Version July 2025
INTRODUCTION —
Childbirth is usually a normal physiologic process, not a medical disorder. It is a vitally important experience beyond the physical or clinical process and is impacted by emotional, spiritual, and societal forces [1]. Fear of childbirth can negatively impact outcomes, including higher rates of cesarean birth and prolonged labors [2,3]; however, childbirth education can decrease fear, increase a sense of control, and minimize the use of medical intervention [4]. This topic will help providers discuss childbirth preparations with patients using a framework that addresses their physical, emotional, and cultural needs. Components of the framework include encouraging the patient to think through their birth preferences and values, build their birth team, and access education and resources on pregnancy, childbirth, and parenting.
Providers should recognize that some patients have had very poor childbirth experiences and pregnancy outcomes that may cause them to be fearful and lack trust in the system. Structural racism is a major contributing factor [5]. Another is the high rate of disrespect and mistreatment, which include loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help [6,7]. Minority patients; patients who give birth in a hospital; and patients with social, economic, or health challenges are most likely to encounter these experiences, which can manifest as depression, anxiety, or classic posttraumatic stress disorder (PTSD) symptoms and have a major impact on breastfeeding, bonding, and future pregnancy plans [8-11].
GENERAL PRINCIPLES —
Conversations about childbirth preparation can begin in the prepregnancy period and continue until childbirth. Specific birth options will vary based on individual obstetrical/medical situations, insurance coverage, and geographic location (eg, birthing location facility). Providers should educate patients about what options are available to them and how to expand their options, when possible.
EXPLORING VALUES AND PREFERENCES —
Patients enter and move through pregnancy with different medical circumstances, social needs, personal values and preferences, level of understanding, and goals. For some, proximity to a neonatal intensive care unit (NICU) may be important; others may desire an unmedicated or "natural" birth; and some may have both as their goal. Providers can help patients think through these issues as they discuss the birth location, birthing care team, mode of birth, pain management, and other aspects of childbirth. Using a checklist to document patients' preferences and communicate with other providers can be helpful.
Completing a worksheet can help patients think about their priorities and can be a component of this process. One such tool is available online from Choices in Childbirth. We suggest introducing this worksheet early in the pregnancy so there will be time to coordinate care if patient values or preferences emerge that would necessitate a transfer of care (eg, to a birth center or securing additional services like a doula).
CHOOSING A BIRTH SETTING —
Births typically take place in one of three locations:
●Hospital
●Birth center (freestanding or hospital owned)
●Home
While most births in the United States take place in hospitals, the rate of community birth (ie, freestanding birth centers or home) is increasing, particularly in families of color [12]. Community birth settings have significantly lower rates of cesarean birth and intervention (eg, episiotomy) and higher rates of breastfeeding and patient satisfaction [7,13].
Patients with low-risk pregnancies who desire a low-intervention birth can consider community birth. Hospital-based providers can help their patients make this decision by educating themselves about whether there are birth center or home birth options in their area, the licensure status of homebirth providers in their state, and the insurance coverage of community birth. Detailed information on community birth is available separately. (See "Birth centers" and "Planned home birth".)
For patients who want or are recommended to give birth in hospitals, providers can discuss whether one hospital is preferable to another based on medical reasons (eg, maternal and/or neonatal level of care) or on the patients' birth preferences (eg, a desire for water birth/hydrotherapy requires that the facility has appropriate tubs).
Patient information on different types of birth settings is available from the Childbirth Connection and others.
CHOOSING A CARE PROVIDER —
The type of care provider options may be affected by medical conditions, geographic region, and/or insurance coverage. Ideally, most pregnant people should have access to a physician (obstetrician, maternal-fetal medicine specialist, or family medicine physician who practices obstetrics) or a midwife (hospital, birth center, or home based). (See "Prenatal care: Initial assessment", section on 'Care provider'.)
Midwifery care has been associated with the same if not better perinatal outcomes across every measure, improved patient satisfaction, and lower health care spending [14,15]. However, midwifery care is underutilized in the United States, comprising only 12 percent of births [16], in contrast to many other economically advantaged nations where midwifery care is often the standard maternity care (eg, 45 percent of births in England [17]). Providers can help patients become familiar with the midwifery option and those who are good candidates for midwifery care can be apprised of the safety and benefits of choosing this model.
