10.2 Childbirth Settings

Women in the United States give birth at home, in birth centers, and in hospital maternity care units. The vast majority (98.4%) of women give birth in hospitals, with almost 1% giving birth at home and about 0.5% giving birth in freestanding birth centers. Hospitals provide a wide array of medical interventions for pregnant women and newborns and range from basic care (Level I), specialty care (Level II), subspecialty care (Level III), and regional perinatal health care centers (Level IV). Levels of care are based on the availability of childbirth resources, including specialists for women with high-risk pregnancies. Examples of medical interventions that are performed in hospital settings during labor and birth include blood work, intravenous (IV) administration of medications, continuous electronic fetal monitoring, cervical ripening, induction or augmentation of labor, artificial rupture of membranes, epidural analgesia, episiotomy, vacuum- or forceps-assisted birth, and cesarean birth.[1]

Health care providers in hospital maternity units may include registered nurses (RNs), midwives, obstetricians (OB/GYNs), family physicians, and pediatricians. Some hospitals may also have specialists immediately available or on call, such as anesthesiologists, maternal-fetal medicine specialists, and neonatologists. The vast majority of hospital births are attended by physicians.[2]

Midwives specialize in the management of pregnancy, birth, and newborn care. The United States has three types of midwives with nationally recognized credentials: certified nurse midwives (CNMs), certified midwives (CMs), and certified professional midwives (CPMs). All credentialed midwives in the United States are differentiated from “lay,” or “traditional” midwives, who practice without having completed formal educational and national certification requirements. CNMs are licensed to practice in all 50 states plus the District of Columbia, but their ability to practice independently or under a collaborative agreement with a physician varies by state.[3]

RNs working on labor and delivery units have many responsibilities[4]:

  • Closely monitor the client and fetus during labor and birth and identify potential complications that require prompt notification of the health care provider
  • Administer prescribed medications and monitor for effectiveness and adverse effects
  • Teach and encourage nonpharmacological interventions, including positioning, to promote comfort and labor progress
  • Assist with obstetric procedures
  • Provide initial postpartum and neonatal care
  • Advocate for the client and newborn with the interprofessional care team

The availability of resources for labor support also varies across hospitals and may include specialized devices to assist in positioning, hydrotherapy in a shower or tub, and telemetry fetal monitoring that allows continuous fetal assessment while the client ambulates or is out of bed. Support for breastfeeding, including access to lactation professionals, also varies across hospitals.[5]

Some birthing centers have volunteer doulas available for clients who request additional support during labor. Doulas are lay people who are trained to provide emotional, physical, and social support during pregnancy, labor, and postpartum. Their training involves a variety of nonpharmacologic techniques to promote comfort for a laboring client. Research shows that clients who use doulas have decreased medical interventions during labor, increased breastfeeding rates, and increased satisfaction in their birthing experience. Nurses work in collaboration with doulas to support laboring clients and promote comfort.[6],[7]

After the immediate postpartum recovery period, the client may be transferred to a postpartum unit in the hospital or remain in the same labor and delivery room, based on the configuration of the maternity unit. Hospitals also have different policies regarding rooming-in, where the newborn remains with the mother and partner instead of spending some extended time in a nursery. Federal law requires that insurance companies cover a post-delivery hospital stay of 48 hours for a vaginal birth and 96 hours post-cesarean birth, although the client may opt to leave earlier if they and the newborn are healthy.[8]

Freestanding birth centers use the midwifery model of care for childbirth for low-risk pregnancies with a goal of natural birth in a homelike setting. If complications arise, or if a client needs epidural anesthesia, they can quickly be transferred to a hospital labor and delivery unit.[9]

Home births occur at a person’s residence and may be attended by a midwife, physician, or other attendant, or by no medical attendant at all, as is preferred by a small number of people. For planned home births, about 80 percent are attended by midwives. Women who plan home births may do so out of a wish to experience physiologic childbirth, a desire for a personalized experience with a sense of control and avoidance of unnecessary medical interventions, a dislike of the hospital atmosphere, a lack of a hospital in their community, financial constraints, personal cultural beliefs and practices, or geographic barriers. Like birth center births, planned home births may result in transfer to a hospital if complications occur.[10]


  1. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on Assessing Health Outcomes by Birth Settings. (2020). Maternal and newborn care in the United States. Birth Settings in America: Outcomes, Quality, Access, and Choice. https://www.ncbi.nlm.nih.gov/books/NBK555484/
  2. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on Assessing Health Outcomes by Birth Settings. (2020). Maternal and newborn care in the United States. Birth Settings in America: Outcomes, Quality, Access, and Choice. https://www.ncbi.nlm.nih.gov/books/NBK555484/
  3. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on Assessing Health Outcomes by Birth Settings. (2020). Maternal and newborn care in the United States. Birth Settings in America: Outcomes, Quality, Access, and Choice. https://www.ncbi.nlm.nih.gov/books/NBK555484/
  4. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on Assessing Health Outcomes by Birth Settings. (2020). Maternal and newborn care in the United States. Birth Settings in America: Outcomes, Quality, Access, and Choice. https://www.ncbi.nlm.nih.gov/books/NBK555484/
  5. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on Assessing Health Outcomes by Birth Settings. (2020). Maternal and newborn care in the United States. Birth Settings in America: Outcomes, Quality, Access, and Choice. https://www.ncbi.nlm.nih.gov/books/NBK555484/
  6. Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal-newborn nursing. OpenStax. Access for free at https://openstax.org/books/maternal-newborn-nursing/pages/1-introduction
  7. Trachsel, L. A. A., Munakomi, S., & Cascella, M. (2023). Pain theory. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK545194/
  8. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on Assessing Health Outcomes by Birth Settings. (2020). Maternal and newborn care in the United States. Birth Settings in America: Outcomes, Quality, Access, and Choice. https://www.ncbi.nlm.nih.gov/books/NBK555484/
  9. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on Assessing Health Outcomes by Birth Settings. (2020). Maternal and newborn care in the United States. Birth Settings in America: Outcomes, Quality, Access, and Choice. https://www.ncbi.nlm.nih.gov/books/NBK555484/
  10. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on Assessing Health Outcomes by Birth Settings. (2020). Maternal and newborn care in the United States. Birth Settings in America: Outcomes, Quality, Access, and Choice. https://www.ncbi.nlm.nih.gov/books/NBK555484/
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