Trends in out-of-hospital births in the United States, 1990-2012.

Although still relatively rare, out-of-hospital births have accounted for a growing share of U.S. births since 2004. In 2012, 1.36% of U.S. births were born outside a hospital, up from 1.26% in 2011 and 0.87% in 2004. The 2012 level is the highest level since 1975. Most of the total increase in out-of-hospital births from 2004­2012 was a result of the increase among non-Hispanic white women, and by 2012, 1 in 49 births to non-Hispanic white women (2.05%) occurred outside a hospital. In 2012, six states had 3%­6% of their births occur outside a hospital. For an additional five states, between 2% and 3% of their births were out-of-hospital births. Variations in the percentages of out-of-hospital births by state may be influenced by differences in state laws pertaining to midwifery practice or out-of-hospital births, as well as by the availability of a nearby birthing center. The number of U.S. birthing centers increased from 170 in 2004 to 195 in 2010 and to 248 in January 2013; 13 states still did not have a birthing center in the most recent period. Compared with hospital births, home and birthing center births tended to have lower risk profiles, with fewer births to teen mothers and fewer preterm, low birthweight, and multiple births. From 2004 through 2012, there was a decline in the risk profile of out-of-hospital births, with fewer births in 2012 than in 2004 to teen and older mothers and fewer preterm and low birthweight births. The lower risk profile of out-of-hospital than hospital births suggests that appropriate selection of low-risk women as candidates for out-of-hospital birth is occurring. Although not representative of all U.S. births, 88% of home births in a 36-state reporting area (comprising 71% of U.S. births) were planned in 2012. Unplanned home births are more likely than planned home births to be born preterm and at low birthweight.

Recent Trends in Out-of-Hospital Births in the United States.

INTRODUCTION: Although out-of-hospital births are still relatively rare in the United States, it is important to monitor trends in these births, as they can affect patterns of facility usage, clinician training, and resource allocation, as well as health care costs. Trends and characteristics of home and birth center births are analyzed to more completely profile contemporary out-of-hospital births in the United States. METHODS: National birth certificate data were used to examine a recent increase in out-of-hospital births. RESULTS: After a gradual decline from 1990 to 2004, the number of out-of-hospital births increased from 35,578 in 2004 to 47,028 in 2010. In 2010, 1 in 85 US infants (1.18%) was born outside a hospital; about two-thirds of these were born at home, and most of the rest were born in birth centers. The proportion of home births increased by 41%, from 0.56% in 2004 to 0.79% in 2010, with 10% of that increase occurring in the last year. The proportion of birth center births increased by 43%, from 0.23% in 2004 to 0.33% in 2010, with 14% of the increase in the last year. About 90% of the total increase in out-of hospital births from 2004 to 2010 was a result of increases among non-Hispanic white women, and 1 in 57 births to non-Hispanic white women (1.75%) in 2010 was an out-of-hospital birth. Most home and birth center births were attended by midwives. DISCUSSION: Home and birth center births in the United States are increasing, and the rate of out-of-hospital births is now at the highest level since 1978. There has been a decline in the risk profile of out-of-hospital births, with a smaller proportion of out-of-hospital births in 2010 than in 2004 occurring to adolescents and unmarried women and fewer preterm, low-birth-weight, and multiple births.

Home births in the United States, 1990-2009.

After 14 years of decline, the percentage of home births rose by 29% from 2004 to 2009, to the point where it is at the highest level since data on this item began to be collected in 1989. The overall increase in home births was driven mostly by a 36% increase for non-Hispanic white women. About 1 out of every 90 births to non-Hispanic white women are now home births. The percentage of home births for non-Hispanic white women was three to five times higher than for any other racial or ethnic group. Home births have a lower risk profile than hospital births, with fewer births to teenagers or unmarried women, and with fewer preterm, low birthweight, and multiple births. The lower risk profile of home compared with hospital births suggests that home birth attendants are selecting low-risk women as candidates for home birth. The increase in the percentage of home births from 2004 to 2009 was widespread and involved selected states from every region of the country. The large variations in the percentage of home births by state may be influenced by differences among states in laws pertaining to births are more prevalent among non-Hispanic white women (7). midwifery practice or out-of-hospital birth (8,9), as well as by differences in the racial and ethnic composition of state populations, as home Studies have suggested that most home births are intentional or planned home births, whereas others are unintentional or unplanned, because of an emergency situation (i.e., precipitous labor, labor complications, or unable to get to the hospital in time) (3,6). Although not representative of all U.S. births (see "Data source and methods"), 87% of home births in a 26-state reporting area (comprising 50% of U.S. births) were planned in 2009. For non-Hispanic white women, 93% of home births were planned (10). Women may prefer a home birth over a hospital birth for a variety of reasons, including a desire for a low-intervention birth in a familiar environment surrounded by family and friends, and cultural or religious concerns (9,11). Lack of transportation in rural areas and cost factors may also play a role, as home births cost about one-third as much as hospital births (9,11,12).

Trends and characteristics of home and other out-of-hospital births in the United States, 1990-2006.

OBJECTIVES: This report examines trends and characteristics of out-of-hospital and home births in the United States. METHODS: Descriptive tabulations of data are presented and interpreted. RESULTS: In 2006, there were 38,568 out-of-hospital births in the United States, including 24,970 home births and 10,781 births occurring in a freestanding birthing center. After a gradual decline from 1990 to 2004, the percentage of out-of-hospital births increased by 3% from 0.87% in 2004 to 0.90% in 2005 and 2006. A similar pattern was found for home births. After a gradual decline from 1990 to 2004, the percentage of home births increased by 5% to 0.59% in 2005 and remained steady in 2006. Compared with the U.S. average, home birth rates were higher for non-Hispanic white women, married women, women aged 25 and over, and women with several previous children. Home births were less likely than hospital births to be preterm, low birthweight, or multiple deliveries. The percentage of home births was 74% higher in rural counties of less than 100,000 population than in counties with a population size of 100,000 or more. The percentage of home births also varied widely by state; in Vermont and Montana more than 2% of births in 2005-2006 were home births, compared with less than 0.2% in Louisiana and Nebraska. About 61% of home births were delivered by midwives. Among midwife-delivered home births, one-fourth (27%) were delivered by certified nurse midwives, and nearly three-fourths (73%) were delivered by other midwives. DISCUSSION: Women may choose home birth for a variety of reasons, including a desire for a low-intervention birth in a familiar environment surrounded by family and friends and cultural or religious concerns. Lack of transportation in rural areas and cost factors may also play a role.