When you’re pregnant, there are many things to consider when preparing to welcome your new family addition. These include choosing an OB-GYN who fits your personal needs, packing all of your essential items in your maternity hospital bag, choosing a name for your baby – and finding the best maternity hospital.
Deciding where to have your baby is a practical and personal matter. Asking questions and doing your own research in advance helps you make an informed decision about where you want to give birth.
Where you live is an obvious factor, but there’s so much more to consider.
Checking each hospital’s quality data can help ensure the best outcomes for you and your baby. Knowing what you want in terms of labor and delivery options helps you and your doctor shape an individual birth plan. Strong support – from breastfeeding guidance to having your partner at your side – also makes a huge difference.
Public data on maternal and fetal outcomes is increasingly available from individual maternity hospitals and statewide websites. If you can’t find it, ask your OB-GYN for more information about the hospitals in your area. These indicators help you compare facilities:
Data shows that a facility, not just individual physicians, drives C-section rates, says Dr. Holly Loudon, an OB-GYN, chair of obstetrics, gynecology and reproductive science at Mount Sinai West and Mount Sinai Morningside and an associate professor at Icahn School of Medicine at Mount Sinai in New York City.
“It’s really important to look at that C-section rate and compare it with other hospitals in the region when you’re choosing where you want to deliver,” Loudon says.
High-risk academic centers, also known as teaching hospitals, often have a higher C-section rate because they have more high-risk deliveries and multiple births.
In the past, it was almost assumed that women who delivered their first babies by C-section would deliver any subsequent babies by C-section, as well. However, vaginal birth after a cesarean section (or VBAC) is possible in many cases. Speak with your provider to verify if this could be an option for you.
Two similar terms are used for this option. “TOLAC means ‘trial of labor after cesarean’ – this is somebody who is trying to have a vaginal birth after they’ve had a C-section,” says Dr. Julia Cormano, an OB-GYN and assistant professor of obstetrics, gynecology and reproductive sciences with UC San Diego Health System. “That’s versus VBAC, which means, ‘vaginal birth after cesarean,’ which implies that they successfully had a vaginal birth after C-section.”
A TOLAC may or may not result in a VBAC.
An uncommon but possible complication of a VBAC is when the scar on the uterus from the previous C-section separates during the vaginal birth attempt, resulting in the need for immediate surgical intervention. Women interested in VBAC can receive counseling from their OBGYNs, who weigh the risks and benefits in their individual cases. Not all women are able to deliver vaginally following a C-section.
NTSV C-section rate
The C-section rate for a woman who has never given birth before with low-risk pregnancies is called the NTSV, which stands for nulliparous, term, singleton, and vertex. These terms describe a first-time mother who is only pregnant with one, full-term baby – and that baby is in a headfirst presentation for delivery.
In other words, these women do not have any risk factors requiring a C-section, and yet their baby is delivered by cesarean. For quality improvement, hospitals/states will track the rate of NTSV deliveries to ensure that unnecessary C-sections are not occurring.
Early elective delivery rate
Scheduled C-sections or inducing labor before 39 weeks of gestation, without medical necessity, is known as early elective delivery. Hospitals must report these early elective deliveries, which are tracked. A high rate of early elective deliveries is considered a red flag in terms of maternity hospital quality.
“We know that babies that are born before 39 weeks ‘just because’ don’t do as well as babies that are allowed to deliver when their moms go into labor naturally,” says Dr. Jennifer Frink, an OB-GYN and medical director of Ascension Michigan Women’s Health Service Line, who practices out of Ascension Borgess Hospital in Kalamazoo, Michigan. This is due to the mother and baby not being naturally ready to deliver, and inducing labor may not be tolerated well. “We also know that people who have inductions before 39 weeks ‘just because’ tend to have a higher risk of ending up with a C-section. Moms and babies don’t do as well.”
Early deliveries aren’t always avoidable. Pregnancy complications like extremely high maternal blood pressure,
decreased fetal heart rate and premature rupture of membranes (water breaking) are possible reasons for early delivery.
