Authors' objectives: Background: Sweden has among the lowest maternal and perinatal mortality rates in the world, with approximately 0.05/1,000 for maternal mortality and 4.3/1,000 for perinatal mortality. The vast majority of births occur in hospital-based obstetric units. Planned home births do occur in several high-income countries, particularly in the Netherlands, Australia, and UK, up to 14%, but less in the Nordic countries, between 0.1 and 3.0%. Voices, for example through Birth Right Sweden, are raised for publicly funded, planned home births in Sweden, integrated into the national healthcare system, to promote autonomy and continuity of care. Even though internationally recommended exclusively for women with expected low-risk birth, the safety of planned home births and births in freestanding midwifery units remains uncertain. Although childbirth is a physiological process, risk levels vary depending on maternal health, fetal development, and access to timely medical interventions. Potential complications include fetal death, fetal distress, neonatal asphyxia, perineal trauma, postpartum haemorrhage, and the need for emergency interventions such as caesarean section or neonatal resuscitation. Question at issue: What are the differences concerning mortality and severe morbidity for mother and child in high-income countries when comparing planned birth outside hospital (planned home birth or birth at freestanding midwifery units) with planned birth at obstetric units in women with expected low-risk births?

Authors' results and conclusions: Results: Nine cohort studies with a total of 1,261,312 women were included. Further 18 case series and two case reports concerning the outcomes peri/neonatal mortality and transfer to hospital were included. The main problem with all cohort studies was risk of bias, particularly selection bias, with consistently healthier women giving birth at home/freestanding midwifery unit compared with birth at obstetric units. Further, outcome reporting might be affected by detection bias due to differences in clinical surveillance, documentation standards, and implications for care, such as the need for transfer. The precision was limited for maternal and peri/neonatal mortality. No maternal mortality was reported. Maternal admissions to intensive care unit were significantly fewer in planned home birth/freestanding midwifery unit births, compared with birth at obstetric units, adjusted OR 0.41 (95% confidence interval (CI) 0.19-0.89). A significantly higher risk for peri/neonatal and neonatal mortality was seen for planned home/freestanding midwifery unit births compared with obstetric units, OR 1.70 (95% CI 1.05-2.74) and OR 2.65 (95% CI 1.45-4.86), respectively. Several critical outcomes for the children were not reported in any of the included articles. There were fewer neonatal intensive unit admissions from planned home/freestanding midwifery unit births, adjusted OR 0.67 (95% CI 0.56-0.81). Severe perineal tears were significantly fewer in planned home/freestanding midwifery unit births, adjusted OR 0.64 (95% CI 0.45-0.93). Further, there were fewer intrapartum caesarean sections, adjusted OR 0.29 (95 CI% 0.26-0.33), and postpartum haemorrhage cases. There was no difference regarding the outcomes postpartum haemorrhage requiring transfusion and neonatal asphyxia. The certainty of evidence for conclusions was low for all outcomes (GRADE ⊕⊕ΟΟ), except maternal mortality where it was very low (GRADE ⊕ΟΟΟ). The outcome postpartum depression was not reported in any of the included studies. Transfer from home/freestanding midwifery units to an obstetric unit was reported in 9.3%-33.3% (20.7% in the largest study). Conclusion: All conclusions are based on low or very low certainty of evidence. Peri/neonatal mortality may be increased in planned midwifery-led home/freestanding midwifery unit births compared with planned obstetric unit births for women with expected low-risk births. However, the absolute risks are low. Reduced rates of some, mainly adverse maternal outcomes, including caesarean section, may occur in planned home/freestanding midwifery unit births. There are several ethical aspects to consider.

Authors' methods: Methods: During May 2024, updated March 2025, two authors performed systematic searches in Medline, Embase, the Cochrane Library, and Cinahl. Websites of Scandinavian national and regional HTA-organisations were visited. Reference lists of relevant reports were also scrutinised for additional references. Two authors screened the obtained titles and abstracts and made the first selection of full-text reports. At least two authors read all full-text reports, independently of one another, and it was finally decided in a consensus meeting which reports should be included in the assessment. Included studies were critically appraised using checklists. The results of each study were summarised per outcome and, when possible, data were pooled in meta-analyses. Metaanalyses were conducted using the random effects model with odds ratio (OR) as point estimate with 95% CI. When available, adjusted OR (AOR) was used in meta-analyses. The certainty of evidence for each outcome was assessed using the GRADE approach for cohort studies. If only one study reported an outcome with AOR the certainty of evidence was based on OR.

Project Status: Completed

Year Published: 2025

URL for published report: https://mellanarkiv-offentlig.vgregion.se/alfresco/s/archive/stream/public/v1/source/available/sofia/su4372-2081313122-161/native/2025_145%20Planned%20home%20birth%202025-11-21.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Organisation Name: The Regional Health Technology Assessment Centre

Contact Address: The Regional Health Technology Assessment Centre, Region Vastra Gotaland, HTA-centrum, Roda Straket 8, Sahlgrenska Universitetssjukhuset, 413 45 GOTHENBORG, Sweden

Contact Name: hta-centrum@vgregion.se

Contact Email: hta-centrum@vgregion.se