Midwife or OB? Homebirth, Hospital, or Birth Center? Factors to Consider

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Midwife or OB? Homebirth or Birth Center? For mom's seeking a natural, intervention free childbirth these choices can be daunting and the considerations that go into the decision making process vary widely based on location and individual circumstances, but they often boil down to a few general categories: Safety and comfort; Cost; and Availability and Logistics.

If you are just starting out in your search for information, I recommend the book The Thinking Woman's Guide to a Better Birth by Henci Goer. It is a thoroughly researched book that presents pros and cons of many different aspects of childbirth. It goes well beyond the simple questions of Midwife vs OB and Homebirth vs Birth Center to investigate various individual birth interventions and interactions to allow you to make informed and detailed choices. Electronic fetal monitoring? Why or why not? Pitocin? When it is necessary and when it is not. When homebirth is safe and when the hospital is safe. And so on. And since it is important to make these decisions as early as possible in pregnancy, I recommend this book as soon as you consider trying to get pregnant.

I devoured The Thinking Woman's Guide to a Better Birth along with a whole stack of books and a slew of websites during my first pregnancy and determined that for me - a fit, healthy woman experiencing a normal, low risk pregnancy - completely intervention free was the way to go. I also decided that I liked the midwifery model of care much more than the medical model of care (in short, the midwifery model assumes birth is a natural body process and focuses on support where the medical model assumes birth is a medical emergency in need of treatment and cure - this is really oversimplifying it, check out the link for more info).

Safety and Comfort

Being on active duty with the Marine Corps at the time, I found out that THE ONLY childbirth my insurance would cover was one performed my Navy doctors in the hospital of their choice. So I figured I would just work with the Navy docs and see about having an intervention free birth in their facility. No go. I was told in no uncertain terms that regardless of what I requested or said, regardless of whether I gave or denied consent, regardless of any of my wishes or desires, regardless of whether it was medically necessary, the Navy docs would give me whatever drugs they wanted, use whatever machines and interventions on me they wanted, and give me whatever birth was easiest for them.

So MacGyver and I chose to give birth outside the hospital with midwives. I really felt like it was my only viable choice since the doctors were quite literally threatening to inject me with drugs I didn't want or need against my will - drugs that would cross over to the baby. We had a wonderful homebirth with Flintstone, attended by two skilled midwives - one a certified nurse midwife, or CNM, and one a certified professional midwife, or CPM, with over 15 years experience. If we still lived there, we would absolutely go with GeorgAnna from Savannah Midwifery again. We would definitely plan another homebirth.

Here in Michigan, the decision is more complicated and more difficult. And they are decisions we need to make as soon as possible. I keep starting and stopping. I contacted some midwives. I did some research. Then I got buried in my work. Midwives book up in a way hospitals don't, so if we decide to go with midwives, we need to decide soon!

Midwifery in Michigan is not nearly as well regulated as it is in some other states. Michigan only licenses and regulates CNMs. There is no licensing or regulation for CPMs, direct entry midwives, or lay midwives (read about types of midwives). This is a problem since the majority of midwives who perform homebirths are not CNMs. CNMs, especially in this area, work almost exclusively for hospitals. Why does licensure and regulation matter? While it may seem obvious that you want licensing and regulation for standard safety measures, the issue goes beyond that.

I can do my due diligence and research CPMs. I can interview them and find out how many births they've attended, where they've trained, whether and how they are insured, and what sorts of difficult births they've attended. I can find out what their hospital transfer protocols are and have standards set in place. But a lot of it is on the honor system in unregulated and under-regulated states. I may not find out whether or not my midwife has been involved in the loss of a child. Whether she has ever been accused of negligence.

And it is ultimately all on me to do that research, because there is no oversight body keeping track for me. And that is scary. I have a lot of faith in the midwifery model of care. I have a lot of faith in natural childbirth for low risk pregnancies. A landmark recent study confirmed that of 17,000 planned midwife attended homebirths, fewer than 1% required transfer to the hospital, and most of those were non-life-threatening. But those few are frightening. Because you don't know ahead of time. Because the negative outcome is unfathomable.

