The Differences Between Birthing and Doulaing: Home Birth vs. Birthing Center vs. Hospital
- Ashley Strengholt
- Aug 15
- 4 min read
1. Does the Setting Change How You Serve Your Client During Labor and Delivery?
Home Birth
A home birth offers the ultimate in familiarity and control—my client is surrounded by their own comforts, smells, and sounds. As a doula, I work closely with the midwife to create a calm, supportive atmosphere, often using tools like birth tubs, rebozos, and massage. There’s freedom to move, eat, and labor without hospital policies dictating the process. I also assist with practical tasks, from setting up the space to helping manage clean-up afterward. While the environment is deeply personal, it’s important to remember that in the event of an emergency, transfer time to a hospital will be longer than from a birthing center.
Birthing Center
Birthing centers offer a “best of both worlds” approach—providing a warm, home-like environment while still giving families access to professional midwifery care and essential medical equipment. As a doula, my role here blends the personalization of home birth with the structure of a facility. I work alongside midwives who follow specific protocols, but still have the freedom to use comfort measures like movement, water immersion, and massage. If a complication arises, birthing centers are designed for a quicker, more organized transfer to a hospital than a home setting.
Hospital Birth
Hospital births provide the most immediate access to medical interventions and emergency care, which can be reassuring for clients with certain risk factors. As a doula, my focus here often shifts toward advocacy—helping my client navigate hospital protocols, understand medical terminology, and make informed decisions in real time. I may need to adapt comfort techniques to work around monitoring equipment, IV lines, or limited mobility, but I still provide essential emotional reassurance and physical support. Hospitals can feel busy and clinical, so part of my role is to help create a sense of calm and personal connection within that environment.
2. Pros and Cons of a Home Birth
Pros:
Lower intervention rates, including cesareans and episiotomies, for low-risk pregnancies (Hutton et al., 2009).
Comfortable, familiar environment with full control over birth atmosphere.
Continuity of care with a chosen provider.
Cons:
Higher neonatal mortality rates compared to hospital births for certain populations (Grünebaum et al., 2020).
Greater likelihood of transfer to hospital (12–16% for first-time mothers).
Emergency situations may require rapid but logistically challenging transport.
3. Complications or Risks That Disqualify a Client for Home Birth
Typical conditions that disqualify someone from home birth include:
Preeclampsia, gestational diabetes, or hypertension.
Breech presentation, twins, or other malpresentations.
Previous cesarean section or uterine surgery (depending on local guidelines). In Washington and Idaho where I practice, VBACs are not prohibited for midwives attending home births.
Preterm labor, post-term beyond safe limits, or placental complications.
4. Risk Statistics: Home vs. Hospital
In the U.S., planned home births with midwives have a 4 times greater risk of neonatal mortality than hospital births with midwives (13.66 vs. 3.27 per 10,000 live births) (Grünebaum et al., 2020). Oregon data shows out-of-hospital births at 3.9 deaths per 1,000 vs. 1.8 per 1,000 in hospitals (Snowden et al., 2015).
While some European studies, such as in the Netherlands, show similar mortality rates for well-screened low-risk home births (de Jonge et al., 2009), the U.S. data consistently indicates increased neonatal risk, especially for first-time mothers.
Home Birth vs. Hospital Birth: Risk at a Glance
Metric | Planned Home Birth | Hospital Birth | Relative Risk Increase |
Neonatal Mortality | 13.66 per 10,000 | 3.27 per 10,000 | ~4× higher |
Perinatal Death (Oregon study) | 3.9 per 1,000 | 1.8 per 1,000 | >2× higher |
Low Apgar Score / Serious Neurologic Dysfunction | Up to 4× higher | Baseline | — |
Transfer to Hospital | 12–16% (first-time mothers) | N/A | — |
Key Notes:
Home birth is safest for low-risk, term, singleton pregnancies.
First-time mothers have a higher likelihood of transfer or complications.
Data vary by country, provider type, and risk screening.
5. Are Water Births Safe?
Water labor—immersion during contractions has evidence of pain relief and shorter labors.Water birth—delivering the baby underwater remains controversial. The midwifery model asserts that the newborn’s dive reflex prevents breathing until air exposure, reducing aspiration risk in clean conditions. The medical model warns that in cases of meconium, distress, or delayed stimulation, aspiration can occur (AAP & ACOG, 2014).
Most U.S. hospitals permit water labor but not water delivery due to limited evidence of safety and difficulty managing emergencies underwater.
6. Baby's First Breath
In utero, babies receive oxygen through the placenta, not lungs. At birth, a combination of increased carbon dioxide, temperature change, and sensory stimuli triggers the first breath, usually within seconds (Vyas et al., 1981).
Fluid is expelled from the lungs during contractions and delivery. Cardiovascular shifts (closure of the foramen ovale and ductus arteriosus) prepare the newborn for air breathing.While midwifery care trusts the protective dive reflex, some newborns aspirate if distress occurs before or during delivery.
7. Supplies for a Home Birth
Parents provide:
Clean linens, waterproof pads, and towels.
Birth tub, if desired.
Snacks, hydration, and comfort items.
Midwife provides:
Sterile birth kit (gloves, scissors, cord clamps).
Monitoring equipment and emergency medications.
Oxygen and IV supplies, if within their scope.
Doula provides:
Comfort tools: rebozo, massage oil, birth ball.
Emotional and advocacy support.
Environment enhancers like music or lighting.
Final Thoughts
Birth setting shapes not only the atmosphere but the nature of doula support. Home births offer intimacy and autonomy but come with measurable increases in neonatal mortality risk. Birthing centers can provide a middle ground, and hospitals offer the most immediate access to interventions. Informed choice—rooted in solid evidence and realistic expectations—remains the cornerstone of safe, supported birth.
References
Grünebaum, A., et al. (2020). Neonatal mortality in the United States is related to location of birth. American Journal of Obstetrics & Gynecology, 222(3), 272.e1–272.e9.
Snowden, J. M., et al. (2015). Planned Out-of-Hospital Birth and Birth Outcomes. New England Journal of Medicine, 373, 2642–2653.
de Jonge, A., et al. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG, 116(9), 1177–1184.
American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (2014). Immersion in Water During Labor and Delivery. Pediatrics, 133(4), 758–761.
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