Recommendation on “Planned Out-of-Hospital Childbirth”: the Position of the Austrian Society of Gynecology and Obstetrics (OEGGG)

Abstract

The debate regarding the role of out-of-hospital childbirth (home births) remains controversial in many countries, including Austria; consequently, the Executive Board of the OEGGG, acting on behalf of our professional society, has decided to issue an updated recommendation concerning planned out-of-hospital births. This recommendation aims to articulate our position within the context of the forensic and clinical requirements of modern obstetric care and to support a revision of legislation governing out-of-hospital childbirth. It was unanimously approved by the entire OEGGG Executive Board following constructive discussion. We consider out-of-hospital childbirth (home birth) to be untenable, as it contravenes established obstetric quality standards—thereby violating the forensic rights of mothers and, even more significantly, the clear safety interests of the child (as a legal entity) during the birth process. Virtually all established clinical diagnostic and treatment methods cannot be employed in a home birth setting and are thus deliberately withheld from the child. Citing proven risks, the OEGGG opposes home birth and—like other professional societies—classifies it as unsafe. Given the elevated risks involved, our primary duty of care is directed toward the child during the birth process.

In the context of the debate surrounding the AWMF S3 guideline ‘Vaginal Birth at Term’ 1 2 , the Executive Board of the Austrian Society for Gynaecology and Obstetrics (OEGGG) had already published a critical statement on out-of-hospital obstetric care (‘home birth care’), which was unanimously adopted in 2021 3 .

The debate over the role of out-of-hospital midwifery remains a contentious issue. Hospitals are regularly confronted with questionable clinical procedures relating to home births; at the same time, media attention on the issue continues, leading the OEGGG Executive Board to issue an updated recommendation on behalf of our professional association.

The aim is to set out our position in light of the legal and clinical requirements of modern obstetrics and to help support an amendment to the legislation governing out-of-hospital childbirth. Following a constructive discussion, this recommendation was unanimously approved by the entire OEGGG Executive Board.

In contrast to out-of-hospital obstetric care, obstetric care provided in hospital – where over 98% of all births in Austria take place – is subject to comprehensive quality assurance as a mandatory legal standard. The “Austrian Public Health Portal” (GESUNDHEIT.GV.AT), for which the Federal Ministry of Labour, Social Affairs and Health acts as media owner and publisher, also takes a clear stance on home births: “Gynaecological professional bodies, such as the Austrian or German Society for Gynaecology (OEGGG, DGGG), oppose home births as they are not sufficiently safe. Emergency care is not adequately available in cases of home birth care; methods for monitoring the unborn and newborn child are inadequate; there is a high rate of transfer to hospital during labour; and – unlike in hospital settings – there is no adequate quality assurance for home births” 4 .

In line with this recommendation, the ‘Out-of-Hospital Birth’ committee of the German Society for Gynaecology and Obstetrics (DGGG), chaired by the then DGGG President, published a position paper on out-of-hospital childbirth as early as 2018 and clearly rejected out-of-hospital childbirth for a third time due to the higher morbidity, the high transfer rates and the incomplete recording of quality data: “…  under these circumstances , out-of-hospital obstetric care is not safe and continues to be rejected by the DGGG” 5 6 .

In Switzerland, the Swiss Midwives’ Association (SHV) published a list of criteria in 2025 (Care and delivery criteria for home births), which was intended to address the previous lack of national guidance on inclusion and exclusion criteria for out-of-hospital obstetric care 7 . At the same time, the SHV takes the view that home births can be a safe alternative to hospital births 7 .

Following this recommendation, in April 2026 the Academy of Foetal-Maternal Medicine (AFMM) of the Swiss Society of Gynaecology and Obstetrics (SGGG) expressly distanced itself from this list of criteria. The AFMM expressed serious concerns regarding individual inclusion criteria and rejected the list of criteria “on the grounds of patient and child safety” 8 . The critical assessment of home births by experts in perinatal medicine is therefore not limited to Austria; it is currently also shared by leading representatives in foetal-maternal medicine in Germany and Switzerland.

In the OEGGG’s view, clinical facilities are essential for providing the safest place for a mother and her child to give birth. Structures in which a transfer is a frequently anticipated part of the care plan should be assessed critically. Consequently, representatives of the OEGGG reject settings in which transfer during labour is a routine care option.

A retrospective cohort study conducted by the University of Bonn showed the rate of transfer from a midwife-led delivery room to a ‘conventional’ and interdisciplinary delivery room with extended options for diagnosis and treatment to be as high as 50.3% 9 . The 2019 quality report ‘Out-of-Hospital Childbirth in Germany’ states that the rate of transfer from out-of-hospital to hospital-based care for first-time mothers is as high as 31.5% 10 .

In Austria, there is indeed a register of ‘out-of-hospital births’ maintained by the Institute for Clinical Epidemiology (Tirol Kliniken) as part of a quality improvement project. This records out-of-hospital births attended by participating midwives and enables them to provide individual quality feedback. However, there is no mandatory, comprehensive and regularly publicly reported national quality assurance scheme involving systematic outcome data collection, benchmarking, or a separate analysis of women transferred during labour in a form comparable to that used in hospital-based obstetric care 11 . The most recent report, published in 2009, stated that the rate of home births requiring transfer was 36.5% for first-time mothers and 6.6% for women who had given birth before 12 . Maternal and neonatal quality indicators for mothers transferred during labour are attributed to hospital obstetric care; consequently, there is no separate quality assessment for this specific group. This results in a methodologically questionable association between home births requiring transfer and a postulated higher rate of poor quality outcomes, to the detriment of hospital births. In the OEGGG’s view, this lack of mandatory comprehensive data collection and transparent reporting of results constitutes another key structural shortcoming of the planned out-of-hospital obstetric care in Austria.