“There are plenty of times when there is something going on with the mom or baby, and the safest thing in that setting is to have a delivery. But there are pretty strict criteria for what those things are. A hospital that stays away from those early elective deliveries values the importance and the safety of physiologic labor,” says Frink.
An episiotomy is a surgical cut made to the vagina during childbirth to help prevent vaginal tearing. Routine use of episiotomy is not recommended, except when indicated in certain clinical situations.
“Another metric that I think a lot of patients want to know would be the episiotomy rate,” Loudon says. “That’s important, because episiotomies have become something that used to be done routinely and now are very rarely needed.”
Maternity Care Team
“People are usually going to make that decision based on their first finding a physician or midwife they feel that they connect with,” Frink says.
Deciding by whom you’ll be cared for “is as important a decision as where you’re getting your care,” she says. “Oftentimes, that provider will have different hospitals where they practice as options.
Shared decision-making is an important healthcare approach in general, Frink says.
“In particular, in maternity care, you want your providers – physician or midwife – and the hospital to embrace this philosophy,” she says. “Your concerns, your fears, your wants and hopes about labor experience goes – you want all those components to be heard and valued by the care team that’s working with you. By the same token, you want to have a team of professionals that, once they listen to those things, are going to give you some options that are medically appropriate for you.”
Items to address about your maternity hospital and care team include:
- “Does the facility have maternal-fetal medicine specialists or perinatologists (doctors who are specially trained in high-risk pregnancies)?” For women with medical conditions like uncontrolled gestational diabetes, problems with the placenta or high blood pressure that put them in a high-risk category, this is pertinent information.
- “Does the hospital offer some other forms of labor and delivery experiences besides traditional physician-led care?” This is worth asking, Frink says. Examples of this include using midwives or the option for a water birth, or delivering in a bathtub.
- “Is there the option for laboring with a midwife or doula?” When hospitals have these support components, it actually has been shown to reduce C-section rates, Cormano notes.
- “Do they have group prenatal care?” Programs like CenteringPregnancy allow expectant mothers at similar pregnancy stages to receive prenatal education and social support in a group setting among their peers, along with one-on-one physical checkups. Emerging research, like a study in the January 2019 Journal of Women’s Health, suggests that group prenatal care is associated with a lower risk of having a preterm birth or having a low birth-weight baby.
Labor and delivery questions to ask your maternity care team include:
- Can I get a maternity ward tour? Before you choose a birthing setting, it’s helpful to get a feel for it first. Many facilities offer both virtual and in-person tours.
- What pain-control options do you offer, including and beyond epidurals? “It’s not just, is there an OB anesthesiologist immediately available – because that’s where you get your epidural quickly,” Loudon says. “But are there also other things, like nitrous oxide? So, do you have alternatives for pain control?”
- What labor position(s) can I deliver in? Can I walk around? “A lot of patients want to be able to ambulate (walk) during labor, or use alternative positions during labor,” Loudon notes. “More and more, hospitals are using wireless fetal monitoring. That’s a way where you can ambulate during labor or at least be more mobile,” by having a fetal monitor that is not connected to a machine.
- Do you have birthing balls? Birthing tubs? Leaning or sitting on the ball can enable alternative labor positions. Birthing tubs can make movement more comfortable during labor and may enable water births for low-risk, single, full-term pregnancies.
- Do you have private birthing rooms/family suites? Although not necessary, having extra privacy and space is nice.
- Can I wear my own maternity hospital gown? Many hospitals allow patients to wear their own maternity gown; however, you will likely be required to wear the hospital gown if you are having a C-section.
- How many support people are allowed to be with me? If you’re having a doula at your birth, make sure they don’t “count” as a support person at your bedside in case you are limited to only one or two support people.
- Will I have induced labor? What goes into that decision? With induced labor, various medications or other methods are used to stimulate contractions instead of waiting for labor to begin on its own. Certain pregnancy complications or medical conditions of the mother may make labor induction necessary or safer. Elective induction for convenience, rather than medical necessity, can be an option, but early elective induction is generally not recommended.
