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While the place of birth plays a crucial role for women's birth experiences, the interest in out- of-hospital births has increased during the Covid-19 pandemic. Related to this, various inter- national policies recommend enabling women to choose where to give birth. We aimed to analyze Swiss women's choice between birth hospitals and birth centers. Employing spatial accessibility analysis, we incorporated four data types: highly disaggregated population data, administrative data, street network data, addresses of birth hospitals and birth centers. 99.8% of Swiss women of childbearing age were included in the analysis (N = 1.896.669). We modelled car travel times from a woman's residence to the nearest birth hospital and birth center. If both birth settings were available within 30 minutes, a woman was considered to have a true choice. Only 58.2% of women had a true choice. This proportion varied con- siderably across Swiss federal states. The main barrier to a true choice was limited accessi- bility of birth centers. Median travel time to birth hospitals was 9.8 ( M = 12.5), to birth centers 23.9 minutes ( M = 28.5). Swiss women are insufficiently empowered to exercise their repro- ductive autonomy as their choice of place of birth is significantly limited by geographical con- straints. It is an ethical and medical imperative to provide women with a true choice. We provide high-resolution insights into the accessibility of birth settings and strong arguments to (re-)examine the need for further birth centers (and birth hospitals) in specific geographi- cal areas. Policy-makers are obligated to improve the accessibility of birth centers to advance women's autonomy and enhance maternal health outcomes after childbirth. The Covid-19 pandemic offers an opportunity to shift policy .
