OBJECTIVES: To evaluate effectiveness, costs and customers' satisfaction of delivery care in the Obstetrics Division of the Hospital of Novara (Italy). METHODS: We evaluate the impact of a new procedure to manage the "birth path" technology ("...women should be encouraged to deliver in the position they find more confortable"). We compared the traditional deliver-care path (consisting in making women deliver in lithotomic position) with a new one re-engineered according to the recommendations of the Cochrane Library, to let women choose the deliver position. We evaluated three aspects of healthcare quality: maternal and foetal clinical outcomes (with logistic regression models), the costs of the new healthcare process (with Activity Based Costing) and customer satisfaction (with a satisfaction survey). RESULTS: The study involved 430 women, without documented risk factors for complicated pregnancy or delivery. Outcome analysis: the probability that the delivery has a perineal wound as outcome almost doubles if the patient does not choose the labour position (OR=2.396, CI95%=1.523-3.771); besides, a higher risk to develop a large wound is associated to a foetal weight >3000 g at expulsion (OR=1.859, CI95%=1.135-3.047), together with the first vaginal delivery (OR=3.295, CI95%=1.982-5.478) and when the woman is more than 30 years old (OR=1.944, CI95%=1.257-3.007 (p<0.01). Economic evaluation: the costs for patient for free position deliveries were slightly higher (range US$679.00 to US$1893.00) than those for the traditional process (ranged US$623.00-US$1737.00). Customer satisfaction: overall satisfaction proved to be independent from the presence of any complications, the humanisation level of the structure, or the type of support, but it was influenced by the possibility to choose the labour position and by the woman's expectations (p<0.01). CONCLUSIONS: Our findings led to the decision to change the traditional process with the new one, the latter having similar costs and better outcomes. Nevertheless, this evaluation process was complex.