When starting a midwifery practice, one of the big decisions to make is what setting to deliver in. Do I want to offer home births, birth center deliveries, or hospital births? Do I want to offer a couple setting options? Today I will focus on home versus birth center practice. I have personally done a practice for years where both services were offered at the same time. I can tell you many advantages and challenges with each setting.
Let’s start with home birth practice. Goods about this option are cost effective (low start up costs for midwife). Midwife only needs training and supplies to practice. She doesn’t have to rent an office (home visits from car work just fine to start out) or have an upkeep costs of birth rooms while volume is lower. Your electric bills need to be paid in an office or birth center whether women is due that month or not. Lower overhead costs means less women need to be on the monthly delivery list. I see that birth centers tend to have a higher volume of clients to serve compared to home birth practices. Not sure if it is additional overhead costs or convenience of ability to increase volume with multiple birth rooms under one roof.
This could be a good or bad thing depending on how you look at it. Home is the mother’s responsibility. You don’t have to clean her home, have her specific birth supplies ready (just midwife supplies), have food ready for family members, or pay bills for that home to keep the lights on. Sometimes it is nice to just come for a birth and leave. Other times, it is hard not knowing where things are located, neighborhood safety at 2am, or how narrow her stairway is for EMS to get up in an emergency situation. Is this person’s dog friendly? Are you allergic to cats? Mother-in-law just stopped by when midwife car showed up at the house. Midwives that do a home birth need to be more adaptive to multiple environments and stressors than a birth center midwife. “We are in their turf and that has a different level of respect when entering the door.” I can easily be not let into a person’s home if not wanted there versus birth center is my territory and families are guest there.
Down side with home births, need to have good back up options for collaborating midwives in area. More midwives needs to be on call and available with a home birth practice versus birth center. If you are at one lady’s home for labor, can’t leave to go check on another mother postpartum or rush for another delivery. With a birth center, office visits can be squeezed in while mother is laboring in tub down the hallway. Two women can be laboring in multiple rooms at your own facility. Once the volume starts to increase, adding another midwife to team means complete birth supply bags she has with her at all times versus birth center has those supplies for whichever midwife is on call. Seen more supplies get expired and used with home births versus birth center practice this way.
Birth center is a concrete location. There are written transport policies to the hospital. Home births vary drastically where the nearest hospital is and time EMS would take to come for emergency situations. Birth centers tend to be more structured and employees have more control of what equipment, building layout, and standards offered. We know if tub can keep up with demands of hot water needs versus a home birth. In an Amish birth, having not electricity at home has its own additional challenges during birth. My water heater in the birth center never ran out of hot water or back up generators always made option of electricity present.
Some states don’t allow home births. Some states don’t have birth center regulations. Learn where you want to practice and what the direct regulations and birth settings are available. Even if there aren’t birth center regulations, it can be created knowing that facility fee will mostly be a cash basis. Creating a professional standard is harder when medical community doesn’t have a state facility regulation reference to know what is being offered at your facility. Home births are cheaper for families and easier to do from a business stand point. Some families are living in an apartment where home isn’t an option. Having a birth center opens up the door for a different community to serve. Women that choose a home birth tend to have different values and needs during pregnancy and birth than birth center clients. Women that choose birth center are looking for a balance between home and hospital care. What kind of midwife are you and where do you want to serve?
As your practice starts to grow, your time becomes a very valuable resource. With home births and no office location, driving to home visit and home births eats into that time. Birth center deliveries have women coming to your clinic and driving to you in labor. Postpartum recovery time tends to be longer with birth center versus home (four to six hours birth center versus two hours home). There is a lot more cleaning required of midwife with bith center deliveries. We have multiple women deliver in this same room. With a home birth, birth assistant or supporting partner can clean up trash and pick things up. “We don’t have to sanitize her home for the next birth there.” Having a women drive to you and potentially delivery in the car in route has different challenges than a midwife driving to her home and not making it in time. Especially in the winter, I would rather be on the slippery roads than my pregnant or anxious Dad’s driving to the birth center.
Home birth practices tend to have a smaller radius to serve than a birth center practice. Midwives can only drive so far and so fast. When multiple women can be calling for labor, there needs to be a restriction on who can be served. I had a 45min radius from office when I was solo and limited back up coverage. With the birth center, we comfortably served a 3hr radius with condition that postpartum home visits were done by a qualified nurse from practice if lived more than 60min away. Last thing we wanted was for midwife to be a day one postpartum visit and another family was driving to birth center for labor evaluation.
Birth center practice has a lot more policies and procedures for facility upkeep and standards. We need to make sure staff understands their roles, cleaning protocols, and checking equipment present regularly in a birth center. Billing was more complicated, because it included a facility and professional services. Home births were billed to insurance plans and basic supplies used were a cash rate to families. Home births tend to be more informal due to changing setting with each birth. It ultimately comes down to what kind of practice do you want to run, what are the needs in the area, and what radius will your practice serve. Think about your competition, your personal goals, and refer to your business plan for guidance on the ultimate mission of your practice.