Jump to the summary »

Periodically, a study of the safety of US home birth, birth in freestanding birth centers, or both (a.k.a., “community births”) appears in the research literature. If its authors are obstetric researchers, the study invariably concludes that community birth is less safe than hospital birth, thereby helping to cement obstetric opinion on that point. Equally invariably, though, the study is flawed. (For a post I did on a different study, see “Dueling Statistics: Is Out-of-Hospital Birth Safe?”) Another one was published this past month, and since it, no doubt, will be making the rounds, I thought it might be helpful to my birth worker followers if I pointed out those flaws.

In that interest, let’s see what the study found and unpack the ways those findings are presented that would likely lead readers to conclude that hospital birth is safer—I am not, I hasten to add, suggesting the authors did this intentionally. It’s that it isn’t possible to be truly objective on such contentious issues, and I believe their unconscious bias led to presenting an unbalanced picture of their results. Nor am I, I also hasten to add, claiming an objectivity they lacked. My differing perspective, though, enables me to see things they won’t.

What Does the Study Say?

Purpose and Study Design

The investigators wanted to compare outcomes according to planned place of delivery (Granger Howard 2026). A concern in making that comparison was that transfers to the hospital might be misclassified as planned hospital births, which would underestimate the risk of community births. For this reason, they chose to use Oregon’s birth certificate as their data source because it included the question: “Did you go into labor planning to deliver at home or at a freestanding birth center?” a question that would enable them to distinguish intended community births that were transferred during labor from planned hospital births.

After excluding births to multiples, breech births, babies with lethal congenital anomalies, and births before 37 weeks, they were left with 348,641 births of which 332,313 (95 percent) were planned hospital births and 16,328 (5 percent) were planned community births. Among planned community births 2,402 (15 percent) were hospital transfers. To address causes other than planned location for birth that could influence results, calculations of comparative risk were statistically adjusted for factors that differed between groups such as first or subsequent birth, prior cesarean, and the presence of any of a list of pregnancy complications (chronic hypertension, gestational hypertension, preeclampsia, eclampsia, prepregnancy diabetes, and gestational diabetes).

Results

I’ve only listed results from the “Outcomes” section of the study’s abstract, an abstract being a summary of the study that precedes the body of the paper. I’ve done that because the abstract is all most people will read.

• Compared with planned hospital birth, planned community birth (including transfers) had:
  • 15 percent higher odds of any use of ventilator support
• Compared with planned hospital birth, transfers had:
  • 5 times higher odds of fetal death (In Oregon, fetal death includes deaths during labor.)
  • 73 percent higher odds of ventilator support
  • 40 percent higher odds of neonatal intensive care admission
  • 5 times higher odds of any adverse newborn outcome (fetal or infant death, 5-minute Apgar score less than 4, or seizures)
  • 33 percent higher odds of instrumental vaginal delivery
  • 54 percent higher odds of cesarean delivery
• Compared with planned hospital birth, completed community births had:
  • 92 percent lower odds of instrumental vaginal delivery
  • 91 percent lower odds of maternal admission to intensive care

What’s Wrong with This Picture?

Turning to what’s wrong with this picture, let’s look at what’s in the picture frame and what isn’t.

What’s Problematic About What’s in the Abstract?

Jumping off the page is that transfers had 5.5 times the odds of fetal death. And if that weren’t sufficiently damning, that statistic is followed by a list of additional adverse newborn outcomes found in excess among transfers. An uncritical reader will surely find those excesses proof positive that planned hospital birth is safer. But there’s a catch: these are excess rates in transfers, not planned community births overall, and you would expect transfers to have increased rates of adverse outcomes. Obviously, if there weren’t a problem serious enough to require a hospital’s resources for care, they wouldn’t have been transfers.

If the study’s objective is to “examine the association between planned place of delivery and perinatal outcomes,” the proper comparison group isn’t transfers; it’s all planned community births. And when you compare all planned community births with planned hospital births, the only newborn adverse outcome in excess in the planned community birth group is, as noted in the abstract, need for ventilator support. Even so, the absolute difference in babies requiring ventilator support was small—a mere 2 more babies per thousand compared with planned hospital births. Furthermore, not reported in the abstract, is that rates of ventilator support longer than six hours did not differ between groups.

