Out-of-Hospital Birth


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.

Related editorial: Promoting Safety in Community-Based Birth Settings

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

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Clinical recommendationEvidence ratingComments

Pregnant patients without a previous vaginal delivery should strongly consider delivery in a hospital.4,10,11


Good-quality cohort studies with inconsistent findings

Pregnant patients at 41 weeks' or more gestation should strongly consider delivery in a hospital.10,11


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

Patients who inquire about planned home birth should be informed that this delivery option is associated with fewer maternal interventions compared with planned hospital birth; however, it is also associated with an increased risk of perinatal death and neonatal seizures or serious neurologic dysfunction.9,29,30


Good-quality cohort studies with inconsistent findings

Pregnant patients with any of the following conditions should plan to deliver in a hospital: fetal malpresentation (breech or other), a previous cesarean delivery, or multiple gestation (twins or higher).4,911,40


Good-quality cohort studies with generally consistent findings

Unassisted childbirth should be strongly discouraged.49


Expert opinion and limited case series

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.

The Authors

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GREGORY LANG, MD, MPH, is a faculty member in the Family Medicine Residency Program at Eisenhower Army Medical Center, Fort Gordon, Ga., and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

EDWIN A. FARNELL IV, MD, FAAFP, is director of Medical Education at Eisenhower Army Medical Center, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

JEFFREY D. QUINLAN, MD, FAAFP, is a professor of family medicine and Chair of and Departmental Executive Officer in the Department of Family Medicine at the University of Iowa College of Medicine, Iowa City. At the time this article was written, Dr. Quinlan was a professor and chair of the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Gregory Lang, MD, MPH, Eisenhower Army Medical Center, 300 Hospital Rd., Fort Gordon, GA 30905 (email: Gregory.t.lang.civ@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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