Four settings, and what you are actually deciding
Between one and two American births in every hundred happen outside a hospital, and the number has been rising for twenty years.
Part 2 of this guide covered how the place you give birth changes what happens to you. This stage is about something narrower and harder: the distance between what a setting is expected to deliver and what it can deliver, and whether anyone gave you the real numbers before you decided.
There are four settings in the world's best studied system, England: your own home, a freestanding midwifery unit, a midwifery unit attached to a hospital, and a hospital labor unit. In the United States there are effectively three: hospital, freestanding birth center, and home.
Here is the scale of it. In 2020 there were 71,870 American community births, meaning births at home or in a freestanding birth center. Within that total, 45,646 were at home and 21,884 in a birth center. Those two counts do not add up to the total, and the record available for this guide does not account for the remainder, so they are printed as published rather than as a complete split. That was 1 in every 50 US births, or 2.0%. Community births rose 19.5% from 2019, and planned home births rose 23.3%, with increases in every state.
Over the longer run, out-of-hospital births rose 72% between 2004 and 2014, from 0.87% to 1.50% of American births. One 2024 paper reports that planned home births rose about 60% between 2016 and 2023, reaching 46,918. Two disclosures about that last paper: it is co-authored by the doctor whose name is on this guide, and its own abstract states that it was drafted with AI assistance. Both facts are on the published record and you are entitled to have them.
ACOG's own figure is older, and the document does not flag it as older: In the United States, approximately 35,000 births (0.9%) per year occur in the home. Approximately one fourth of these births are unplanned or unattended.
The national data brief underneath that figure is from 2014. That last sentence of the quotation matters more than it looks. An unplanned home birth is a different event from a planned one, and mixing the two makes planned home birth look worse than it is.
One more fact about the American picture that changes how you should read everything else. In 2014, 67.1% of planned home births were paid for out of the woman's own pocket, against 31.9% of birth center births and 3.4% of hospital births. In 2020, more than two thirds of planned home births were still self-paid. This is, for most American women, a decision that costs money rather than saves it.
"If I transfer to the hospital in labor, who bills me, and for what?"