Am Fam Physician. 2021 Jun 1;103(11):672-679.
Patient information: See related handout on having a baby outside of a hospital, written by the authors of this article.
Author disclosure: No relevant financial affiliations.
Since the 1970s, most births in the United States have been planned to occur in a hospital. However, a small percentage of Americans choose to give birth outside of a hospital. The number of out-of-hospital births has increased, with one in every 61 U.S. births (1.64%) occurring out of the hospital in 2018. Out-of-hospital (or community) birth can be planned or unplanned. Of those that are planned, most occur at home and are assisted by midwives. Patients who choose a planned community birth do so for multiple reasons. International observational studies that demonstrate comparable outcomes between planned out-of-hospital and planned hospital birth may not be generalizable to the United States. Most U.S. studies have found statistically significant increases in perinatal mortality and neonatal morbidity for home birth compared with hospital birth. Conversely, planned community birth is associated with decreased odds of obstetric interventions, including cesarean delivery. Perinatal outcomes for community birth may be improved with appropriate selection of low-risk, vertex, singleton, term pregnancies in patients who have not had a previous cesarean delivery. A qualified, licensed maternal and newborn health professional who is integrated into a maternity health care system should attend all planned community births. Family physicians are uniquely poised to provide counseling to patients and their families about the risks and benefits associated with community birth, and they may be the first physicians to evaluate and treat newborns delivered outside of a hospital.
Although uncommon, planned out-of-hospital births are becoming increasingly popular in the United States. From 2004 to 2017, the number of out-of-hospital births in the United States increased by 75%.1 In 2018, out-of-hospital births represented 1.64% of all births, which translates to one in every 61 newborns being delivered in a location other than a hospital.2 Although small in magnitude, this is a reversal of the trend that occurred during the 20th century in which the frequency of hospital births rose from 37% in 1935 to more than 99% by 1970, where it remained essentially unchanged until 2004.3
SORT: KEY RECOMMENDATIONS FOR PRACTICE
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Good-quality cohort studies with inconsistent findings
Good-quality cohort studies with inconsistent findings
Patients planning community birth should ensure that their maternity and neonatal health professional is licensed and meets International Confederation of Midwives Global Standards for Midwifery Education, is practicing within an integrated and regulated health system, and has access to safe and timely transport to a nearby hospital.9,13,15,16,54
Expert opinion and consensus guidelines in the absence of studies
Referencesshow all references
1. MacDorman MF, Declercq E. Trends and state variations in out-of-hospital births in the United States, 2004–2017. Birth. 2019;46(2):279–288....
2. Martin JA, Hamilton BE, Osterman MJK, et al. Births: final data for 2018. Natl Vital Stat Rep. 2019;68(13):1–47. Accessed April 10, 2020. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_13-508.pdf
3. Malloy MH. Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004. J Perinatol. 2010;30(9):622–627.
4. Cheyney M, Bovbjerg M, Everson C, et al. Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health. 2014;59(1):17–27.
5. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. ACOG committee opinion no. 766 summary: approaches to limit intervention during labor and birth. Obstet Gynecol. 2019;133(2):406–408.
6. Grobman WA, Rice MM, Reddy UM, et al.; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379(6):513–523.
7. National Institutes of Health. High-risk pregnancy. Updated November 6, 2018. Accessed July 12, 2020. https://www.nichd.nih.gov/health/topics/high-risk
8. Armstrong J, McDermott P, Saade GR, et al. Coding update of the SMFM definition of low risk for cesarean delivery from ICD-9-CM to ICD-10-CM. Am J Obstet Gynecol. 2017;217(1):B2–B12.e56.
9. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Committee opinion no. 697: planned home birth. Obstet Gynecol. 2017;129(4):e117–e122.
10. Grünebaum A, McCullough LB, Sapra KJ, et al. Planned home births: the need for additional contraindications. Am J Obstet Gynecol. 2017;216(4):401.e1–401.e8.
11. Bachilova S, Czuzoj-Shulman N, Abenhaim HA. Effect of maternal and pregnancy risk factors on early neonatal death in planned home births delivering at home. J Obstet Gynaecol Can. 2018;40(5):540–546.
12. Stapleton SR, Osborne C, Illuzzi J. Outcomes of care in birth centers: demonstration of a durable model. J Midwifery Womens Health. 2013;58(1):3–14.
