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Am Fam Physician. 2021;103(11):672-679

Related editorial: Promoting Safety in Community-Based Birth Settings

Patient information: See related handout on having a baby outside of a hospital, written by the authors of this article.

This clinical content conforms to AAFP criteria for CME.

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

Clinical recommendationEvidence ratingComments
Pregnant patients without a previous vaginal delivery should strongly consider delivery in a hospital.4,10,11 BGood-quality cohort studies with inconsistent findings
Pregnant patients at 41 weeks' or more gestation should strongly consider delivery in a hospital.10,11 BGood-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 CExpert 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 BGood-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 BGood-quality cohort studies with generally consistent findings
Unassisted childbirth should be strongly discouraged.49 CExpert opinion and limited case series

Out-of-hospital birth, often referred to as community birth, can be planned or unplanned. Of those that are planned, the most commonly chosen location is the home; 62% of out-of-hospital births were at home in 2018.1,2 Deliveries at free-standing birth centers have also increased and made up roughly one-third of community births in 2018.2 Most maternal and newborn health professionals who attend planned out-of-hospital births in the United States are midwives.2,4 In 2018, only 4.2% of out-of-hospital births were attended by physicians.2

Given their unique role spanning care provided by midwives, obstetricians, and pediatricians, family physicians can provide trusted guidance to patients and families who express an interest in out-of-hospital birth.

Patient Selection

Patients inquiring about community birth should be counseled that an appropriate candidate should have a low-risk pregnancy (Table 158 ) that is at term with a single fetus in vertex presentation and should have no previous cesarean delivery.9 Planned hospital birth is strongly recommended for patients with conditions that increase the risk of maternal or neonatal adverse outcomes, including nulliparity and gestational age of 41 weeks or more4,10,11 (Table 29,1214 ). Planned community birth should be attempted only in the presence of a maternal and newborn health professional who meets or exceeds the International Confederation of Midwives Global Standards for Midwifery Education, working within an integrated, regulated maternity care system with the ability to consult and transfer to a higher level of care in a timely manner if necessary.9,1316

American College of Obstetricians and Gynecologists
Low risk: A clinical scenario lacking clear demonstrable benefit for medical intervention. What constitutes low risk will vary depending on individual circumstances and the proposed intervention.5
Eunice Kennedy Shriver National Institute of Child Health and Human Development
Low risk: No maternal or fetal indication for delivery before 40 5/7 weeks.6
High risk: The mother, fetus, or both are at higher risk for health problems during pregnancy or labor vs. a typical pregnancy.7
Society for Maternal-Fetal Medicine
Low risk: All term, singleton, vertex, live birth deliveries without previous cesarean delivery or high-risk diagnoses.8
Preexisting medical conditions
Any significant medical condition that could impact childbirth, including:
 Asthma requiring hospitalization
 Bleeding disorder
 Confirmed cardiac disease
 Diabetes mellitus
 Hepatic disease
 Hypertensive disorders
 Hyperthyroidism
 Orthopedic condition limiting vaginal delivery
 Renal disease
 Seizure disorder
 Systemic lupus erythematosus
 Thromboembolic disorder
Evidence of active infection with hepatitis, HIV, herpes simplex virus, syphilis, or tuberculosis
Maternal age of 35 years or older
Psychiatric conditions requiring inpatient care
Substance abuse or dependence
Previous obstetric conditions
Cesarean delivery or uterine surgery
Intrauterine fetal death or stillbirth
Postpartum hemorrhage
Preeclampsia with preterm birth or eclampsia
Retained placenta requiring manual removal
Shoulder dystocia
Current obstetric conditions
Any condition necessitating pharmacologic induction of labor
Evidence of fetal congenital anomaly
Gestational age of 41 weeks or more
Gestational diabetes
Gestational hypertension
Intrauterine growth restriction
Malpresentation
Multiple gestation
Oligohydramnios
Placenta accreta, increta, or percreta
Placenta previa
Placental abruption
Polyhydramnios
Preeclampsia
Prepregnancy body mass index greater than 35 kg per m2
Preterm labor
Prolonged rupture of membranes without active labor
Rh isoimmunization
Significant anemia

Issues of Safety

Establishing the safety of community birth is difficult primarily because the concept of safety in relation to birth setting is variable depending on the perception of risk by patients, their families, and the various maternal and newborn health professionals. This is reflected by the differences in position statements regarding the best practices for place of birth for low-risk pregnancies among the organizations that represent maternal and newborn health professionals (Table 39,1315,17,18 ). Choice of birth setting may be influenced by health, pregnancy status, family needs, and religious or cultural values. Patients may perceive that, compared with hospital birth, out-of-hospital birth is safer for any of the reasons listed in Table 4.1924 Furthermore, several studies substantiate comparable outcomes for out-of-hospital birth in low-risk pregnancies attended by midwives.4,12,2527

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