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Giving birth at home was once the norm, but after deliveries in the United States started taking place in hospitals at the beginning of the 20th century, the pendulum shifted toward institutional deliveries.

Currently, about 1 percent of births—or around 35,000—is at home, but as the COVID-19 pandemic continues to overwhelm the country’s health-care systems, expectant parents are looking for alternative birth plans outside of hospitals—and they’re turning to midwives.

The increased demand for midwives during the pandemic

Midwives play a major role in providing out-of-hospital care for pregnant people. Amid the COVID-19 pandemic, they’ve been seeing an increase in inquiries for births at home and at birth centers—both of which give low-risk, healthy pregnant people and their support people the option to avoid the hospital.

Vanessa Caldari, founder and director of Mujeres Ayudando Madres (MAM), a nonprofit reproductive health center that provides midwifery and other services for pregnant people in Puerto Rico, is a midwife with 25 years of experience. Caldari sees the demand for out-of-hospital birth growing each year, which tracks with national trends: The rate of home births has increased from 0.87 percent in 2004 to 1.50 percent in 2014. “I’ve spoken with other colleagues through this pandemic, and most are seeing an increase in patients. That is happening everywhere,” she said.

All over the country, midwives are getting flooded with calls. Caldari stressed that midwives have always been there for their communities, and the growing need for them now reflects how important their work is.

Kim Pekin, founder and director of Premier Birth Center in Virginia, has also seen an increase in the demand for out-of-hospital providers. Pekin’s practice is a freestanding birth center that also offers the option for home birth, and their requests for at-home deliveries and birth center deliveries have more than doubled since the COVID-19 outbreak.

“It has doubled across the board,” Pekin said. “I get a lot of home birth inquiries, especially those who are late to care. I have to limit that option somewhat, because staffing could be a concern with an increase of deliveries. We also want to be able to honor the commitments of those who have made this choice earlier in their pregnancy. There are a lot of midwives to help in the community, so these late transfers are finding safe places for care.”

Questions and concerns about out-of-hospital birthing

When looking for a midwife, birth center, or other out-of-hospital practice, many people have similar questions.

“Number one question for us is cost,” Caldari said. “Because home births aren’t covered by insurance. Out-of-hospital birth should be considered a community health service. It should be covered by insurance as a human right to give birth with whomever you want however you want.”

Though it varies by state, the average out-of-pocket cost of giving birth in the United States is over $4,500 for people with health insurance. But while the overall cost of giving birth at home is often lower than hospital birth, only a few states require that insurance plans cover home birth.

Questions about potential complications also arise when midwives conduct consultations with potential clients. “Anyone can really birth, but you need trained skilled attendants to recognize [when transfer to a hospital is needed] or how to manage an emergency,” Caldari said.

Midwives are trained to monitor risk, stabilize patients in emergency situations, and transfer them to a hospital if needed. For example, a patient with high blood pressure or other risk criteria may need to go to the hospital either before or during labor; part of the job of the midwife is to pay attention to these potential complications.

At times, pregnant people want to transfer their care from the hospital to a birth center or midwifery practice. “Obtaining records is a challenge right now. A lot of time is wasted trying to chase records,” Pekin said. Patients considering a provider change mid-pregnancy should try to keep copies of their medical records.

Late transfers are evaluated at Premier Birth Center on a case-by-case basis. “We had to put late care rules in place,” Pekin said. “We need to make sure mothers meet the risk criteria and are adequately prepared for natural birth.”

Pregnant people who have support, have taken childbirth classes, and have the mindset for natural childbirth make the best candidates for home birthing. Pekin and Caldari agreed that patients often do a good job “self selecting” and only inquire about out-of-hospital birth if they are committed to the model of care.

What you need to know before deciding on a home birth

Giving birth at home with the help and guidance of a midwife can be a nurturing and transformational experience, but it isn’t for everybody.

“Don’t look for this alternative because you are scared of the hospital,” Caldari said. “What you resist shall persist. When you are feeling secure, there is a risk reduction. Don’t choose out-of-hospital birth because you’re scared. [Hospitals] are trying to do their best to make people feel safe. Really choose home birth or choose a midwife-assisted birth because you feel comfortable with the model of care.”

If a person is having a normal pregnancy and was already planning on an unmedicated birth, Pekin suggests they try a birth center or an at-home birth. “Midwives are the experts in ‘natural’ physiologic birth,” she said. “We have the tools to give that one-on-one support. The hospital may not be able to do that if they need to eliminate support [people] at your birth right now.” Many hospitals have had to restrict the number of people attending deliveries to lessen potential exposure to COVID-19.

Consider which birth plan gives you the best chance to have the birthing experience that you envision for yourself.

Where can I find a midwife in my area?

Expecting parents may not know anyone with personal experience with out-of-hospital delivery. There are a few resources that can help you locate a midwife in your area: The American College of Nurse Midwives, a professional organization of midwives who have completed graduate-level training in both nursing and midwifery, has a “find a midwife” feature on their website that can match you with a provider in your area. Midwives Alliance of North America, which is open to both certified nurse midwives and certified professional midwives, is another valuable resource to locate a home birth midwife.

While many pregnant people may choose to move their birth plans from a hospital to their homes during the pandemic, freestanding birthing centers offer a middle ground. These facilities have the ambiance of a home-like environment but must follow state health regulations and licensing requirements. Freestanding birthing centers are an alternative for people who want to avoid the hospital but may not be able to deliver at home.

Susan Stapleton, board chair of the Commission for the Accreditation of Birth Centers (CABC), explained that much like home birth midwifery practices, birth centers have been preparing for COVID-19 care. “As childbearing families are exploring community birth in freestanding birth centers, CABC-accredited birth centers are showing a strong commitment to staying up-to-date with COVID-19 guidelines and evidence,” Stapleton said. “It has been clear to me that the midwives in these birth centers are doing everything possible to keep both their client and their staff safe, and to provide the best possible experience for childbearing families.”

The World Health Organization declared 2020 the International Year of the Nurse and Midwife. It is a fitting distinction that these providers are being honored as catalysts for better health care in this moment, Caldari said—a prediction that may continue well beyond COVID-19.