Abstract
IMPORTANCE: Studies examining community births (ie, births that occur outside of a hospital setting, such as at home or in a birth center) often misclassify transfers to hospitals as hospital births. Oregon uniquely tracks planned birth location at labor onset. OBJECTIVES: To examine the association between planned place of delivery and perinatal outcomes in Oregon. DESIGN, SETTING, AND PARTICIPANTS: This was a population-based cohort study of singleton, nonbreech infants without lethal anomalies born at 37 to 44 weeks' gestation in Oregon between January 2012 and December 2020. Data were analyzed from October 2023 to September 2025. EXPOSURES: Planned hospital births vs planned community births, including completed community deliveries at home or a birthing center and those resulting in hospital transfer. MAIN OUTCOMES AND MEASURES: Outcomes included fetal, neonatal, and infant death; 5-minute Apgar scores less than 7 or less than 4; neonatal seizure; ventilator support; neonatal intensive care unit admission; delivery procedures; maternal intensive care unit admission; maternal blood transfusion; and severe perineal lacerations. Adjusted logistic regression models were used to determine the association between planned community or planned hospital births and outcomes. Propensity score analysis was conducted to account for overall differences in measured covariates between groups. RESULTS: Among 348 641 birthing individuals (mean [SD] age, 29.0 [5.8] years; 7383 non-Hispanic Black [2.1%], 66 013 Hispanic [18.9%], 235 269 non-Hispanic White [67.6%], and 38 668 [11.1%] other, including Asian/Pacific Islander, American Indian or Alaska Native, and multiple races), 332 313 planned to deliver in a hospital (95.3%) and 16 328 planned to have a community birth (4.7%). There were 2402 planned community births that were transferred to a hospital for delivery (14.7%). Compared to planned hospital births, planned community births had higher odds of 5-minute Apgar score less than 7 (adjusted odds ratio [aOR], 1.34; 95% CI, 1.19-1.50) and ventilator support (aOR, 1.14; 95% CI, 1.05-1.24). Transferred deliveries had increased odds of most adverse outcomes and medical interventions (fetal death: aOR, 5.47; 95% CI, 2.67-11.20; 5-minute Apgar score <7: aOR, 2.02; 95% CI, 1.64-2.50; 5-minute Apgar score <4: aOR, 2.21; 95% CI, 1.43-3.41; any ventilator support: aOR, 1.73; 95% CI, 1.47-2.03; neonatal intensive care unit [NICU] admission: aOR, 1.40; 95% CI, 1.15-1.71; any neonatal outcome: aOR, 2.49; 95% CI, 1.76-3.53; augmentation of labor: aOR, 1.65; 95% CI, 1.51-1.80, operative vaginal delivery: aOR, 1.33; 95% CI, 1.11-1.59; and cesarean delivery: aOR, 1.54; 95% CI, 1.39-1.59), whereas completed community births were not associated with most perinatal outcomes and had lower odds of most medical interventions (5-minute Apgar score <4: aOR, 1.01; 95% CI, 0.73-1.40; neonatal seizure: aOR, 1.19; 95% CI, 0.68-2.10; any ventilator support: aOR, 1.01; 95% CI, 0.91-1.11; ventilator support >6 hours: aOR, 0.64; 95% CI, 0.48-0.87; NICU admission: aOR, 0.52; 95% CI, 0.44-0.61; any neonatal outcome: aOR, 0.81; 95% CI, 0.60-1.10; induction of labor: aOR, 0.03; 95% CI, 0.03-0.04; augmentation of labor: aOR, 0.04; 95% CI, 0.03-0.04; operative vaginal delivery: aOR, 0.08; 95% CI, 0.06-0.11; maternal intensive care unit admission: aOR, 0.09; 95% CI, 0.05-0.19; and maternal blood transfusion: aOR, 1.05; 95% CI, 0.83-1.32). Propensity score-adjusted results aligned with the main findings. CONCLUSIONS AND RELEVANCE: While the risks of perinatal outcomes and likelihood of interventions were generally reduced in completed community births, transferred deliveries had higher odds of most perinatal outcomes and interventions. Misclassifying transfers as hospital births may mask risks associated with planned community births. These risks should be clearly communicated during patient counseling and considered in policy decisions.