Planned out-of-hospital births doubled during pandemic

Planned out-of-hospital (OOH) births have doubled since the COVID-19 pandemic, with notable shifts in the maternal risk profile of those choosing to deliver outside of hospitals, according to research presented at the American Academy of Pediatrics (AAP) 2025 National Conference & Exhibition in Denver, Colorado.^1,2

The study, The Changing Landscape of Planned Out-of-Hospital Births, was conducted by researchers at Cincinnati Children’s and analyzed OOH births across Cincinnati and surrounding areas between January 2018 and December 2023. Investigators found that the rate of OOH births rose from 1.5% before the pandemic to 3.0% after April 2020.

“As intensive care doctors who care for critically ill infants in the neonatal intensive care unit (NICU), it is important to understand the changing landscape of where, when, and how pregnant people are delivering their babies and the associated impact on infant health outcomes,” said study coauthor Emily Miller, MD, MS, FAAP, of Cincinnati Children’s.

Methods

This retrospective cohort study included 1601 planned OOH births, with 1234 occurring in the post-pandemic era. Data were collected from the Ohio Department of Health birth certificates and vital statistics files. Maternal and neonatal characteristics were compared between pre-pandemic (January 2018–February 2020) and post-pandemic (April 2020–December 2023) cohorts.

Variables analyzed included sociodemographic profiles, body mass index (BMI), prenatal care utilization, and neonatal outcomes. Statistical comparisons were performed using Wilcoxon rank sum tests for continuous variables and Chi-square or Fisher’s exact tests for categorical variables.

Key findings

The analysis revealed several significant differences in maternal profiles post-pandemic:

• Demographics: Increased representation of Black or Asian race and Hispanic ethnicity among post-pandemic OOH births.
• Education: More mothers with high school, collegiate, or graduate-level education chose OOH births after the pandemic.
• Risk factors: Post-pandemic mothers were more likely to be overweight or obese and to have fewer prenatal visits.
• Age: The mean age of post-pandemic mothers decreased compared to pre-pandemic cohorts.

Despite these changes, neonatal outcomes, including rates of adverse events and completion of routine screenings, were largely unchanged between groups. The study did note differences in ocular prophylaxis use, with more families opting out in the post-pandemic period.

Clinical context

The American College of Obstetricians and Gynecologists (ACOG) advises against planned home births for high-risk pregnancies, including those complicated by advanced maternal age, chronic illness, multiple gestation, or prior obstetric complications. Researchers emphasized the importance of these guidelines as more families consider OOH births.

Emily Miller, MD, MS, FAAP, underscored the importance of weighing maternal risks and neonatal outcomes. “As more parents choose to deliver their infants outside of a hospital, it is important to understand associated infant health outcomes, including the risk of adverse events such as birth injury, need for respiratory support, and death, so families can weigh the potential benefits and risks, consider their individual circumstances, and ensure access to appropriate medical care if needed,” she said.

Implications

The findings show that while neonatal outcomes have remained relatively stable despite increased maternal risk factors, the doubling of OOH births highlights the need for continued monitoring and comparative analyses with in-hospital births. Ongoing work aims to examine neonatal outcomes in matched cohorts to better understand how evolving maternal risk profiles may influence infant health.

The authors also pointed to broader healthcare challenges, such as rural hospital closures and potential reductions in access to obstetric care due to Medicaid cuts, which may influence birth setting decisions.

“Expectant mothers must consider all circumstances when deciding where they ultimately want to give birth,” Miller noted.

The researchers concluded that while absolute rates of adverse neonatal outcomes remain low, the trend toward OOH births requires careful attention from pediatricians, obstetricians, and policymakers to ensure that families are adequately informed of both the risks and resources available.

References:

1. American Academy of Pediatrics. Expecting mothers increasingly turn to at-home births: New research. Eurekalert. September 26, 2025. Accessed September 26, 2025. https://www.eurekalert.org/news-releases/1098923
2. Berbari H, Ehrlich S, Liu C, Hill M, Miller E. The Changing Landscape of Planned Out-of-Hospital Births. Abstract. Presented at: American Academy of Pediatrics 2025 National Conference & Exhibition. September 26-30, 2025. Denver, Colorado.