Your Body, Your Choice — But Also, Your Information
Planned home birth, patient autonomy, and why informed consent needs better tools
A woman tells her obstetrician she wants to deliver at home. What happens next says a lot about the state of American obstetrics.
In some offices, the conversation is short: the doctor says no, lists the dangers, and moves on. In others, the midwife says yes, lists the comforts, and moves on. In both cases, the woman leaves with an incomplete picture. And in both cases, someone has failed her — not because of what they recommended, but because of what they didn’t explain.
The home birth debate in the United States has hardened into opposing camps. On one side, an obstetric establishment that treats the request as reckless. On the other, a natural birth movement that frames hospital birth as inherently interventionist and traumatic. Both sides claim the evidence. Neither side does a great job of presenting it fairly.
I want to try something different.
Autonomy is not the end of the conversation
Let me be clear about my starting position: every woman has the right to decide where she gives birth. ACOG says this explicitly in Committee Opinion No. 697: “Each woman has the right to make a medically informed decision about delivery.” I agree.
But notice the modifier: medically informed. Autonomy without information is not autonomy — it is abandonment dressed up as empowerment. A woman who chooses home birth because she was told it is “just as safe” has not been given the foundation for an autonomous decision. Nor has a woman who chooses the hospital solely because her doctor said home birth is “crazy” without explaining the actual data.
True informed consent requires three things: disclosure of relevant information, comprehension by the patient, and voluntary decision-making free from coercion. In the home birth conversation, all three are routinely violated. Providers on both sides disclose selectively, confirm what they already believe, and — subtly or overtly — steer.
What the evidence actually shows
The honest answer is that the evidence is mixed, and how you interpret it depends heavily on which country you’re talking about.
In integrated health systems like the Netherlands, the United Kingdom, and parts of Canada — where certified midwives have hospital privileges, standardized transfer protocols exist, and transport times are short — studies show comparable perinatal outcomes for planned home births among low-risk women. The large Birthplace in England study and multiple Dutch cohort studies support this conclusion, and the most comprehensive meta-analysis (Hutton et al., EClinicalMedicine 2019) found no difference in perinatal or neonatal mortality for intended home versus hospital births within these systems.
The United States is not one of those systems.
In the US, Wax et al. (AJOG 2010) found that planned home births had fewer interventions but a nearly threefold increase in neonatal mortality among nonanomalous infants. Grünebaum et al., using CDC linked birth-infant death data from 2010–2017, found neonatal mortality of 3.27 per 10,000 for hospital midwife-attended births versus 13.66 per 10,000 for all planned home births — a more than fourfold difference. Critically, this difference persisted regardless of whether the home birth was attended by a certified nurse-midwife or a direct-entry midwife.
ACOG’s own summary: planned home birth is associated with “a more than twofold increased risk of perinatal death (1–2 in 1,000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction.”
Why the discrepancy between countries? The answer is not the mothers or the midwives — it is the system. In the Netherlands, a midwife recognizing a complication can have the patient in an operating room within 15 minutes. In large swaths of the United States, that transfer might take 45 minutes to an hour — or longer. The midwifery credential varies wildly by state. There is no national requirement for hospital integration. The safety net has gaps.
This does not mean home birth is indefensible in the United States. It means that its safety depends on a specific set of conditions being met — and those conditions are far more demanding than most discussions acknowledge.
The problem with both sides
The natural birth community tends to emphasize the advantages: fewer interventions, lower cesarean rates, continuous support, freedom of movement, familiar environment. These are real. The meta-analyses consistently show fewer episiotomies, less oxytocin augmentation, fewer operative deliveries, and lower infection rates in planned home births. For a woman who has had a traumatic hospital experience, these are not trivial considerations.
But the movement frequently minimizes the disadvantages. No epidural availability. No continuous fetal monitoring. No cesarean capability. No neonatal resuscitation team. No blood bank. Transfer rates of 10–37% for first-time mothers — meaning up to one in three will end up in the hospital anyway, but now with a delay that may have consequences. The planned home birth of a breech-presenting fetus carries an intrapartum mortality of 13.5 per 1,000. These numbers are often absent from the “informed choice” materials handed to expectant mothers by home birth advocates.
The obstetric establishment, meanwhile, too often dismisses the request without engaging with it. “Just have the baby in the hospital” is not informed consent. It is paternalism. And paternalism — even well-intentioned paternalism — erodes exactly the trust that makes hospital birth safe. A woman who feels unheard is a woman who may stop communicating with her providers, decline monitoring, or make decisions in isolation. We cannot protect patients by shutting them out of the conversation.
What informed consent actually requires
The ethics here are not complicated. They are just inconvenient.
Informed consent for planned home birth requires disclosing the advantages and the disadvantages — all of them. It requires presenting the data in absolute terms, not just relative risk. It requires acknowledging what we don’t know (there has never been an adequate randomized trial). It requires confirming that the patient understands the specific conditions under which home birth is reasonable — and the specific conditions that make it dangerous.
