Thesis advisor: Joyce K. Edmonds / Background: Midwifery-led birth centers (BC) provide positive perinatal outcomes for women and birthing people at low perinatal risk that exceed national outcomes in the United States. Yet, less than 1% of all births occur in BCs. The Coxon conceptual model of birth setting decision-making provides the most comprehensive research framework about how people decide where to give birth. Research is essential for the promotion of an informed decision-making approach regarding birth setting options and the facilitation of access to high value BC care. This dissertation aims to study birth setting decision-making, specifically decision-making about BCs, in the United States. Methods: Three methods were used to address the overall dissertation aim. An integrative review was conducted to evaluate factors influencing birth setting decision-making in the United States, examining research studies from 2011-2022. A secondary data analysis of the population- based Listening to Mothers in California survey identified factors associated with interest in BC care in a future pregnancy among respondents who experienced hospital birth in California. Finally, a hermeneutic phenomenological study was conducted to explore the decision-making experiences of participants with Medicaid health insurance and who chose to give birth in a freestanding BC in Massachusetts. Results: Four themes were generated from 23 research studies included in the integrative review. The themes represented factors influencing birth setting decision-making in the United States: Birth Setting Safety Versus Risk, Influence of Media, Family, and Friends on Birth Setting Awareness, Presence or Absence of Choice and Control, and Access To Options. In the Listening to Mothers in California survey, respondents (N = 1447) were more likely to express interest in future BC care if they had experienced pressure from health professionals to have an obstetric intervention, believed childbirth is a process that should not be interfered with unless medically necessary, sought information about hospital cesarean rates, had a doula in labor, and experienced mistreatment. Finally, qualitative data from participant interviews (N = 12) generated five analytic themes that described the BC decision-making process: Desire to Step Away From “the System,” Access to Birth Center Care, Influence of Partners, Family, Friends, the Media, and Birth Workers, the Built Environment of the BC, and the Temporal Dynamics of Decision- Making. Conclusions: The findings from this dissertation extend our knowledge about BCs as a unique and necessary decision process and choice for perinatal care in the United States. Illuminating why and how people decide to seek care at BCs is vital to expanding access and supporting informed, values-based decision-making about birth settings. By making specifications and refinements to the Coxon conceptual model about birth-setting decision-making, a novel pathway is now available for further research and discovery about how people decide where to give birth in the United States and how to best support their choice. / Thesis (PhD) — Boston College, 2023. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.