On this page11 sections
- Key takeaways
- Birth center vs hospital at a glance
- Who is a good candidate for a birth center?
- What does the evidence say about birth center outcomes?
- How often do people transfer to a hospital?
- Pain relief: what each setting offers
- Licensing and accreditation for birth centers
- Choosing a hospital: the Birthing-Friendly designation
- Which is right for you?
- Questions people ask
- Sources
Key takeaways
- ACOG and SMFM describe birth centers as serving low-risk women with a single, full-term, head-down baby who are expected to have an uncomplicated birth.
- In a national study of 15,574 women who planned birth center births, 6% had a cesarean and 16% transferred to a hospital before giving birth. 1.9% of mothers or newborns needed an emergency transfer.
- In CMS's Strong Start evaluation, Medicaid patients in birth center prenatal care had fewer preterm births and cesareans than a matched comparison group, at lower cost.
- Licensing varies by state. CABC accreditation means a center meets the national AABC Standards for Birth Centers.
- For hospitals, the CMS Birthing-Friendly designation flags hospitals in a perinatal quality collaborative that use maternal safety practices.
Choose a birth center if your pregnancy is healthy and low-risk, you want a midwife-led birth without an epidural, and the center has a clear plan for getting you to a hospital if you need one. Choose a hospital if you have a medical condition or pregnancy complication, want an epidural available, or simply want an operating room down the hall.
Hospitals are still where almost everyone gives birth. In 2023, 97.7% of US births happened in a hospital and 0.6% in a freestanding birth center [2]. But birth centers are growing. AABC counts more than 400 freestanding birth centers in 40 states and DC, more than double the number a decade earlier [3].
Birth center vs hospital at a glance
| Birth center | Hospital | |
|---|---|---|
| Who it's for | Low-risk, single, full-term, head-down pregnancies [1] | Everyone, including high-risk pregnancies |
| Who attends you | Mostly midwives. 91% of 2023 birth center births were attended by midwives [2] | Obstetricians, family physicians or nurse-midwives, plus nurses |
| Epidural | Means transferring to a hospital [16] | Available. In 2015, 73.1% of US women in labor had an epidural or spinal block [9] |
| Other pain relief | Water immersion [15], and nitrous oxide at some centers [8] | Varies by hospital. Some offer nitrous oxide [8] |
| Cesarean if needed | Transfer to a hospital | On site |
| Newborn intensive care | Transfer to a hospital | On site at many hospitals |
| Medicaid | Covered when the center is licensed or recognized by the state [12] | Covered |
Who is a good candidate for a birth center?
The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine describe birth centers as providing care for "low-risk women with uncomplicated singleton term vertex pregnancies who are expected to have an uncomplicated birth" [1]. In plain English:
- One baby, not twins or more
- Full term, not in preterm labor
- Head down at the end of pregnancy
- No significant medical or pregnancy complications, such as preeclampsia or diabetes that needs medication
Birth centers screen for this throughout pregnancy, and a complication that shows up at 36 weeks can move your birth to a hospital. Policies on vaginal birth after cesarean (VBAC) vary from center to center, so ask. A clinician should be part of this decision: if you have any chronic condition or a complicated past pregnancy, get your risk reviewed before you commit.
What does the evidence say about birth center outcomes?
The National Birth Center Study II followed 15,574 women who planned and were eligible for a birth center birth at 79 midwifery-led centers in 33 states [4]. Wherever they ended up giving birth:
- 93% had a spontaneous vaginal birth, 1% an assisted vaginal birth and 6% a cesarean [4]
- There were no maternal deaths [4]
- The neonatal death rate was 0.40 per 1,000, excluding birth defects [4]
The Strong Start evaluation for CMS compared Medicaid patients who got prenatal care through birth centers with matched patients in typical Medicaid care [5]. About 46% of the birth center group gave birth at the center, and the rest in hospitals [5]. Compared with the comparison group, their babies were less likely to be preterm (6.3% vs 8.5%) or low birth weight (5.9% vs 7.4%), and their cesarean rate was 17.5% vs 29.0% [5]. Delivery costs were 21% lower, and costs from delivery through the baby's first birthday were 16% lower [5].