So I want to know if my midwife has been sued for negligence or recklessness - and I shouldn't have to be a lawyer to be able to find that out. Heck, there should be a state body standing by to review licenses and suspend or revoke them when necessary. So that is a big challenge for us this time around here in Michigan. The amount of research required to find a midwife is staggering. And I haven't found any CNMs (licensed and regulated by the state) that do homebirths. Which brings us to the birthing center.

At least two friends have mentioned the local "Alternative Birthing Center." Neither of them have used it, though I did find a blog of someone who did. I've also done a little bit of research on the Birth Center's website. It seems well equipped to deliver an healthy, intervention free birth, and is still one of my front runners for consideration, but I still have concerns about being in an establishment affiliated with a hospital and I only have on birth story from a few years ago to base their approach on, so I need to do a lot more research in that area. I haven't yet determined if this is a facility covered by our insurance, but it should be. We haven't yet met their midwives to determine if they are a fit with us.

So that basically addresses Safety and Comfort - finding a person/place that won't attempt to force or coerce me into having unnecessary birth interventions while at the same time offering a level of safety in an emergency.


We paid for Flinstone's birth entirely out-of-pocket thanks to the patronizing and disrespectful conduct of Naval Hospital Beaufort. I fought to get our expenses reimbursed for 2 years - the insurance company was willing to complete the reimbursement from the very beginning, but was unable to do so without an endorsement from the Naval Hospital because I was on Active Duty when I gave birth. This went all the way up to the national level, where I was given the response "The way the staff at Beaufort Naval Hospital acted was completely unacceptable and will not happen in the future, however we are not going to force them to sign the endorsement." Even after repeated requests, The U.S. Navy Bureau of Medicine refused to put their response to my appeal in writing. Probably because it was completely legally unfounded and unsatisfactory.

Even having to pay out of pocket, Flintsone's birth costs were only a fraction of what a hospital birth would cost. The average cost of an uncomplicated hospital birth at the hospital the Navy attempted to coerce me into using was $22,000 at that time (according to the accounting department at that hospital). The average cost of a midwife attended home birth was $2,000-$3,000.

This time around, I have insurance that will cover a homebirth but only with a CNM - which is my route of choice if I can find a CNM. Our co-pay will be the same (20% for network, 30% for non-network) regardless of where we give birth - home, birth center, hospital. But 20% of a $3000 home birth is a heck of a lot less money than 20% of a $22,000 hospital birth. I do not yet know how much the alternative birth center charges.

Sure, we'd all love to say that cost isn't a consideration, that health and safety are paramount, but unfortunately I don't make nearly enough money for that to actually be true. While health and safety are the main concerns, cost is going to play into the consideration, too. One of several factors to be weighed against each other as we make our ultimate birth choices.

Availability and Logistics

If we decide to go with another home birth, we need to choose quickly because any given midwife can only perform one homebirth at a time - well, in most cases. So the pressure is on to make this choice in a timely manner otherwise homebirth might be taken off the table for us. I do believe the Alternative Birth Center also has a limited availability, so, again, I need to get on making this decision.  We'll probably start by checking out the Birth Center.

With both of these options. there is one factor that continues to nag at me: Time. With Flintstone, my water broke with little to no lead up. As soon as my water broke, contractions set it and sped up steadily. I had been told by everyone from my mom to my midwife that first labors often take a while and I should bank on about 24 hours of labor. I got 10. And if I had been better at reading my body's signals, it probably would have been faster.

The 10 hour labor wasn't a problem. It was a bit stressful, but was also kind of nice - over quickly and all. At the time, I worked 12 minutes from home and lived 5 minutes from the hospital. The midwives had to come in from an hour away, but that didn't seem like much when everyone kept telling me how long labor took. I went into labor and hung around at work for a couple hours before a stress free and quick drive home.

This time around, I live 30 minutes away from work in perfect traffic and at least 15 minutes from the nearest hospital should there be an emergency. My current OB is close to my work but far from my home (not that I have any intention of giving birth with an OB). The Alternative Birth Center is 35 minutes from my home and 20 minutes from my job (depending on which job I'm working on a given day). It is quite possible that this time around my labor will go even faster than last time, and let me tell you I am not interested in giving birth at work.

Maybe I'll just start teleworking when I get close to my due date...

So the last major consideration when contemplating location is how difficult it will be to get to any of these places - even home, if I go into labor at work again.

Looks like I really need to get on scheduling interviews and calling up my insurance company...


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