Community births in the United States, 2016–2024: post-pandemic patterns across racial and ethnic groups

Introduction

Community births, defined as intended home births and births in freestanding birth centers, account for only a small proportion of U.S. deliveries but have grown steadily in recent years. These settings are associated with higher risks of neonatal morbidity and mortality compared with hospital births, yet the number of families choosing them continues to rise [1].

The American College of Obstetricians and Gynecologists considers the hospital as the safest place for delivery and outlined strict criteria for the selection of appropriate candidates for home birth [2]. But these criteria have not been widely implemented by midwives practicing outside hospitals with increased risk profiles during the COVID-19 pandemic. [3], [4], [5], [6]. This gap has contributed to a significantly higher risk of adverse outcomes, including elevated rates of neonatal morbidity and mortality [7], 8]. Although international systematic reviews have reported comparable or even favorable outcomes for low-risk women delivering at home or in birth centers, these findings are limited to carefully selected low-risk populations within integrated maternity systems [9], 10]. This limitation does not reflect the reality of U.S. community births, where risk profiles are often higher and midwifery services are less consistently integrated into the healthcare system, resulting in outcomes that differ substantially from those reported in low-risk international cohorts. In contrast, in the United States, a large proportion of women who pursue community births have high-risk conditions such as prior cesarean delivery, advanced maternal age, twins, breech presentation, or medical comorbidities, making direct comparison misleading and safety concerns more pronounced [11]. Families nevertheless turn to community births for multiple reasons, including the desire for a more natural or personalized experience, concerns about cesarean delivery and other hospital interventions, dissatisfaction from prior hospital encounters, and, more recently, fears about hospital care during the COVID-19 pandemic [12]. Behavioral science insights have suggested that cognitive biases may contribute to underestimation of risks and overemphasis on perceived benefits of home birth, while structured approaches to counseling may help ensure more balanced decision-making [12].

In contrast to countries such as England and the Netherlands, where out-of-hospital birth is fully integrated into the maternity system and rates have remained stable or declined, the United States stands out for continued increases despite well-documented safety concerns. Understanding how birthplace patterns vary across racial and ethnic groups, and how they changed during and after the pandemic, is essential for shaping clinical counseling and health system responses.

The objective of this study is to evaluate national trends in birthplaces by race and ethnicity, with particular attention to changes observed during the COVID-19 pandemic and in the years that followed.

Methods

We conducted a retrospective, descriptive, population-based cohort study of all recorded term live births in the United States from 2016 through 2024, using publicly available natality data from the CDC WONDER database [13]. Data were stratified by year, birthplace, and race/ethnicity. According to the CDC classification, place of births were classified as: Hospital, Freestanding birth center, Home (intended), Home (not intended), Unknown or other. For subgroup analyses, “home (not intended)” and “home (unknown if intended)” were combined. We used the following CDC categories: Hispanic, non-Hispanic (NH) White, NH Black, NH Asian, NH American Indian/Alaska Native (AmInd), NH Native Hawaiian/Pacific Islander (Haw), NH more than one race (>1), and Unknown ethnicity. We assessed absolute counts and proportions per year by birthplace. The primary outcome was the change in community births (intended home+freestanding birth center) between 2016 and 2024. We did not conduct formal statistical tests of trend; rather, our analyses were descriptive.

Results

Overall trends

Table 1 shows the proportion change of birthplace for each year from 2016 to 2024, Figure 1 shows relative changes in Community Births (intended home plus birth center births) by years for the 4 main racial/ethnic groups and Figure 2 shows relative changes in birthplaces by years overall and for each racial/ethnic group. Between 2016 and 2024, the proportion of hospital births decreased from 98.3 % (3,494,408) to 97.6 % (3,157,655), a decline of 0.8 percentage points. During the same period, the proportion of intended home births rose from 0.82 % (29,016) to 1.45 % (47,045), representing a 62 % relative increase. Freestanding birth center births also grew, from 0.55 % (19,617) to 0.69 % (22,308), a 25 % relative increase. Births at home without intention increased slightly, while the “unknown/other” category declined. Overall, community births (intended home plus freestanding birth center) increased from 1.37 % of U.S. births in 2016 to 2.14 % in 2024.

Table 1:

Proportion of birthplace by year 2016–2024.