A systematic review of 17 studies covering at least 84,500 women admitted to birth centers found no study with a statistically higher rate of newborn death in birth centers than among low-risk women giving birth in hospitals [6]. The authors flagged real weaknesses in the research and noted that first-time mothers, mothers over 35 and pregnancies past 42 weeks may carry higher risk in any setting [6].
The caveat for all of this: birth center patients are screened to be low-risk, so these studies can't tell you how a higher-risk pregnancy would do there. ACOG's position is that hospitals and accredited birth centers are the safest settings for birth [7].
How often do people transfer to a hospital?
Transfers are common and mostly not emergencies. In the national birth center study [4]:
| Transfer | Share |
|---|---|
| Transferred to a hospital before admission to the birth center | 4% |
| Transferred during labor | 12% |
| Gave birth at the birth center | 84% |
| Mothers transferred after giving birth at the center | 2.4% |
| Newborns transferred after birth | 2.6% |
| Mothers or newborns needing an emergency transfer | 1.9% |
Before you choose a center, ask:
- Which hospital do you transfer to, and how long is the drive?
- Does a midwife come with me and stay?
- Do you have a formal agreement with physicians at that hospital?
- What share of your clients transfer, and what share are emergencies?
ACOG and SMFM's maternal care guidance notes that national birth center standards call for each center to have an established consultation, collaboration or referral system [1].
Pain relief: what each setting offers
Hospitals offer epidurals and other spinal blocks, which are recognized as the most effective pain relief for labor [9]. In a study of 2.6 million US women who labored in 2015, 73.1% used one [9]. Nitrous oxide is also increasingly available in US hospital maternity units [8]. Ask what your hospital offers.
Birth centers are not where you get an epidural. In US research on home and birth center births, deciding you want an epidural is listed as a reason for transferring to hospital care [16]. Ask each center which pain-relief options it does offer. Water is a common one: among the 15,574 low-risk women in AABC's national birth center data, there were 3,998 water births [15]. AABC's position is that licensed or accredited birth centers should be able to offer nitrous oxide, a gas you breathe through a mask and control yourself [8].
If you're unsure how you'll feel in labor, that's normal. Ask the birth center what happens if you decide mid-labor that you want an epidural. Expect the answer to be a transfer to a hospital [16].
Licensing and accreditation for birth centers
Birth center rules depend on your state. AABC reports that more than 80% of states have some form of birth center regulation [10].
Accreditation is a separate, voluntary step. The Commission for the Accreditation of Birth Centers (CABC) accredits centers using the AABC Standards for Birth Centers, currently the only established national standards [11]. ACOG recognizes accredited birth centers as "an integral part of regionalized care" [1]. CABC publishes a searchable list of the centers it accredits.
Medicaid must cover freestanding birth center services when the center is licensed or otherwise recognized by the state [12]. Check whether a center is licensed in your state and whether it's CABC-accredited, then confirm your insurance network. For prices, see birth center cost vs hospital birth cost.
Choosing a hospital: the Birthing-Friendly designation
If a hospital is the right fit, CMS's Birthing-Friendly designation is one starting point. CMS created it "to identify hospitals and health systems with a demonstrated commitment to improving maternity care quality" [14].
To earn it, a hospital must report both that it participates in a statewide or national perinatal quality improvement collaborative and that it has implemented patient safety practices or bundles related to maternal morbidity [13]. It's a measure of safety programs, not of outcomes, so it's worth also asking a hospital:
- What's your cesarean rate for first-time mothers with low-risk pregnancies?
- Do you have midwives on staff, and can I labor in a tub?
- What level of newborn intensive care do you have on site?
- Can my doula stay with me?
Browse Birthing-Friendly hospitals from CMS data, or birth centers by state.