Most importantly, it requires a systematic approach. Currently, the “informed consent” for home birth is often a conversation — variable in content, dependent on the provider’s perspective, and rarely documented in a way that ensures completeness. A woman might hear about the lower cesarean rate but not the higher neonatal mortality. She might hear that transfer is available but not that transfer times in her area exceed 30 minutes. She might be told she’s “low risk” without anyone systematically verifying that she meets the criteria that make that designation meaningful.
This is where we saw a gap, and why we built two tools.
Two tools for a better conversation
The Home Birth Informed Consent Tool presents 10 evidence-based advantages and 20 evidence-based disadvantages of planned home birth, each requiring individual acknowledgment. The advantages are real and drawn from published meta-analyses: lower intervention rates, higher spontaneous vaginal delivery rates, continuous one-on-one midwifery support, familiar environment. The disadvantages are equally evidence-based and include the items that are most frequently omitted from home birth counseling: the absence of cesarean capability, neonatal resuscitation limitations, the twofold to threefold increase in neonatal mortality in US data, the 10–37% transfer rate, and the absence of adequate pain relief options. Every item must be individually checked before the consent is complete. You cannot skip what is uncomfortable.
The Home Birth Eligibility Checklist takes a different approach. Instead of asking the woman to understand the risks in the abstract, it asks her to verify — one item at a time — that she meets the specific pre-labor conditions required for home birth to be appropriate. Twenty-eight items across three categories: maternal health (no hypertension, no diabetes requiring insulin, no cardiac disease, no prior cesarean, BMI under 40), obstetric history (no prior shoulder dystocia, no prior fourth-degree tear), and current pregnancy (singleton, cephalic, term, no preeclampsia, no placenta previa, no fetal growth restriction, adequate prenatal care). Every unchecked item generates a specific explanation of why it contraindicates home birth — not a vague warning, but a precise clinical rationale.
The tool then goes further: even if all 28 pre-labor criteria are met, the report displays the intrapartum conditions that must remain true during labor (clear fluid, no fever, no need for augmentation, appropriate labor progress, no fetal heart rate abnormalities) and the system and logistics requirements that must be in place (licensed attendant, neonatal resuscitation capability, uterotonic medications, pre-arranged transport plan, receiving hospital within 20–30 minutes).
The framework concludes with a statement that matters: This does not claim hospital birth is required for everyone. It defines something narrower — a pregnancy in which clinicians can reasonably expect a spontaneous vaginal delivery that will not depend on immediate surgical, anesthesia, blood bank, or neonatal resuscitation resources.
That is the actual eligibility question. Not “Do you want a home birth?” but “Is there a reasonable clinical basis for expecting that you will not need resources that are only available in a hospital?”
Respecting autonomy means respecting the patient
The deepest irony of the home birth debate is that both sides claim to be protecting women’s autonomy while neither side consistently does the work that autonomy demands.
Respecting a woman’s autonomy is not telling a woman what to do. It is also not telling her whatever she wants to hear. It is making sure she has the information — the real information, presented honestly, completely, and in a way she can understand — and then respecting her decision.
A woman who reviews 20 specific risks, checks each one to confirm she understands it, verifies that she meets 28 eligibility criteria, understands the intrapartum conditions that must hold, and still chooses home birth — that woman has made an informed decision. Her autonomy is robust. Her providers can support her plan with a clear conscience.
A woman who was told “home birth is beautiful and safe” and is being lied to that studies show it’s safe (these studies are not US-based studies and most women are not told that the US system is way different) and signed a generic consent form has not made an informed decision.
Her autonomy has been undermined by incomplete information, regardless of how empowering the language felt.
We built these tools because the conversation deserves better than ideology. Both tools are free and available online. Use them. Share them with your patients. Share them with colleagues. If you think something is missing, tell us.
The goal is not to prevent home births. The goal is to make sure that every woman who chooses one does so with her eyes open.
References
ACOG Committee Opinion No. 697. Planned Home Birth. Obstet Gynecol. 2017;129(4):e117-e122.
Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol. 2010;203(3):243.e1-8.
Grünebaum A, McCullough LB, Arabin B, Chervenak FA. Neonatal mortality in the United States is related to location of birth rather than the type of birth attendant. Am J Obstet Gynecol. 2020;223(2):254.e1-8.
Hutton EK, Reitsma A, Simioni J, et al. Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: a systematic review and meta-analyses. EClinicalMedicine. 2019;14:59-70.
Snowden JM, Tilden EL, Snyder J, et al. Planned out-of-hospital birth and birth outcomes. N Engl J Med. 2015;373(27):2642-2653.
Grünebaum A, McCullough LB, Brent RL, et al. Perinatal risks of planned home births in the United States. Am J Obstet Gynecol. 2015;212(3):350.e1-6.
Janssen PA, Saxell L, Page LA, et al. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ. 2009;181(6-7):377-383.
Chervenak FA, McCullough LB, Brent RL, et al. Planned home birth: the professional responsibility response. Am J Obstet Gynecol. 2013;208(1):31-38.