understanding these options allows us to better support clients as they navigate the maternity care system. We can support as they make informed choices. We can help them find a providers who align with their preferences, values, and medical needs.
Birth location can influence everything from provider relationships and hospital policies to comfort measures, intervention rates, and postpartum recovery. As doulas, we do not choose birth locations for families. However, we can play an important role in helping families understand the differences between available options.
Here are the most common birth settings in the United States and how we can help families evaluate their options.
Hospital Birth With a Private Practice Provider
Many pregnant people in the U.S. receive prenatal care from a private obstetrician or midwifery practice. They will then plan to give birth in a hospital where their provider has privileges.
In this model, the provider operates independently from the hospital but collaborates with hospital staff during labor and delivery.
Private practices might offer:
- Continuity of prenatal care
- Longer appointments
- Established relationships with providers
However, it’s important for doulas to help clients understand that their chosen provider may not always attend the birth. Most practices operate on an on-call rotation. This means whichever provider is on call when labor begins will typically attend the birth.
Questions Doulas Can Encourage Families to Ask
Helping families ask thoughtful questions during prenatal care can improve their understanding of how birth might unfold.
Some helpful questions include:
- How does the on-call system work?
- Will I meet all providers in the practice during pregnancy?
- What are the hospital’s policies regarding movement, monitoring, and pushing positions? What pushbacks occur if people opt out of these policies?
- What are the cesarean and intervention rates at this hospital?
- Are the provider and hospital covered by insurance?
Even when clients feel confident about their provider, hospital policies can significantly influence the birth experience, making these conversations important.
Hospital Birth Through a Clinic System
Some families receive prenatal care through hospital-based clinics or group practices. Sometimes due to insurance requirements, financial considerations, or accessibility. There are many areas in the US which are maternity care deserts. This means families have very few options in their area and may need to drive quite a while for care.
In these settings, clients typically see multiple providers during pregnancy. The clinician attending the birth may be someone they have never met before.
While clinic care can provide accessible and affordable maternity services, the experience may include less continuity of care.
How Doulas Support Clients in Clinic Models
In situations where clients may not know the provider attending their birth, doulas can offer valuable continuity and emotional support.
Encourage clients to ask:
- How many providers work in the clinic?
- Who typically attends births?
- What hospital policies might impact labor and birth? Is there pushback for patients practicing full autonomy?
- What is the typical response to patients requesting different positions, comfort techniques, etc., during birth?
Because clinic systems often involve rotating providers, doula support can help create consistency throughout the birth experience.
Birth Center Birth With Midwives
Freestanding and hospital-affiliated birth centers provide care for low-risk pregnancies, typically under the care of midwives. The type of midwife attending may vary state to state. In the US, many birth centers employ Certified Nurse Midwives (CNM), Certified Midwives (CM), or Certified Professional Midwives (CPM). Each state is unique in midwifery legalities.
Birth centers are designed to support physiological birth, emphasizing minimal intervention, freedom of movement, and individualized care.
Common features of birth centers include:
- Home-like birth environments
- Water immersion options
- Lower intervention rates
- Longer prenatal visits focused on education and holistic care
Some birth centers are located within hospitals, while others are freestanding facilities with transfer agreements with nearby hospitals. All birth centers offer some level of medical support such as IV fluids, oxygen, etc. Some may also provide lower risk pharmacological pain relief such as IM pain medication and nitrous oxide.
Questions Doulas Can Encourage Clients to Ask
When clients are considering a birth center, doulas can help them explore:
- Will they meet all midwives before labor?
- What circumstances would require transfer to a hospital?
- Which hospital would they transfer to?
- How long can families stay after birth?
Birth centers often align well with families seeking physiological birth. Doulas frequently play an important role in providing comfort measures and emotional support during labor.
Home Birth With a Midwife
Home birth is another option some families consider. This is particularly common for those seeking a familiar and low stress environment.
Home birth is typically attended by certified professional midwives (CPMs), certified nurse midwives (CNMs), direct entry midwives, or licensed midwives, depending on state regulations.
For low-risk pregnancies, planned home birth with qualified providers can offer several benefits:
- Continuous midwifery care
- Personalized attention
- A familiar and comfortable environment
- Lower intervention rates
Home birth providers also have clear protocols for transporting to a hospital if complications arise.
Questions Doulas Can Encourage Clients to Ask
When supporting families exploring home birth, doulas can suggest asking:
- What are the transfer protocols if complications arise?
- How far is the nearest hospital?
- Is there a backup midwife?
- What postpartum care is included?
- How is the birth covered financially or through insurance?
- What type of midwifery training, credentials, etc., does the midwife and their backups have?
Doulas attending home births often help with comfort measures, emotional reassurance, and supporting the birth team.
How Birth Location Influences the Birth Experience
While many factors affect labor and birth, the birth setting can shape policies, expectations, and available support.
Some important factors include:
- Freedom of movement in labor
- Monitoring policies
- Pain management options
- Access to water immersion
- Provider continuity
- Transfer procedures
Understanding these differences allows doulas to help clients prepare for their birth experience regardless of the setting.
The Role of the Doula in Birth Setting Decisions
As doulas, we do not direct families toward a particular birth location. Instead, we provide education, emotional support, and evidence-based information so families can make decisions that feel right for them.
Doulas support clients by:
- Helping families understand their birth setting options
- Encouraging informed conversations with providers
- Providing continuous support during labor
- Promoting physiological birth practices when appropriate
- Supporting communication between clients and care teams
Research consistently shows that continuous labor support improves birth outcomes, including shorter labor, reduced interventions, and increased satisfaction with the birth experience.
Helping Families Make Informed Birth Choices
Choosing where to give birth is a deeply personal decision influenced by many factors, including medical history, access to providers, insurance coverage, and family preferences.
Doulas help families navigate these choices with confidence by offering education, reassurance, and support throughout pregnancy and labor.
When families understand their options and feel supported in their decisions, they are more likely to have positive and empowering birth experiences.
Interested in becoming a doula or expanding your knowledge of evidence-based birth support? Register now and get started on your doula journey!
Author: Aliza Juliette Bancoff
Aliza Juliette Bancoff is a well-known doula and doula trainer who has been providing doula services to families for over a decade. She is the founder of Main Line Doulas, a doula group providing doula support in the great Philadelphia area for the last decade, the International Doula Institute, which provides online doula training and lactation training and certification programs and the International Breastfeeding Institute which provides lactation training and certification. She is the co-founder of United Birth, a company devoted to increasing access to doulas across the country to make the perinatal time safer both physically and emotionally. “Every birthing person deserves access to quality doula support. And we are working to make that a reality across the country. The work we are doing to get doulas to every birthing person will decrease the black infant and maternal mortality rate significantly by 2030.” Says Bancoff. Aliza is known for her compassionate and empowering approach to doula work, and she has been featured in numerous media outlets, including United Nations Maternal Health Report, Parent Magazine, CafeMom, theBump and many more. Aliza's journey into doula work began when she gave birth to her first child and felt a strong calling...