Year	Hospital	Freestanding birth center	Home (intended)	Home (not intended)	Unknown or other
2016	98.32 % (3,494,408)	0.55 % (19,617)	0.82 % (29,016)	0.11 % (3,853)	0.20 % (7,202)
2017	98.30 % (3,410,796)	0.57 % (19,772)	0.82 % (28,402)	0.11 % (3,885)	0.20 % (7,025)
2018	98.26 % (3,349,861)	0.58 % (19,754)	0.85 % (28,921)	0.11 % (3,815)	0.20 % (6,914)
2019	98.23 % (3,302,486)	0.59 % (19,916)	0.86 % (29,019)	0.11 % (3,809)	0.20 % (6,695)
2020	97.89 % (3,177,971)	0.67 % (21,729)	1.07 % (34,809)	0.13 % (4,195)	0.24 % (7,824)
2021	97.65 % (3,200,289)	0.71 % (23,382)	1.32 % (43,205)	0.15 % (4,837)	0.17 % (5,477)
2022	97.58 % (3,205,030)	0.72 % (23,800)	1.38 % (45,330)	0.16 % (5,260)	0.15 % (4,980)
2023	97.53 % (3,139,845)	0.71 % (22,977)	1.45 % (46,565)	0.16 % (5,184)	0.15 % (4,753)
2024	97.55 % (3,157,655)	0.69 % (22,308)	1.45 % (47,045)	0.16 % (5,138)	0.15 % (4,867)

Figure 1:

Relative changes in community births (intended home plus birth center births) by years and 4 main racial/ethnic groups with 2016 as baseline (100 %).

Figure 2:

Relative changes in birthplaces by years and for each racial/ethnic group with 2016 as baseline (100 %).

Discussion

This national analysis demonstrates that community births in the United States continued to increase beyond 2022 and through 2024 [1]. However, the trajectories varied substantially by race and ethnicity. For most groups – including non-Hispanic White, Hispanic, Asian, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and multiracial women – the pandemic surge in community births has persisted, suggesting that out-of-hospital birth is becoming a more established feature of the U.S. maternity landscape. By contrast, among non-Hispanic Black women, community births peaked during 2020–2021 but subsequently declined, underscoring that the pandemic-related rise was not uniform in its durability.

It is important to consider potential biases introduced by changing denominators across racial and ethnic groups. For example, non-Hispanic White births declined by more than 10 % between 2016 and 2024, while Hispanic births increased. In smaller populations, even modest absolute shifts can appear disproportionately large when expressed as percentages. This limitation is important for contextualizing subgroup findings and should be borne in mind when interpreting differences across groups, proportional comparisons may overstate or understate the magnitude of change within groups, particularly for smaller populations such as American Indian/Alaska Native or Native Hawaiian/Pacific Islander women. Absolute numbers remain low in some subgroups, and even small shifts can appear large when expressed as percentages.

The persistence of elevated community birth rates in many groups beyond the COVID-19 pandemic surge highlights potential structural and cultural drivers that extend beyond pandemic disruptions [12], 13]. These include dissatisfaction with perceived overuse of medical interventions in hospitals, the desire for more personalized and culturally responsive care, and mistrust of institutional settings. Systemic factors such as hospital closures and the expansion of maternity care deserts further exacerbate disparities by limiting access to safe, facility-based obstetric care [14], [15], [16]. For example, American Indian/Alaska Native women and women in rural areas may face geographic barriers that may leave community birth as one of the few accessible options. In contrast, for non-Hispanic Black women, the temporary pandemic surge followed by a decline may reflect a complex interplay of mistrust, heightened awareness of safety risks, and possible targeted outreach efforts after the peak pandemic years.

International comparisons underscore the distinctiveness of the U.S. experience. In countries such as England and the Netherlands, where midwifery is fully integrated into the healthcare system, out-of-hospital birth is embedded within a regulated framework that ensures close collaboration, standardized credentialing, and seamless transfer to hospitals when needed [17]. Outcomes reported from these systems, particularly for carefully selected low-risk women, are therefore not directly comparable to those in the United States. By contrast, U.S. midwifery is characterized by fragmented regulation and variable credentialing, ranging from certified nurse-midwives with rigorous hospital-based training to lay or direct-entry midwives whose education and oversight may be inconsistent across states. This heterogeneity, coupled with the absence of a consistently integrated transfer system, means that out-of-hospital birth in the U.S. carries higher risks and greater variability in outcomes. For these reasons, applying international evidence to the U.S. setting risks obscuring important safety concerns and overestimating the protective effect of midwifery in a context where training, integration, and regulatory safeguards differ substantially.