13. American Academy of Pediatrics Committee on Fetus and Newborn. Planned home birth. Pediatrics. 2013;131(5):1016–1020.
14. American College of Nurse-Midwives. Midwifery provision of home birth services: American College of Nurse-Midwives [published correction appears in J Midwifery Womens Health. 2016;61(4):538]. J Midwifery Womens Health. 2016;61(1):127–133.
15. American College of Nurse-Midwives. Position statement. Planned home birth. Accessed April 10, 2020. https://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000251/Planned-Home-Birth-Dec-2016.pdf
16. Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database Syst Rev. 2012;(9):CD000352.
17. Association of Women's Health, Obstetric and Neonatal Nurses. Midwifery. J Obstet Gynecol Neonatal Nurs. 2016;45(3):454–457.
18. Midwives Alliance of North America. Homebirth position paper. Accessed April 10, 2020. https://mana.org/sites/default/files/pdfs/MANAHomebirthPositionPaper_0.pdf
19. Boucher D, Bennett C, McFarlin B, et al. Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health. 2009;54(2):119–126.
20. Declercq E, MacDorman MF, Menacker F, et al. Characteristics of planned and unplanned home births in 19 states. Obstet Gynecol. 2010;116(1):93–99.
21. Descieux K, Kavasseri K, Scott K, et al. Why women choose home birth: a narrative review. MAHEC Online J Research. 2017;3(2):1–10.
22. Adams ED. Birth environments: a woman's choice in the 21st century. J Perinat Neonatal Nurs. 2016;30(3):224–227.
23. Declercq ER, Sakala C, Corry MP, et al. Listening to mothers II: report of the second national U.S. survey of women's childbearing experiences. J Perinat Educ. 2007;16(4):9–14.
24. Neuhaus W, Piroth C, Kiencke P, et al. A psychosocial analysis of women planning birth outside hospital. J Obstet Gynaecol. 2002;22(2):143–149.
25. Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ. 2005;330(7505):1416.
26. Nethery E, Gordon W, Bovbjerg ML, et al. Rural community birth: maternal and neonatal outcomes for planned community births among rural women in the United States, 2004–2009. Birth. 2018;45(2):120–129.
27. Jackson DJ, Lang JM, Swartz WH, et al. Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care. Am J Public Health. 2003;93(6):999–1006.
28. Sandall J, Soltani H, Gates S, et al. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev. 2016;(4):CD004667.
29. Snowden JM, Tilden EL, Snyder J, et al. Planned out-of-hospital birth and birth outcomes. N Engl J Med. 2015;373(27):2642–2653.
30. Grünebaum A, McCullough LB, Sapra KJ, et al. Early and total neonatal mortality in relation to birth setting in the United States, 2006–2009. Am J Obstet Gynecol. 2014;211(4):390.e1–390.e7.
31. Alliman J, Phillippi JC. Maternal outcomes in birth centers: an integrative review of the literature. J Midwifery Womens Health. 2016;61(1):21–51.
32. Janssen PA, Saxell L, Page LA, et al. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician [published correction appears in CMAJ. 2009;181(9):617]. CMAJ. 2009;181(6–7):377–383.
33. Hutton EK, Cappelletti A, Reitsma AH, et al. Outcomes associated with planned place of birth among women with low-risk pregnancies. CMAJ. 2016;188(5):E80–E90.
34. Hill I, Dubay L, Courtot B, et al. Strong start for mothers and newborns evaluation: year 5 project synthesis. Volume 1: cross-cutting findings. 2018. Accessed February 1, 2020. https://downloads.cms.gov/files/cmmi/strongstart-prenatal-finalevalrpt-v1.pdf
35. Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: a meta-analysis [published correction appears in Am J Obstet Gynecol. 2011;204(4):e7–e13]. Am J Obstet Gynecol. 2010;203(3):243.e1–243.e8.
36. Grünebaum A, McCullough LB, Bornstein E, et al. Professionally responsible counseling about birth location during the COVID-19 pandemic. J Perinat Med. 2020;48(5):450–452.
