Out-of-hospital births increased adverse outcomes risk


Multiple studies have indicated a greater risk of neonatal morbidity and mortality when births occur in out-of-hospital settings.

Infant feet | Image Credit: © Simon Dannhauer - © Simon Dannhauer - stock.adobe.com.

Infant feet | Image Credit: © Simon Dannhauer - © Simon Dannhauer - stock.adobe.com.

Avoidable adverse perinatal outcomes in the United States are more common in out-of-hospital settings, according to a recent review published in the American Journal of Obstetrics & Gynecology.

Hospitals are the settings of 98.3% of births in the United States, homes 1.1%, freestanding birth centers 0.5%, and other places 0.1%. A decrease in hospital births from 98.33% to 98.01% was seen in the first year of the COVID-19 pandemic, with home births increasing from 1.03% to 1.26% and freestanding birth center births increasing from 0.53% to 0.61%.

Maternal and neonatal mortality and morbidity rates among high-resource countries are highest in the United States, with Black and Native American patients seeing even greater rates. Because of a lack of data, the association between site of birth and mortality and morbidity outcomes is unclear.

Fewer interventions are seen in out-of-hospital settings, leading some patients to seek an out-of-hospital birth to avoid unnecessary procedures. The American College of Obstetricians and Gynecologists reported uncertain benefits from obstetrical practices to low-risk women, who may seek an out-of-hospital birth to reduce medical interventions.

While beliefs have arisen that out-of-hospital birth settings are safer, these claims have been proven wrong. Statistics from the CDC on over 3.5 million US births have been used by many publications, but when patients experience unplanned transfers from out-of-hospital settings to hospitals, this data attributes adverse outcomes to hospital settings.

As these transfers are associated with an increased risk of adverse outcomes, this leads to an increasein adverse events attributed to hospitals and an underestimation in outcomes associated with out-of-hospital settings. However, multiple studies have found increased neonatal morbidity and mortality in out-of-hospital settings compared to hospitals.

Poorer perinatal outcomes were found in women having in planned home births in the Birthplace in England study. Factors increasing the risks in out-of-hospital births include higher maternal age, breech presentation, and late-term gestation.

Recent findings have shown a more than doubled neonatal mortality rate in out-of-hospital settings, with about 1 to 2 deaths per 1000 births. Life-saving interventions are often unavailable in out-of-hospital settings, allowing hospital deliveries to save infants’ lives.


Grünebaum A, Bornstein E, McLeod-Sordjan R, et al. The impact of birth settings on pregnancy outcomes in the United States. American Journal of Obstetrics & Gynecology. 2023. doi:10.1016/j.ajog.2022.08.011

This article was initially published by our sister publication Contemporary OB/GYNI.

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