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Birth centers

Susan Stapleton, DNP, CNM, FACNM
Section Editor
Vincenzo Berghella, MD
Deputy Editor
Kristen Eckler, MD, FACOG


The United States out-of-hospital (OOH) birth rate hovered around 1 percent during the 1970s, '80s, and '90s, but began to rise during 2008 [1], reaching 1.54 percent in 2015 [2]. Of slightly more than 61,000 OOH births that year, 63.1 percent were home births and 30.9 percent took place in free-standing birth centers [2]. For women thought to be at low risk for obstetric complications when they go into labor, entering labor care at a birth center can result in greater satisfaction, cost savings, and the same or better outcomes than in-hospital births [3].

This topic will provide a brief history of the development of birth centers in the United States and the evidence regarding the birth center model of care. Home birth is reviewed separately. (See "Planned home birth".)


For most of the 20th century, out-of-hospital births took place in the mother's home, maternity homes, clinics, or a birth room in a doctor's office. During the first half of that century, those sites served women who did not have access to, could not afford, or did not want the services of physicians and acute care hospitals. During this era, the first American nurse-midwifery services were established to provide care for the poor, eg, the Frontier Nursing Service in Kentucky, the Maternity Center Association in New York City, and La Casita, operated by the Medical Mission Sisters in Santa Fe.

The proportion of births in hospitals rose from 37 percent in 1935 to 97 percent in 1960, and reached 99 percent by the 1970s [4]. Several developments after World War II led to this change: (1) The GI Bill broadened opportunities for medical education, which resulted in doubling of the number of medical schools and new physicians; (2) the Hill Burton Act promoted the construction of community hospitals, which improved access to hospital care; (3) hospitals offered methods of pain relief in labor that were unavailable in the home; and (4) the expansion of employer-based health insurance and the beginning of Medicaid paid for care for pregnant women but only for maternity services provided by physicians and hospitals, not for out-of-hospital births.

As a result, birth moved from mostly in homes to mostly in hospitals and from care provided mostly by traditional midwives to care provided by physicians. Since births in American hospitals were attended exclusively by clinicians assisted by nurses, nurse-midwifery did not develop in the United States as it had in other similarly developed countries. In contrast, midwifery had been well-established in Europe since the 1700s, and the movement of births from homes to hospitals was accompanied by the movement of midwives into hospitals.

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Literature review current through: Oct 2017. | This topic last updated: Nov 14, 2017.
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