Takeaways
- Hospital transfers drive most risks: Planned community births that required transfer had significantly higher odds of adverse outcomes, including fetal death and low Apgar scores.
- Completed community births had low intervention rates: When deliveries remained in the community setting, most outcomes were similar to hospital births, with fewer medical interventions.
- Accurate classification is essential: Misclassifying transfers as hospital births may underestimate risks associated with planned community birth and should be addressed in counseling and policy planning.
A population-based cohort study of Oregon births from 2012 to 2020 found that perinatal risks associated with planned community birth differed substantially depending on whether delivery occurred in the community setting or required transfer to a hospital. The findings, published in JAMA Pediatrics, highlight the importance of risk-appropriate counseling and systems that support timely intrapartum transfer.1
The study evaluated 348,641 singleton, nonbreech births without lethal anomalies at 37 to 44 weeks’ gestation. Of these, 332,313 (95.3%) were planned hospital births, and 16,328 (4.7%) were planned community births, including those taking place at home or in a freestanding birth center. Transfers accounted for 2402 of the planned community births (14.7%).
Oregon is the only state that records planned place of delivery at the onset of labor on birth certificates, allowing the authors to classify births accurately and avoid misclassification of transfers as planned hospital deliveries—an issue that has limited prior research. As the authors note, misclassification “may mask risks associated with planned community births,” underscoring the need for precise data collection.2
Maternal characteristics and risk profile
Individuals planning a community birth differed demographically from those planning a hospital birth. Planned community birth was more common among patients who were White, older than 35 years, married, college-educated, and self-paying for care. Transfers occurred more often among nulliparous patients and those with higher body mass index or hypertensive disorders.
The prevalence of hypertensive disorders among transferred births was the highest across all groups. The authors found that hypertensive conditions were “underreported in vital records compared to hospital data,” emphasizing the value of linked data sources for accurate assessment.
Infant outcomes
Compared with planned hospital births, planned community births (including transfers) had higher adjusted odds of a 5-minute Apgar score less than 7 (adjusted odds ratio [aOR], 1.34; 95% CI, 1.19–1.50) and any neonatal ventilator support (aOR, 1.14; 95% CI, 1.05–1.24). However, they had lower odds of NICU admission (aOR, 0.69; 95% CI, 0.61–0.78).
When births requiring transfer were examined separately, risks increased across multiple infant outcomes. Transfers were associated with higher odds of fetal death (aOR, 5.47; 95% CI, 2.67–11.20), 5-minute Apgar score less than 7 (aOR, 2.02; 95% CI, 1.64–2.50), neonatal ventilator support (aOR, 1.73; 95% CI, 1.47–2.03), and NICU admission (aOR, 1.40; 95% CI, 1.15–1.71).
In contrast, completed community births were not associated with increased odds of most outcomes. The authors reported decreased odds of NICU admission and most medical interventions, reflecting the low-intervention philosophy of community-based care.
Maternal outcomes
Planned community births (including transfers) were associated with reduced odds of labor induction and augmentation, operative vaginal delivery, cesarean delivery, and maternal ICU admission. Completed community births showed particularly low rates of intervention.
Among transfers, however, the likelihood of operative deliveries and augmentation was higher than in planned hospital births, suggesting that complications prompting transfer may contribute to these results.
Implications for clinical practice
The study supports nuanced counseling about planned community birth. As the authors emphasize, “These risks should be clearly communicated during patient counseling and considered in policy decisions.” They further note that regulatory environments, such as Oregon’s midwifery licensure mandate and birth center oversight, may influence safety.
The findings underscore the need for:
- clear informed consent for individuals considering community birth
- vigorous risk selection
- appropriate prenatal care
- formalized and efficient hospital transfer protocols
Given the elevated risks observed among transfers, the study reinforces the importance of integrated systems of care that ensure timely access to emergency obstetric and neonatal services.
References
- Granger Howard ME, Phibbs CS, Lorch S, Passarella M, Boghossian NS. Planned Community Birth and Birth Outcomes. JAMA Pediatrics. Published online November 24, 2025. doi: https://doi.org/10.1001/jamapediatrics.2025.4840
- Snowden JM, Tilden EL, Snyder J, Quigley B, Caughey AB, Cheng YW. Planned out-of-hospital birth and birth outcomes. N Engl J Med. 2015;373(27):2642-2653. doi:10.1056/NEJMsa1501738