A study conducted in Linz and published in 2024 examined the clinical outcomes of home births requiring transfer with the following findings: home births requiring transfer and births at birthing centres have higher rates of interventions during labour, vacuum extractions and emergency caesarean sections compared with planned hospital births. One multifactorial regression analysis demonstrated significantly higher risks of unfavourable outcomes for all neonatal outcome parameters (APGAR score, pH level and transfer rate) 13 .

A recent Cochrane review comparing planned home births with hospital births was unable to make any reliable statements regarding differences in maternal or perinatal mortality and morbidity due to the lack of randomised controlled trials 14 . The authors identified only one small pilot study involving 11 female participants. At the same time, they point out that the evidence is currently predominantly based on observational studies, the validity of which is limited by potential selection and confounding effects. From the OEGGG’s point of view, this leaves a significant level of uncertainty as to whether the two forms of care are actually comparable. High-quality randomised trials do not appear to be feasible given the high preference many women have for their chosen place of birth, nor are they ethically justifiable given the current evidence.

A study published in The Lancet found that the decline in neonatal mortality in China correlated with the introduction of hospital births, with neonatal mortality remaining higher in districts where home births continued to take place 15 16 .

A case-control study conducted in New York investigated the risk of neonatal hypoxic-ischaemic encephalopathy in planned home births compared with planned hospital births. The authors take a self-critical view of the relatively small number of cases, describing it as a limiting factor in the evidence. Nevertheless, this study demonstrated that, in this cohort, home births were associated with a 21-fold higher risk of hypoxic-ischaemic encephalopathy 17 .

Another American retrospective cohort study found a significant increase in perinatal mortality among the home-birth cohort, by a factor of 3.6 18 .

In their critical assessment of the planned provision of out-of-hospital obstetric care, representatives of the OEGGG also draw on the findings of the American College of Obstetricians and Gynaecologists 19 20 , which report a twofold increase in perinatal mortality and a threefold higher rate of perinatal neurological injury compared with hospital-based obstetrics.

Another analysis carried out by a high-profile research group under the auspices of the World Association of Perinatal Medicine and the International Academy of Perinatal Medicine confirmed the significantly increased risk of foetal morbidity and mortality associated with midwife-led home births. The analysis showed that, due to its ‘subjective’ scoring criteria and lack of reproducibility, the APGAR score is not a quality assurance tool. Unfortunately, in home births, apart from confirming the newborn’s vitality, the APGAR score is the only documentable ‘quality parameter’. The analysis showed that, across all home births, a 5-minute APGAR score of 10 was recorded in over 52% of cases. However, the same APGAR score is recorded after hospital births in only 3.7% of cases attended by midwives and 3.7% of cases attended by doctors. The American findings also showed, however, that hospital births attended by midwives yield similar or better outcomes than hospital births attended by doctors. The authors argue that, given their professional responsibilities, perinatal specialists should advise against planned home births and emphasise the inadequacy of the home birth setting for a rapid and effective response to obstetric emergencies. Perinatal specialists are responsible for ensuring an adequate safety culture and, at the same time, should support as ‘natural a birth experience’ as possible in hospital 21 .

We would like to emphasise that our clearly stated position is in no way directed against the quality of care provided by midwives, but relates exclusively to the structural conditions surrounding home births. Our concerns would be expressed in exactly the same terms if qualified perinatal specialists were to carry out home births in collaboration with midwives, but were faced with the same quality issues due to the lack of structural facilities outside hospital settings.

Nor do we consider out-of-hospital childbirth to be acceptable, as it runs counter to established quality standards in obstetrics and thus to the legal rights of mothers and – far more significantly – to the clear safety interests of the child, as a legal person, who is in the process of being born.

Virtually all established methods for clinical diagnosis and treatment are unavailable in home births and are therefore deliberately withheld from the child. For example, ultrasound scans cannot be carried out to assess the baby’s condition or to detect placental abnormalities. Furthermore, emergency procedures – which are frequently impossible to predict in advance – laboratory tests, adequate analgesia, the replacement of blood products or the provision of emergency medical first aid to the child are not feasible in a non-hospital setting. There are also no diagnostic or therapeutic options available for managing moderate or complex delivery injuries. The deliberate disregard for clinical standards is viewed very critically by medical lawyers 22 .

From the OEGGG’s perspective, there is a severe contradiction in the fact that hospital-based obstetric care is subject to comprehensive quality assurance, regular evaluations, and stringent legal requirements, meaning compliance with established guidelines is used as the benchmark for the quality of care. By contrast, planned out-of-hospital births take place within a structural framework in which essential diagnostic, therapeutic, and emergency medical facilities are either unavailable or only available to a limited extent. At the same time, Austria currently lacks a mandatory, comprehensive and publicly transparent quality assurance system that would enable a valid assessment of maternal and neonatal outcomes. In the OEGGG’s view, this discrepancy is unsatisfactory both in terms of modern quality standards and from the perspective of patient and child safety.

OEGGG rejects home birth care on the grounds of the proven risks and, like other professional bodies, classifies it as unsafe. Given the increased risk, our primary concern is for the child being born, towards whom we have a special responsibility not only as a professional body but also as Austrian society.

Representatives of the OEGGG are calling on the social security authorities to modify funding arrangements for home births on the grounds of the proven risks involved. Furthermore, the OEGGG recommends that the legislature carry out a fundamental review of the legal basis for the planned out-of-hospital obstetric care.