Who is at home, and who is attending
Some American planned home births involve a breech baby, twins, a previous cesarean or a pregnancy past 41 weeks. That is a different problem from home birth itself, and it is the one you can do something about.
Disclosure: three of the studies with the American numbers in this topic are co-authored by the doctor whose name is on this guide. They are the proposal to extend the contraindication list, the 2010 to 2012 prevalence figures, and the 2016 mortality re-analysis quoted at the end.
There are two very different claims that get run together, and separating them is the most useful thing you can take from this stage.
The first is "home birth is dangerous." The international evidence does not support that as a general statement, and for a woman having a later baby in a well-integrated system it points the other way.
The second is "planned home birth as it is currently practised in the United States includes pregnancies that no guideline considers eligible." That one is supported, with numbers.
ACOG names three absolute contraindications, verbatim: The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth.
Three. Not five. Some of the authors of the studies above have proposed adding a first birth and 41 weeks or more, for a total of five. That is their published proposal, not a guideline, and ACOG's document was reaffirmed in 2026 still listing three.
Here is how often those situations turn up at American midwife-attended planned home births, on 2010 to 2012 birth records. These are the proportions as published; the counts behind them were not available for this guide, so none is invented here.
| At a midwife-attended planned home birth | How often, 2010 to 2012 |
|---|---|
| Baby past 41 weeks | 28.19% |
| Previous cesarean | 4.4% |
| Breech presentation | 0.74% |
| Twins | 0.64% |
| Midwife not certified by the American Midwifery Certification Board | 65.7% |
The authors' conclusion, in their own words: At least 30% of midwife-attended planned home births are not low risk and not within clinical criteria set by ACOG and AAP, and 65.7% of planned home births in the United States are attended by non-AMCB certified midwives, even though both AAP and ACOG state that only AMCB-certified midwives should attend home births.
That last clause is these authors' description of the two societies' positions, and this guide could not read the pediatric society's own statement, so it is attributed to them rather than to the societies.
The counter-observation, which belongs here. Those are 2010 to 2012 data. A different research group, reading the same national source, reports that risk selection has been improving: that the medical and social risk profile of out-of-hospital births improved substantially between 2004 and 2014, and that in 2020 women having planned home and birth center births were less likely than hospital patients to be teenagers, to smoke, to be obese, or to have a preterm, low-birthweight or multiple birth. Their 2022 paper gives no figures for those characteristics in the record available here, so none is printed. The direction of travel is genuinely contested between two groups reading the same data, and you should know that rather than being handed one side.
Big babies. A registry of 68,966 American planned community births from 2012 to 2018 found birthweights of 4,000 to 4,499 g in 16%, 4,500 to 4,999 g in 3.3%, and 5,000 g or more in 0.4%. Heavier babies carried a steadily higher chance of heavy bleeding after birth. That registry pools home with birth center births and is not a national figure for home birth alone.
Babies born before 37 weeks. There is no reliable published figure for how often American planned home births happen before 37 weeks. Almost every mortality study above deliberately restricts itself to 37 weeks and later, so those studies cannot answer the question at all. Anyone who gives you a number for this should be asked where it came from.
Now the credentials, because the letters are not decoration.
| Title | Education required | Board certified? |
|---|---|---|
| Certified Nurse-Midwife (CNM) | Graduate degree; trained and licensed in nursing and midwifery | Yes, by the American Midwifery Certification Board |
| Certified Midwife (CM) | Graduate degree | Yes, by the same board |
| Certified Professional Midwife (CPM) | High school diploma or equivalent; one route requires no degree or diploma at all | No |
| Direct-entry midwife | No degree required; routes include self-study and apprenticeship | No |
| Lay midwife | No degree; trained informally | No |
Which of these may practise, and under what licence, is set state by state and changes. This guide does not print a count of states, because the published count available here is a decade old and could not be confirmed as current. Ask about your own state.
ACOG's position is explicit: In comparison with planned out-of-hospital births attended by American Midwifery Certification Board-certified midwives, planned out-of-hospital births by midwives who do not hold this certification have higher perinatal morbidity and mortality rates. At this time, for quality and safety reasons, the College specifically supports the provision of care by midwives who are certified by the American Midwifery Certification Board (or its predecessor organizations) or whose education and licensure meet the International Confederation of Midwives Global Standards for Midwifery Education. The College does not support provision of care by midwives who do not meet these standards.
"What is your licence status in this state, and what does it allow you to do?"
"Would you attend a breech baby, twins, a birth after a previous cesarean, or a birth at 42 weeks? If yes, what does ACOG say about that?"
"At what point would you tell me I am no longer a candidate for a home birth?"