37. American Association of Birth Centers. Freestanding birth centers offer options during COVID-19 pandemic. Accessed April 10, 2020. https://www.birthcenters.org/news/494795/Freestanding-Birth-Centers-Offer-Options-During-COVID-19-Pandemic.htm
38. March of Dimes. Nowhere to go: maternity care deserts across the U.S. Accessed April 10, 2020. https://www.marchofdimes.org/materials/Nowhere_to_Go_Final.pdf
39. Kozhimannil KB, Hung P, Henning-Smith C, et al. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA. 2018;319(12):1239–1247.
40. Tilden EL, Cheyney M, Guise JM, et al. Vaginal birth after cesarean: neonatal outcomes and United States birth setting. Am J Obstet Gynecol. 2017;216(4):403.e1–403.e8.
41. Grünebaum A, McCullough LB, Brent RL, et al. Perinatal risks of planned home births in the United States. Am J Obstet Gynecol. 2015;212(3):350.e1–350.e6.
42. Barger MK, Dunn JT, Bearman S, et al. A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy Childbirth. 2013;13:83.
43. Cheng YW, Snowden JM, King TL, et al. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol. 2013;209(4):325.e1–325.e8.
44. Grünebaum A, McCullough LB, Sapra KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol. 2013;209(4):323.e1–323.e6.
45. Brocklehurst P, Hardy P, Hollowell J, et al.; Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011;343:d7400.
46. de Jonge A, Geerts CC, van der Goes BY, et al. Perinatal mortality and morbidity up to 28 days after birth among 743 070 low-risk planned home and hospital births: a cohort study based on three merged national perinatal databases. BJOG. 2015;122(5):720–728.
47. van der Kooy J, Birnie E, Denktas S, et al. Planned home compared with planned hospital births: mode of delivery and perinatal mortality rates, an observational study. BMC Pregnancy Childbirth. 2017;17(1):177.
48. Holten L, de Miranda E. Women's motivations for having unassisted childbirth or high-risk homebirth: an exploration of the literature on ‘birthing outside the system’. Midwifery. 2016;38:55–62.
49. Kaunitz AM, Spence C, Danielson TS, et al. Perinatal and maternal mortality in a religious group avoiding obstetric care. Am J Obstet Gynecol. 1984;150(7):826–831.
50. World Health Organization. Fact sheets. Maternal mortality. Accessed April 10, 2020. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
51. Vedam S, Stoll K, MacDorman M, et al. Mapping integration of midwives across the United States: impact on access, equity, and outcomes. PLoS One. 2018;13(2):e0192523.
52. Cheyney M, Olsen C, Bovbjerg M, et al. Practitioner and practice characteristics of certified professional midwives in the United States: results of the 2011 North American Registry of Midwives survey. J Midwifery Womens Health. 2015;60(5):534–545.
53. Midwives Alliance of North America. State by state. Accessed April 10, 2020. https://mana.org/about-midwives/state-by-state/
54. American College of Nurse-Midwives. Position statement. Principles for licensing and regulating midwives in the United States in accordance with the global standards of the International Confederation of Midwives. Accessed April 10, 2020. https://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000287/Principles-for-Licensing-and-Regulating-Midwives-in-US-According-to-ICM-Global-Standards-March-2014.pdf
55. Anton S, Darragh I, Khalsa MA, et al. North American Registry of Midwives. 2016 annual report. Accessed April 10, 2020. https://narm.org/pdffiles/2016NARMAnnualReport.pdf
56. American Association of Birth Centers. National standards for birth centers. Accessed July 12, 2020. https://www.birthcenters.org/page/standards
57. American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Levels of maternal care: obstetric care consensus no. 9 [published correction appears in Obstet Gynecol. 2019; 134(4):883]. Obstet Gynecol. 2019;134(2):e41–e55.
58. Blix E, Kumle MH, Ingversen K, et al. Transfers to hospital in planned home birth in four Nordic countries—a prospective cohort study. Acta Obstet Gynecol Scand. 2016;95(4):420–428.
59. Souter V, Nethery E, Kopas ML, et al. Comparison of midwifery and obstetric care in low-risk hospital births. Obstet Gynecol. 2019;134(5):1056–1065.
60. Ecker J, Minkoff H. Home birth: what are physicians' ethical obligations when patient choices may carry increased risk?. Obstet Gynecol. 2011;117(5):1179–1182.
Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions