ACOG’s New Position on Out-of-Hospital Birth: When Diplomacy Replaces Patient Safety

Reading it, one might think ACOG had finally decided to address the growing phenomenon of planned home birth in America with the clinical rigor our patients deserve. One would be wrong.

On December 10, 2025, the American College of Obstetricians and Gynecologists released a position statement titled “Transfer Protocols for Out-of-Hospital Birth.” Reading it, one might think ACOG had finally decided to address the growing phenomenon of planned home birth in America with the clinical rigor our patients deserve.

One would be wrong.

What ACOG has produced is a masterclass in institutional fence-sitting—a document so carefully calibrated to avoid controversy that it abandons any pretense of meaningful clinical guidance. At a time when out-of-hospital birth rates are rising and rural obstetric deserts are expanding, ACOG has chosen diplomatic ambiguity over patient protection.

What the Statement Actually Says

The document’s core recommendations can be summarized briefly: out-of-hospital birth attendants should have transfer agreements with hospitals, hospitals should accept transfers, and everyone should communicate respectfully. The statement endorses “shared decision-making” and notes that 10-25% of planned out-of-hospital births require transfer.

That’s essentially it.

ACOG acknowledges that “hospitals and birth centers that are both licensed and accredited are the safest settings for birth” but immediately genuflects to patient autonomy, noting that “each patient has the right to make a medically informed decision about delivery.”

No reasonable clinician disputes patient autonomy. The question is: what constitutes a “medically informed decision”? On this crucial point, the statement is silent.

The Glaring Omission: Patient Selection Criteria

Perhaps the most striking absence in this document is any mention of who should and should not be considered appropriate candidates for out-of-hospital birth. The statement accepts as a given that patients who “prefer” home birth will have one, without acknowledging that preference alone is insufficient grounds for clinical decision-making.

Where is the guidance on prior cesarean delivery? On breech presentation? On multiple gestation, preterm labor, preeclampsia, placental abnormalities, or fetal growth restriction? These are not edge cases—they are common clinical scenarios that make out-of-hospital birth genuinely dangerous.

ACOG’s own 2017 Committee Opinion No. 697 on planned home birth at least acknowledged that “appropriate candidate selection” is essential. This new statement abandons that principle entirely, treating all planned out-of-hospital births as equivalent regardless of risk stratification.

In countries with successful home birth programs—the Netherlands, the United Kingdom—rigorous screening criteria determine eligibility. Low-risk pregnancies with trained midwives and rapid hospital access can achieve reasonable outcomes. But “low-risk” must actually mean something, defined by evidence-based criteria rather than patient preference alone.

The “Birth Attendant” Euphemism

Throughout the document, ACOG refers to “out-of-hospital birth attendants” without ever distinguishing between the vastly different types of providers who attend home births in America.

Certified Nurse-Midwives (CNMs) complete master’s or doctoral programs, undergo rigorous national certification, train in hospital settings managing complications, and practice under state nursing board oversight. Certified Professional Midwives (CPMs), by contrast, may obtain certification primarily through apprenticeship, attending home births supervised by other CPMs, without standardized clinical training in managing emergencies.

This distinction matters enormously. In the UK and Netherlands, all midwives meet uniform, rigorous training standards and are integrated into the national healthcare system. The United States has a two-tiered midwifery system with dramatically different competency requirements, yet ACOG pretends this distinction doesn’t exist.

When ACOG recommends that “birth attendants” have transfer agreements, are they suggesting hospitals should extend collaborative relationships to providers whose training may be inadequate to recognize when transfer is needed? The statement doesn’t say.

Transfer Rates Without Context

The statement notes that “an estimated 10-25% of planned out-of-hospital births involve intrapartum or postpartum transfer.” This statistic appears without any meaningful context.

What proportion of these transfers are emergent versus routine? What are maternal and neonatal outcomes when transfer is needed but delayed? What about the irreducible time delays inherent in out-of-hospital emergencies?

When cord prolapse occurs, when placental abruption presents, when shoulder dystocia is encountered, when postpartum hemorrhage begins, minutes matter. A 30-minute transfer time, even under optimal conditions, may be 30 minutes too long.

The Birthplace in England study found that for nulliparous women planning home birth, the odds of an adverse perinatal outcome were nearly three times higher than for those planning hospital birth.

These are not abstractions. They are dead and damaged babies. ACOG’s statement treats transfer as a logistical consideration rather than a clinical one with life-or-death implications.

Informed Consent Reduced to Platitudes

The statement calls for “shared decision-making regarding risks and benefits” without specifying what information patients should actually receive. This is informed consent as performance rather than substance.

Should patients be told that planned home birth is associated with increased neonatal mortality in multiple large studies? That Apgar scores are lower and neonatal seizures more common? That nulliparous women face substantially higher risks than multiparous women in the out-of-hospital setting?

Genuine informed consent requires disclosure of material risks, information that a reasonable patient would want to know. ACOG has the expertise and authority to specify what constitutes adequate disclosure for planned out-of-hospital birth.

Instead, it offers vague endorsements of “patient-centered tools” and “decision aids” without defining their content.

No Accountability, No Improvement

The statement contains no mention of mandatory outcome reporting, data collection, or quality metrics for out-of-hospital birth. We cannot improve what we refuse to measure.

States vary wildly in their requirements for reporting home birth outcomes. Many have none. Without systematic data collection, we cannot identify which practices, providers, and patient populations achieve acceptable outcomes and which do not.

ACOG could have called for standardized outcome reporting as a condition of collaborative transfer agreements. It did not.

The Evidence Problem

The references ACOG cites are notably selective. The Stapleton and Nethery studies represent favorable data points; the substantial body of literature demonstrating increased neonatal morbidity and mortality with planned home birth goes unmentioned.

The Wax meta-analysis in the American Journal of Obstetrics and Gynecology found a tripling of neonatal mortality risk with planned home birth. Grünebaum and colleagues have published extensively on the increased risks associated with midwife-attended home birth, particularly with CPM attendants. The Birthplace UK study’s secondary analyses revealed concerning outcomes for specific subgroups. None of this appears in ACOG’s reference list. Grünebaum and colleagues wrote about “The impact of birth settings on pregnancy outcomes in the United States” No mention by ACOG.

Selective citation is not evidence-based medicine. It is advocacy dressed in academic clothing.

A Failure of Professional Responsibility

Professional medical organizations ought to exist, in part, to establish standards that protect patients, even when those standards prove unpopular with some constituencies.

ACOG has the expertise to define appropriate candidate selection criteria for out-of-hospital birth, to distinguish between adequately and inadequately trained providers, and to specify what constitutes genuine informed consent.

Instead, it has produced a document designed to offend no one: not home birth advocates, not hospital administrators, not midwifery organizations of any stripe.

The only constituency left unprotected by this ACOG statement is the one that matters most, pregnant patients and their babies who deserve honest, evidence-based guidance.

“Hospitals are safest, but do what you prefer with whoever you choose, and please have a transfer plan” is not clinical guidance. It is a liability hedge wrapped in collegial language.

Our patients deserve better. ACOG can do better. The question is whether it has the institutional courage to try.