That’s not all. The abstract states that planned community births “were not associated with most perinatal outcomes” but follows that statement with a list of adverse newborn outcomes whose differences weren’t statistically significant, meaning statistical calculation showed that the difference was probably due to chance. This isn’t a common thing to do. Usually, abstracts only report outcomes where differences were statistically significant. The critical reader who understands statistical concepts will notice that the confidence intervals accompanying their odds ratios overlaps “1,” which indicates that the difference wasn’t statistically significant. The uncritical reader or one who doesn’t know what the overlap means is likely to assume these adverse outcomes are increased in planned community births overall.

What’s Problematic About What Isn’t in the Abstract?

We’ve now established that rates of adverse outcomes are essentially a wash between groups according to planned place of birth, although you wouldn’t think so if you just read the study’s abstract. This brings us to what isn’t in the abstract that should have been.

Here again the abstract is deficient. It fails to include a list of superior outcomes strongly favoring planned community birth:

• Compared with planned hospital birth, planned community birth (including transfers) had:
  • 87 percent lower odds of maternal admission to intensive care
  • 82 percent lower odds of cesarean delivery
  • 70 percent lower odds of instrumental vaginal delivery
  • 49 percent lower odds of severe perineal tears (the tissue between the base of the vagina and the anus)

Especially important is the difference in cesarean rates because it’s a big one: 5 percent with planned community birth versus 24 percent with planned hospital birth—that’s 19 fewer cesareans per 100 planned community births. Reducing cesareans is a major advantage of planned community birth because of the increased risk of severe adverse outcomes in future pregnancies. What’s more, the difference would have been even bigger had the researchers reported rates at first births separately. Respectively, 60 percent and 64 percent of the two groups had previous births. Their presence in the mix masks the effect on first births because subsequent births are at much lower risk for cesarean.

What’s Problematic About the Study’s Data?

The investigators chose to compare adverse outcome rates with planned community birth versus planned hospital birth, full stop, but that’s not the pertinent research question. The pertinent research question for a truly fair comparison is to compare low-risk planned community births with a qualified birth attendant with a similarly low-risk planned hospital birth population.  Nine percent of community birth attendants were not qualified, i.e., they were “other midwife” (i.e., not a certified or licensed midwife), they were a family member or friend, or they were an RN or EMT, and 6 percent weren’t low risk, i.e., it was a VBAC labor or a hypertensive pregnancy. True, the investigators accounted for differing percentages of risk factors between the two groups, but having a qualified birth attendant and being at low-risk for having complications in labor are factors known to impact the safety of community birth.

Update

On July 1, 2026, Jennifer Hufty made this comment on facebook to my post of the key points of this article:

I read your full critique of this study, and I think you made some excellent points.

I would also like to make one additional criticism that I noticed upon reviewing the study. The authors correctly state that “Oregon uniquely tracks planned birth location at labor onset,” but they fail to mention that birth certificate data does not distinguish between planned assisted home birth and planned unassisted home birth (ie. freebirth). This is highly problematic when assessing the rate of rare adverse outcomes, such as neonatal death, on the basis of birth location. More specifically, it might skew the results against the community birth cohort by inflating the rate of these outcomes.

In Summary

To sum up, a study that at first glance appears to show hospital birth to be the safer option actually found that newborn outcomes were similar between groups. What’s more, adverse maternal outcomes were more common with planned hospital birth. Chief among these was a major increase in cesarean delivery, a difference that makes planned community birth—provided the labor is at low risk and attended by a qualified birth attendant—much the superior option.

Your Takeaway

So, we’ve learned that the bias of US obstetric researchers against community birth results in well-conducted studies whose data and conclusions appear sound but which reveal problems with both when subjected to closer scrutiny. Your takeaway, then, is if you want trust-worthy evidence on the relative safety of planned community versus hospital birth in the United States, stick to research led by midwives. They, too, publish well-conducted studies, and theirs don’t suffer from anti-community birth bias.

You can also, I should add, find reliable evidence in studies conducted in other countries that, unlike the United States, have integrated maternity care systems, that is, systems where community birth practitioners can readily consult, collaborate, and transfer care. Obstetric researchers in those countries are more likely to have a clear-eyed view of community birth, but even there, midwife-led research is the better bet.