- Does your facility offer VBAC/TOLAC? If you’re interested in VBAC, ask if the facility allows it. “Working at UCSD, we actually get a lot of referrals from other places that might not offer it,” Cormano says. Because trying to have a VBAC comes with the risk of the C-section scar line opening, sometimes known as uterine rupture, a hospital must be equipped to quickly respond. “The risk is less than 1% for an average patient undergoing a trial of labor,” she says. “But it can be a very dangerous outcome. It requires an emergency C-section. It requires being in a setting where people can respond within seconds.”
- Do you offer gentle C-sections? Women who need cesareans may have the option to feel more connected during childbirth. “We’re doing more with what some people are calling ‘gentle cesareans’ or ‘family-centered cesareans,’ where we use clear drapes so you can see your baby right after they’re born through a clear drape,” Loudon says. “And then have immediate skin-to-skin contact and even breast-feeding right away. It can make the cesarean birth more like a vaginal birth experience and less like an operation.”
- Is delayed cord clamping available? With this option, doctors wait for a short period after delivery to clamp and cut the umbilical cord. That allows extra time for nutrient-rich blood in the placenta and cord to flow to the baby.
NICU and Emergency Capabilities
If it’s likely that your baby will spend some time in neonatal intensive care after delivery, or your pregnancy is considered high risk, you might ask:
- Is there an anesthesiologist in the hospital 24/7?
- Is there a pediatrician in the hospital 24/7?
- What is the blood bank’s availability – are transfusions possible around the clock?
- Does your hospital have a neonatal intensive care unit?
- What level is the NICU? Hospital NICU levels vary – level I, II, III, or IV. If your baby requires more advanced NICU treatments, like needing to be on a ventilator and the hospital only has a level I or II NICU, your baby may need to be transferred to a higher acuity hospital.
- Does the NICU have private rooms? “Increasingly, in new hospitals, rather than the NICU being one giant space, there are individual rooms for these babies so that parents can room in, even once (parents) are discharged from the hospital,” Cormano says. However, this option is still fairly uncommon.
- How often can I see my baby in the NICU? Some hospitals offer tech options for parents like real-time, 24/7 video access to their newborns in intensive care.
- If my baby unexpectedly is in need of NICU care, and the hospital does not have a NICU, where does the baby get transferred to? How does the baby get transferred?
Breastfeeding is shown to be optimal for babies, but it’s definitely a learning experience for new mothers. Ask about international board-certified lactation consultants on staff.
You also can look for Baby-Friendly facilities. Baby-Friendly hospitals and birthing centers are designated as such for their high standards in supporting and enabling breastfeeding as soon as possible after birth. Rooming for healthy babies and mothers, and maternity staff that’s fully trained in breastfeeding care and problem-solving for feeding difficulties make continued breastfeeding more likely when families go home. Unlike some hospitals, Baby-Friendly facilities don’t distribute baby formula samples from manufacturers, which can discourage consistent breastfeeding.
Expectant parents should have all the resources and support that they need for a healthy prenatal, delivery and postpartum course.
“One of the most important things for a lot of the patients that we serve is: Do they make it easy for me?” Frink says. “Do they find a way to get me the care and that’s convenient for me? Do they acknowledge and respect the history, and sometimes the baggage, I bring in?”
Asking questions like these will help you understand if a facility can meet your individual requirements:
- Does the hospital offer additional resources, like maternal health navigators and community health workers who can help families with any additional community resources that may be available to them and will follow families through their hospital stay?
- Do you have a program that gives car seats or cribs to people in need?
- Do you have transportation options like Lyft or Uber rides, or bus or subway tokens, for my appointments?
- Can you connect me with food programs if needed?
You can look through the U.S. News Maternity Care ratings to find high-performing maternity care near you. These ratings highlight key factors of care for uncomplicated pregnancies. If yours is a complicated or high-risk pregnancy requiring more intensive care, see the Best Hospitals for Neonatology rankings for the care of a high-risk newborn.