Chapter 11 – Choosing the place of birth

The birth of a child marks the culmination of a nine-month journey. If the pregnancy has followed a physiological course, the expectant mother and the baby are in good health, the baby is full-term, well-developed, and in a cephalic position. In the absence of high-risk factors, the birth is also expected to be physiological. These are conditions present in the majority of births.

That’s why it’s important to tailor childbirth assistance based on obstetric risk, to ensure it is always appropriate. Just as it’s done during pregnancy — where care varies according to the risk of complications and the health of the woman and fetus — assistance during labor must not be excessive nor insufficient. However, risk is a dynamic parameter, which can change over time and must be continuously monitored by healthcare professionals. When birth is expected to be physiological, it can be attended solely by a midwife, with maternal and neonatal outcomes equivalent to those of a physician-led delivery, but with fewer invasive interventions (such as cesareans and episiotomies) and greater satisfaction from the mother, who — with the midwife’s support — feels more in control and gains confidence in her maternal abilities.

Giving birth with midwifery-led care is still not possible everywhere in Italy, but only in a few dozen maternity units that have established specific protocols. In these units, a specialist physician is always available but is only called upon by the midwife in case of complications that require medical intervention.

There are also midwife-led birth centers located within hospitals, but independent from the maternity ward — such as those at S. Martino Hospital in Genoa, S. Anna Hospital in Turin, Careggi Hospital in Florence, and Spedali Civili in Brescia. These are still rare in Italy.

There are out-of-hospital, privately managed birth centers, also known as maternity homes, from which the laboring woman can be quickly transferred to a hospital if needed.
Lastly, there is the option of home birth, assisted by experienced midwives, possible only if there is quick access to a nearby hospital. Except for a few rare cases where hospitals provide home birth services, home births in Italy today are exclusively handled by freelance midwives, many of whom are affiliated with the National Cultural Association of Midwives for Home Birth and Maternity Homes.
Provided the women are carefully selected, motivated, and assisted by qualified professionals, those who plan a home birth or choose a maternity home have the same health outcomes as those who give birth in hospitals (28).

So far, we’ve discussed physiological birth. In the presence of risk factors that may shift labor and delivery toward a pathological course — such as advanced maternal age, obesity, or a multiple pregnancy — the assistance of a gynecologist is necessary, and the most appropriate place for birth is a hospital maternity unit that manages at least 500 births per year, preferably 1,000 or more, to ensure staff have sufficient experience to manage uncommon complications.

If the pregnancy is pathological — for example, in cases of gestational diabetes or intrauterine growth restriction — the woman should go to a large hospital where multidisciplinary specialists are available, and be cared for by a gynecologist specialized in maternal-fetal medicine.

According to the latest data from the Ministry of Health, 89.2% of births take place in public or accredited hospitals, 10.5% in private clinics, 0.1% elsewhere. 63.9% of mothers chose a facility that handles more than 1,000 births per year, while 5.8% chose one that manages fewer than 500.

As with all other aspects of reproductive health and pregnancy, the choice of location and type of birth assistance should be made by the woman — informed and consciously, based on her needs and preferences. For this reason, during pregnancy, it’s important that the mother-to-be learn about the available options and facilities in her area, visiting them in person or calling to inquire about their protocols and health outcomes.
Questions to consider include: Is continuous one-to-one midwife support offered? Can the partner or a trusted person be present during labor and birth? What is the cesarean rate? How often are vacuum extractions or episiotomies used? Is skin-to-skin contact between mother and baby allowed immediately after birth?

Another important aspect to consider, especially in the case of fetal complications or preterm birth, is whether the hospital has a Neonatal Intensive Care Unit (NICU) — vital for the survival and quality of life of babies born extremely or very preterm, between 22 and 31 weeks of gestation. Nationwide, as of 2016, there were 173 NICUs, 104 of which are located in hospitals that handle over 1,000 births per year, the others in hospitals managing 500 to 800 births per year.

Finally, it’s important to know that midwife-led birth centers typically do not offer pharmacological pain relief during labor and birth. Women who wish to receive epidural anesthesia should ask in advance.
Although labor analgesia has been officially included in the Essential Levels of Care (LEA) and should be guaranteed to all women who request it, in practice not all Italian maternity units offer it. This is because round-the-clock anesthesiology coverage is required.
According to the 2017 National Outcomes Evaluation Program by the Ministry of Health, only 176 out of 500 facilities (public and private) provided 24/7 epidural anesthesia during labor.