Providers should be prepared to talk about culturally responsive and racially concordant care. Racism, not race, is the root of obstetrical health disparities and racial concordance between the patient and provider has been associated with better outcomes and better experiences [18,19]. All providers should be prepared to talk about their own approach to culturally responsive care, which may include implicit bias training, engagement with doulas, approach to informed consent, quality initiatives around cesarean births, or other health equity work. If a patient seeks care with a provider of their racial, ethnic, and/or linguistic background, transfer to an appropriate colleague or practice can be facilitated.
Information on choosing an obstetric care provider can be found online from Choices in Childbirth, Birth Without Bias, and others.
UNDERSTANDING THE CHILDBIRTH CARE TEAM —
Patients need to know who may be involved in their care during birth, including nurses, anesthesiologists, pediatricians, or other specialists. This is particularly important at teaching institutions, where patients should ask questions about whether residents or students are part of their care and consent to care by these individuals [20].
BUILDING A BIRTH SUPPORT TEAM —
Continuous labor support reduces the length of labor, need for pharmacologic pain management, forceps- and vacuum-assisted vaginal birth, and cesarean birth, and improves the birth experience [21].
Doulas are trained professionals who provide emotional, physical, and informational support to clients during pregnancy, birth, postpartum, and beyond. They are a central strategy for improving birth outcomes in the United States and reducing racial/ethnic health disparities. Many states and insurers cover doula care. (See "Continuous labor support by a doula".)
Providers can encourage patients to seek support from certified doulas in addition to support from chosen family and friends. They can also educate their patients' lay support people about what to expect in the labor process. Childbirth education classes and online resources can be helpful. One classic resource is the book "The Birth Partner" by Penny Simkin.
COMPREHENSIVE PAIN MANAGEMENT OPTIONS —
Pain in childbirth may be the leading concern or source of anxiety for a pregnant person. It is important to have a discussion around pain management that recognizes the value of and indications for all available pain management techniques. If the planned birth setting does not offer some common pain management techniques or the technique(s) the patient is planning, the patient should be aware of this so they can make informed decisions about their birth location or different choices.
Pain management techniques are reviewed in detail separately. (see "Pharmacologic management of pain during labor and delivery" and "Nonpharmacologic approaches to management of labor pain"):
ACCESSING FORMAL CHILDBIRTH EDUCATION —
Formal childbirth education classes can come in different formats and with different focus; for example, courses on vaginal birth after cesarean and groups for LGBTQIA+ parents. Ongoing equity issues with childbirth education can include cost, language, and cultural appropriateness. It is therefore important that providers and patients know what local childbirth education options are available. There is no evidence that one type of childbirth education is superior to another, so it is important that patients and families find classes that are inclusive and meet their learning and cultural needs.
Online resources offering virtual childbirth education classes and options are also available. These include:
●Mindfulness-Based Childbirth and Parenting
Books:
●Giving Birth with Confidence [22]
●Ina May's Guide to Childbirth [23]
●Our Bodies, Ourselves: Pregnancy and Birth Book [24]
●The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Labor Companions [25]
●Labor Progress Handbook [26]
●Mindful Birthing: Training the Mind, Body and Heart for Childbirth and Beyond [27]
●Gentle Birth, Gentle Mothering [28]
●Preparation for a Hospital Birth [29]
Three traditional birth education options are:
●Lamaze – Lamaze preparation is a philosophy that affirms that birth is normal and natural, individuals have an inherent ability to give birth, birth is important in the individuals' lives, and the health care provider and place of birth affect the birth experience. Breathing is only one of many comfort strategies taught in contemporary Lamaze classes. Individuals are now encouraged to work with their labors, find comfort in response to their contractions, and push in response to the urge to push, rather than letting the labor control their bodies.
●Hypnobirthing – Hypnobirthing is based on the belief that when an individual is prepared physically, mentally, and spiritually, they can experience the joy of birth in an easier, more relaxed, and potentially pain-free manner. Self-hypnosis and deep relaxation are important components of this method.
●Mindful Birthing – Mindful Birthing, developed by Nancy Bardacke, is an adaptation of mindfulness-based stress reduction and incorporates meditation, yoga, and mindfulness into childbirth education.
CREATING A BIRTH PLAN —
For some patients, it is helpful to create a written birth plan; others may engage in a conversation about "birth goals." Patients with birth plans report higher satisfaction than those without [30]. They also report that the process of creating a birth plan helped educate them on their options during birth. Despite documented maternal and neonatal benefits to birth plans, some providers feel that they can interfere with clinical practice or lead to adverse outcomes.
The benefits of a birth plan may include:
●An opportunity to express patient values and preferences to the care team before labor and throughout the birth process, which helps to build trust, self-advocacy, and trauma-informed care.
