Choosing Prenatal Care and Birth Setting
This page gives guidance about how to make the decision broadly - click here for specifics about different San Francisco birth locations
The decision about where to receive prenatal care and where to give birth are related - for instance, an OB practice has admitting privileges at a certain hospital, or a birth-center provides both prenatal care and labor & delivery (L&D).
If you are going the OB/hospital route, you can make the decision in either order (just make sure your insurance is accepted):
Choose the OB and then go with whatever hospital she has affiliation
Choose the hospital and then find an affiliated OB
5 Questions to ask yourself
How much do you value convenience?
You’ll have 10-15 prenatal appointments, so proximity may be helpful (OB practice might be different location than hospital). Is there a good online portal or just phone calls?
How much do you value protecting against downside risk?
If you’re worried about something going wrong during labor and deliver, or you are a high-risk pregnancy, probably best to go to a well-equipped hospital (NICU, C-section)
High risk pregnancies include twins/multiples, pre-existing conditions like diabetes or high blood pressure, conditions that develop because of pregnancy like preeclampsia (high blood pressure and potentially kidney/liver issues, diagnosed around week 20) or gestational diabetes (high blood sugar, diagnosed around week 24), breech baby (feet first position, don’t know until the end!)
How much do you value having a more natural birth?
Birth Centers, homebirths and certain hospitals may be more conducive to avoiding medical intervention. Bringing a doula to any setting can also help achieve this goal. This can be a polarizing topic, so if you’re not sure yet how you feel, read the linked guidance and I’m happy to discuss in greater depth on a call, with zero judgment.
How much do you value comfort?
Do hospitals freak you out and you’d prefer a homey vibe? Or does comfort for you look like a spacious and modern hospital room with state-of-the-art equipment and nice views? Immersion in warm water helps some women relax and manage labor pain - some hospitals offer bathtubs, while others only have showers which may be less comfortable since you have to stand
Are you interested in group prenatal care vs. 1:1?
Group care (called “centering”) allows you to connect with and learn alongside other women, but it’s not for everyone - appointments are longer and less flexible scheduling, and midwives often rotate so less continuity. Another way to achieve the group experience is a birth prep class, offered by most hospitals in your third trimester
This may seem like a big decision to make early on, but actually there’s some flexibility:
You can always switch OBs part-way through pregnancy, not a huge hassle. Especially easy if switching within the same hospital affiliation
If you’re in labor, any hospital will accept you even if you aren’t pre-registered or affiliated through your OB; downside is you won’t know the doctors and may pay more if out-of-network
If you’re planning to give birth at home or a birth center, you can still get ultrasounds and lab work done through an outside prescription. However, may be insurance challenges
Birth Settings
Hospital:
Most common choice in the U.S.
Allows you access to modern technology in case of emergency or for pain relief
Variation across hospitals in how “natural birth” friendly, but no hospital will force you to get an epidural if you don’t want one
When comparing outcomes like C-section rates across hospitals, remember it’s affected by the demographics served (older, higher risk women = higher C-section rate), not just staff philosophy
Consider if you’re comfortable with a teaching hospital or not - on the one hand, it means less experienced residents or medical students providing care and likely many others in the room observing (though you can always ask that they step out if you prefer more privacy). On the other hand, residents/students may be more attentive and eager to prove themselves, plus they are supervised by an experienced physician.
Birth Center:
Freestanding facility provides a more home-like environment and is run by midwives rather than OBs. They can write prescriptions to have ultrasounds and labwork done at a hospital
During birth, they may offer nitrous oxide for pain, but won’t induce labor medically, no epidurals, and can’t perform C-sections
Another major difference is that you will return home a few hours after birth (assuming it’s all healthy) rather than stay overnight, and then checkups on mom and baby will happen at home
Find out which hospital you’d be admitted at if complications arise (happens in ~16% of cases)
Birth Centers may be in-network for a number of insurances but will still end up being more expensive for you than a hospital.
Homebirth:
Chosen by only 1% of Americans
Home atmosphere can help you relax, which can aid labor
Every prenatal and postnatal appointment is with same midwife, so greater continuity of care and relationship building
Look for a highly qualified midwife (ideally a CNM) so they can identify if hospital transfer is necessary (happens in ~30% of first-time homebirths)
Not usually covered by insurance
Birth Professionals
OBGYN:
Doctor who specializes in pregnancy and is affiliated with a particular hospital (but not guaranteed to be on-call when you deliver)
Some are solo practitioners, others are part of a group practice; benefit of group practice is you can meet other OBs who could end up being on-call and they have a similar philosophy as your OB
During L&D, most care is actually provided by rotating set of nurses who will vary in quality at any hospital
Midwife:
Medical professional who supports low-risk pregnancies and offers a more holistic, lower-intervention approach than an OB
They also typically spend more time with patients both prenatally and postnatally than OBs
Midwives may work collaboratively with an OB in a hospital, or on their own at a birth center or homebirth setting
Three levels of training: Certified Nurse Midwives (CNM) are most highly trained with a full nursing degree; Certified Midwives (CM) have graduate degree and certification; Certified Professional Midwives (CPM) have only certification
Birth Doula:
Provides physical, emotional and informational support during final months of pregnancy and at birth
Not a medical professional and doesn’t deliver babies, but instead provides coaching, comfort measures (e.g. massage, counterpressure) and advocacy
Evidence suggests they reduce risk of C-sections and lower use of epidurals and forceps
Additional part of birth team in a hospital, birth center or homebirth
The term “doula” also refers to postpartum doula, who supports during the day or night after the baby is born (some offer both birth and postpartum)
More on choosing a birth doula here
My Two-Cents
You can have an empowering and beautiful birth in any setting (or a miserable one)! Mostly biological luck, but your preparation and mindset can make a big difference
While your birth experience matters, ultimately the most important thing is a healthy mom and baby
You don’t need to decide your birth preferences* now; your general orientation towards the natural vs. medical spectrum can be just one factor as you decide on a birth setting/provider. You can check out my overview of medical interventions to better understand the risks and benefits.
People have strong opinions on these issues: try your best to glean useful information to make informed choices but without falling into the shame or comparison trap. This challenge continues once you become a parent with issues like breastfeeding and sleep training, so it’s good practice!
My personal rec for your first baby: give birth in a hospital with a doula supporting - best of both worlds!
*Notice I didn’t use the more common term “birth plan”? Very few labor experiences go exactly to plan, so while it’s valuable to align on your ideal labor in advance, it’s important to bake in some flexibility
