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Transfer Protocols for Out-of-Hospital Birth

Position Statement

December 10, 2025 

While the majority of births in the United States take place in a hospital or accredited birth center setting, there are patients who prefer to give birth outside the hospital and who prefer a nonphysician birth attendant. Rates of planned out-of-hospital birth are expected to continue to rise.1 There has also been an alarming increase in labor and delivery unit closures in recent years, putting access to a nearby delivery hospital out of reach for a growing number of patients. More than 100 rural hospitals closed their labor and delivery units since 2020, impacting the majority of states.2 Over half of rural hospitals in the United States do not offer labor and delivery services.3

ACOG believes that hospitals and birth centers that are both licensed and accredited are the safest settings for birth, while also recognizing that each patient has the right to make a medically informed decision about delivery.4 Research supports that an integrated maternity care system with risk-appropriate care contributes to reducing maternal morbidity and mortality, including inequities in outcomes.5,6

An estimated 10–25% of planned out-of-hospital births involve intrapartum or postpartum transfer of care to a hospital for neonatal or maternal health needs.7,8 Protocols for safe and timely intrapartum transfer of the laboring patient should be in place for all patients planning to give birth outside the hospital setting, regardless of apparent obstetric or neonatal risk factors during pregnancy and onset of labor.9,10  In 2024, the Centers for Medicare & Medicaid Services, or CMS, finalized updated Conditions of Participation for all hospitals that receive Medicare and Medicaid funding, regardless of the presence of labor and delivery units. Effective July 1, 2025, hospitals must have written policies and procedures for the transfer of patients to the appropriate level of care.11 ACOG further recommends that hospitals establish transfer protocols in collaboration with the receiving hospitals.

In advancement of ACOG’s goal to achieve optimal maternal and neonatal health outcomes regardless of intended place of birth, ACOG:

  • Supports policies that encourage out-of-hospital birth attendants, as well as all non-birthing facilities, to establish a relationship with a hospital with a labor and delivery unit that is prepared to accept a transfer if a higher level of care for a laboring or postpartum patient is needed
  • Recommends each out-of-hospital birth attendant have written transfer protocol agreements that are mutually agreed upon with the hospital(s) who would be receiving patients in the event of need for transfer
  • Supports policies that require clear communication by out-of-hospital birth attendants to their patients regarding transfer protocols, including prevalence, logistics, limitations, and scenarios in which a transfer may occur, to foster shared decision-making regarding risks and benefits
  • Encourages institutions with labor and delivery units to establish mutually respectful and collaborative relationships with out-of-hospital birth attendants in their community to construct patient-centered transfer protocols, education, and simulation to optimize quality and safety of birth in their region of practice
  • Supports the exploration of creative solutions to foster increased collaboration with out-of-hospital birth attendants, including development of a decision aid or other patient-centered tools to support shared decision-making and foster safe and timely transfer of intrapartum and postpartum patients

References

  1. MacDorman MF, Barnard-Mayers R, Declercq E. United States community births increased by 20% from 2019 to 2020. Birth. 2022 Sep;49(3):559-568. doi: 10.1111/birt.12627. Epub 2022 Feb 25. PMID: 35218065.
  2. https://chqpr.org/downloads/Rural_Maternity_Care_Crisis.pdf
  3. Ibid.
  4. Planned home birth. Committee Opinion No. 697. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e117–22.
  5. Levels of maternal care. Obstetric Care Consensus No. 9. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134:e41–55.
  6. Osei-Poku GK, Prentice JC, Easter SR, Diop H. Delivery at an inadequate level of maternal care is associated with severe maternal morbidity. Am J Obstet Gynecol. 2024 Nov;231(5):546.e1-546.e20. doi: 10.1016/j.ajog.2024.02.308. Epub 2024 Mar 2. PMID: 38432412.
  7. Stapleton SR, Osborne C, Illuzzi J. Outcomes of care in birth centers: demonstration of a durable model. J Midwifery Womens Health. 2013 Jan-Feb;58(1):3–14. doi: 10.1111/jmwh.12003. Epub 2013 Jan 30. PMID: 23363029.
  8. Nethery E, Schummers L, Levine A, Caughey AB, Souter V, Gordon W. Birth Outcomes for Planned Home and Licensed Freestanding Birth Center Births in Washington State. Obstet Gynecol. 2021 Nov 1;138(5):693–702. doi: 10.1097/AOG.0000000000004578. PMID: 34619716; PMCID: PMC8522628.
  9. Planned home birth. Committee Opinion No. 697. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e117–22.
  10. Planned Home Birth. Position Statement. American College of Nurse-Midwives. December 2016. Planned-Home-Birth-Dec-2016.pdf.
  11. 42 CFR 482.43(c)

Approved by the Board of Directors: November 2025