●An opportunity for open communication during pregnancy about what is and is not possible in the chosen birth setting or in a particular labor condition.
There are many sample birth plans available online in English and Spanish or patients may create their own. Topics can include:
●Names of support people
●Communication style and preferences
●Pain management goals
●Preferences for labor, birth, and immediate postpartum
●Disclosure of previous health care or life events that may impact the individual's mental or emotional state during labor
ADDRESSING A BIRTH PLAN THAT MAY NOT BE REALISTIC —
An early discussion is needed when what the patient wishes in their birth plan and what the provider feels is realistic or recommended are discordant. Two issues should be considered: Is what the patient requests not possible because it is medically not recommended or unsafe or because of the specific policies of the planned birthing facility? It is important that providers do not conflate these two issues in communicating with the patient, especially as many American hospitals have been slow to adopt policies that support physiologic birth (ie, intermittent auscultation, water birth, expectant management of prelabor rupture of membranes, etc).
If the patient has a preference that goes against a clinical recommendation, providers can begin by asking what led to this preference: A previous good or bad experience, something they read that concerned them, something they heard from a friend or family member? The provider can then review what the clinical recommendation is and why, and ultimately engage in shared decision-making about the final plan.
If the issue is that the patient's preference is not possible in the planned birthing facility, ask the patient how important it is to them and if they want to transfer care from their provider if necessary to pursue birthing options in their community that could accommodate their preference. It is also a great opportunity for providers to advocate for increasing labor, pain management, and birthing options within their own facility.
ADDRESSING DISAPPOINTMENT WHEN DEVIATION FROM THE BIRTH PLAN BECOMES NECESSARY —
Even with preparations and planning, the nature of birth is unpredictable and complications can arise that challenge the birthing person, their support team, and their clinical team. As always, open communication and shared decision-making are essential. If the clinical team is aware of a patient's goals/birth plan, they can work to maintain elements of that plan that are still feasible despite a change in the patient's medical status (eg, skin-to-skin care in the operating room in the event of a cesarean birth, transfer from a homebirth midwife to a hospital-based midwife).
It is important for providers to acknowledge the disappointment and grief of "losing" the vision that patients, their partners, and their families may have had for the birth. Birth is a physiological, emotional, and spiritual process that has to be tended to even in the context of a "healthy mom, healthy baby." Providers can address disappointment at the time of labor and birth and also reassure patients that they can continue to process their feelings in the following days, weeks, and months. This processing can involve their obstetrical provider, their birth team, or perinatal mental health specialists. For patients who may have experienced birth trauma, providers can refer to local and national resources to help process their birth experience:
●March of Dimes resource “The toll of birth trauma on your health”
●Postpartum Support International
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General prenatal care".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Labor and childbirth (The Basics)" and "Patient education: How to tell when labor starts (The Basics)" and "Patient education: Managing pain during labor and childbirth (The Basics)")
PATIENT PERSPECTIVE TOPIC —
Patient perspectives are provided for selected disorders to help clinicians better understand the patient experience and patient concerns. These narratives may offer insights into patient values and preferences not included in other UpToDate topics. (See "Patient perspective: Managing pain during labor and delivery".)
SUMMARY AND RECOMMENDATIONS
●Value of preparing for childbirth – Preparation for childbirth that addresses the individual's physical, emotional, and cultural needs can reduce fear, increase the sense of control, and minimize the use of medical intervention. Specific birth options will vary based on individual obstetrical/medical situations, insurance coverage, and geographic location. Providers should ensure that their patients know what options are available to them and how to expand their options, when possible. (See 'Introduction' above and 'General principles' above.)
●Components of childbirth preparation
•Provider responsibilities:
-Understanding the patient's values and preferences (see 'Exploring values and preferences' above)
-Helping the patient understand their options when choosing a care provider, birth setting, and support team (see 'Choosing a care provider' above and 'Choosing a birth setting' above and 'Building a birth support team' above)
-Helping the patient understand the personnel and procedures in the birth setting, including options for managing pain (see 'Understanding the childbirth care team' above and 'Comprehensive pain management options' above)
•Patient responsibilities:
-Accessing formal childbirth education (see 'Accessing formal childbirth education' above)
-Creating a birth plan and discussing it with their provider (see 'Creating a birth plan' above)
ACKNOWLEDGMENT —
The UpToDate editorial staff acknowledges Judith A Lothian, RN, PhD, LCCE, FAAN, who contributed to earlier versions of this topic review.