Which is right for you?
| Your situation | Best fit |
|---|---|
| Healthy, low-risk pregnancy, and you want an unmedicated, midwife-led birth | Accredited birth center, or a hospital with midwives |
| You want an epidural, or want the option | Hospital |
| Twins, breech baby, preeclampsia, diabetes needing medication or another complication | Hospital, with physician care |
| Prior cesarean | Talk with a clinician. Some birth centers accept VBAC, many families choose a hospital |
| You live far from any hospital | Ask any birth center about transfer time before deciding |
| You want a midwife either way | Look for hospitals with nurse-midwives, or read about types of midwives |
Questions people ask
Can I get an epidural at a birth center?
Plan on a hospital if you want one. In US research on home and birth center births, deciding you want an epidural is listed as a reason for transferring to hospital care. Ask a center which pain relief it does offer. Water births are common at birth centers, and AABC says licensed or accredited centers should be able to offer nitrous oxide.
Is a birth center safe?
For healthy, low-risk pregnancies, studies of birth centers that follow national standards show low intervention rates. A systematic review found no study with higher newborn death rates at birth centers than for low-risk hospital births. ACOG calls hospitals and accredited birth centers the safest settings for birth.
What happens if something goes wrong at a birth center?
Your midwife transfers you to a partner hospital. Most transfers aren't emergencies. In the national birth center study, 1.9% of mothers or babies needed an emergency transfer. Ask any center which hospital it uses and how long the drive takes.
Does Medicaid cover birth centers?
Yes. Freestanding birth center services are a mandatory Medicaid benefit when the center is licensed or otherwise recognized by the state. Private plan coverage varies, so check your network.
Can I have a VBAC at a birth center?
Some birth centers accept people planning a vaginal birth after a prior cesarean, and some don't. Ask each center about its policy and get your obstetric history reviewed by a clinician.
Sources
Numbers in brackets in the guide link to these sources.
- 1.Levels of Maternal Care (Obstetric Care Consensus No. 9)American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine, 2019
- 2.Births: Final Data for 2023 (National Vital Statistics Reports Vol. 74, No. 1), Table ICDC National Center for Health Statistics, 2025
- 3.HistoryAmerican Association of Birth Centers (AABC), 2026
- 4.Outcomes of care in birth centers: demonstration of a durable model (Stapleton, Osborne and Illuzzi)Journal of Midwifery & Women's Health, 2013
- 5.Strong Start for Mothers and Newborns Evaluation: Year 5 Project Synthesis, Volume 1Urban Institute for the CMS Innovation Center, 2018
- 6.Neonatal Outcomes in the Birth Center Setting: A Systematic Review (Phillippi et al.)Journal of Midwifery & Women's Health, 2018
- 7.Planned Home Birth (Committee Opinion No. 697)American College of Obstetricians and Gynecologists (ACOG), 2017
- 8.Position Statement: Nitrous Oxide for Labor AnalgesiaAmerican Association of Birth Centers (AABC), 2018
- 9.United States State-Level Variation in the Use of Neuraxial Analgesia During Labor for Pregnant Women (Butwick et al.)JAMA Network Open, 2018
- 10.BC RegulationsAmerican Association of Birth Centers (AABC)
- 11.About the CABCCommission for the Accreditation of Birth Centers (CABC)
- 12.Mandatory & Optional Medicaid BenefitsMedicaid.gov (Centers for Medicare & Medicaid Services)
- 13.Maternal Morbidity Structural Measure: Measure SpecificationsCenters for Medicare & Medicaid Services (CMS)
- 14.Maternal HealthCenters for Medicare & Medicaid Services (CMS), 2026
- 15.Position Statement: Immersion in Water during Labor and BirthAmerican Association of Birth Centers (AABC), 2014
- 16.Planned Home Births in the United States Have Outcomes Comparable to Planned Birth Center Births for Low-Risk Birthing Individuals (Bovbjerg et al.)Medical Care, 2024