These findings also highlight the need for policy-level interventions. Addressing maternity care deserts through expansion of hospital-based services and ensuring consistent national standards for midwifery credentialing would reduce unsafe variations in practice and improve equitable access to safe obstetric care.

Fully informed consent is central to counseling of pregnant women, not only about birthplace decisions [5], 18], 19]. Informed consent is not simply the act of signing a document; it requires that patients receive complete, accurate, and comprehensible information about risks, benefits, and alternatives, and that they have the opportunity to ask questions in a supportive environment.

Because out-of-hospital births are consistently associated with higher neonatal risks [2], 3], 7], 8], professional responsibility requires a process of fully informed consent that leads to directive counseling. In this context, clinicians should recommend hospital birth as the safest option while still respecting patient autonomy. This approach is supported by the American College of Obstetricians and Gynecologists, whose 2021 Committee Opinion on informed consent and shared decision-making emphasizes that patients must receive clear, accurate, and comprehensible information about risks, benefits, and alternatives to make meaningful decisions [18]. Directive counseling, when properly practiced, is consistent with these principles: it ensures that patients are informed while also receiving professional guidance about the safest course of action. We recognize that some experts and professional bodies emphasize ‘shared decision-making’ in discussions of birth location. However, we deliberately distinguish informed consent with directive counseling from shared decision-making. Shared decision-making presumes equipoise among options, whereas in the case of community vs. hospital birth, equipoise does not exist because hospital birth is demonstrably safer. Informed consent, properly conducted, ensures accurate disclosure of risks, benefits, and alternatives, preserves patient autonomy, and fulfills the physician’s professional responsibility to recommend hospital birth as the safest course. Importantly, directive counseling must not be equated with paternalism. As articulated in the professional responsibility model, physicians have an ethical duty not only to respect autonomy but also to use their expertise to prevent avoidable harm [20]. Paternalism implies overriding patient choice, whereas directive counseling preserves autonomy while fulfilling the physician’s responsibility to recommend hospital delivery as the option that best protects maternal and neonatal safety. Without this process, women may underestimate risks, undermining both ethical obligations and clinical safety.

The CDC natality database is an important part of assessing maternal and neonatal health in the United States [21]. While the CDC natality database represents a major strength in providing comprehensive national data, reliance on this resource also poses limitations. Misclassification of intended vs. unintended home births remains possible, and the completeness of reporting may vary by jurisdiction. In addition, under the current federal administration, the CDC has experienced budget cuts and organizational changes, raising concern that access, timeliness, and continuity of natality data could be compromised in the future. Any disruption to this dataset would hinder surveillance of maternal and neonatal outcomes and limit the ability of clinicians and researchers to monitor national trends in birthplace.

In sum, the sustained growth of community births beyond the pandemic years highlights potential systemic weaknesses in U.S. maternity care across racial and ethnic groups. Addressing these patterns requires a dual approach: ensuring fully informed consent with directive counseling and reforming hospital-based care to reduce unnecessary intervention and guarantee safe, respectful, and accessible maternity services. Only through this combined strategy can preventable perinatal morbidity and mortality be reduced while addressing the legitimate concerns of diverse patient populations.

Conclusions

From 2016 to 2024, community births in the United States nearly doubled, with sustained increases in most racial and ethnic groups but only a temporary rise among non-Hispanic Black women. Patterns in birthplace clearly shifted during the COVID-19 pandemic, with increases seen across most groups, but the specific drivers remain uncertain. The persistence or decline of these trends beyond 2021 likely reflects multiple, overlapping factors that are difficult to disentangle.

Because out-of-hospital births are consistently associated with higher neonatal risks, fully informed consent is essential. Professional responsibility requires accurate disclosure of risks and alternatives, comprehension by the patient, and the opportunity for meaningful dialogue. It should lead to directive counseling, where clinicians recommend hospital delivery as the safest option while respecting patient autonomy.

Finally, continued access to reliable data is important. The CDC natality database is a vital national source, but its continuity may be threatened by budgetary and organizational changes. Safeguarding this resource is important for public health surveillance and evidence-based guidance. Improving maternal and neonatal outcomes will require both strengthened informed decision-making and reforms in hospital-based care to reduce unnecessary interventions and ensure trust in hospital births.