Background: In many high-income countries, out-of-hospital birth sits within a nationally regulated, midwifery-led system with uniform credentials, defined risk criteria, and formal transfer pathways. The United States has no such framework. Regulation is set state by state: midwife credentials range from certified nurse-midwives to direct-entry midwives with no nursing training, freestanding birth centers may be licensed, voluntarily accredited, or unregulated, and hospital integration is often informal. Such births now account for roughly 1.3% of U.S. deliveries and are rising. Texas is comparatively permissive, with limited facility oversight and low midwifery integration.

Objective: To describe neonatal outcomes after out-of-hospital birth in this weakly regulated setting and assess birth center preparedness.

Methods: Retrospective cohort study at a 106-bed Level IV neonatal intensive care unit (NICU) — the highest U.S. acuity designation — in Fort Worth, Texas. Record review identified 226 neonates admitted after out-of-hospital birth (2020–2024). Outcomes were NICU length of stay (LOS), in-hospital mortality, and severe morbidity. Structured surveys on staffing, equipment, and transfer protocols were sent to all 13 freestanding birth centers in the county.

Results: Of 5,570 NICU admissions, 226 (4.1%) followed out-of-hospital delivery: 110 birth center, 99 home, 17 en route. Home-born infants fared worse than birth center transfers: median LOS 11.5 versus 5 days; mortality 6.1% versus 1.8%. Ten neonates (4.4%) died, most from severe hypoxic-ischemic encephalopathy (n=7) or sepsis (n=3). Six of 13 centers responded. All screened for group B Streptococcus but only two consistently gave intrapartum prophylaxis; half had intravenous access; none had defibrillators, advanced airway equipment, or physician involvement in intrapartum care.

Conclusion: In a permissive regulatory environment, neonates transferred after out-of-hospital birth had high morbidity and mortality, with home birth carrying greater risk than birth center delivery. Findings support uniform safety standards, mandatory accreditation, and integration of community birth into regional perinatal systems — relevant wherever out-of-hospital birth expands without oversight.

David Riley, MD, MBA, is a neonatologist at Cook Children's Medical Center in Fort Worth, Texas, and Director of Research and Education for Fort Worth Neonatology, Pediatrix Medical Group of Texas. He serves as Chief Medical Officer of AyuVis Research and is a member of the faculty at the Anne Burnett School of Medicine at Texas Christian University.

He practices in Cook Children's 106-bed Level IV neonatal intensive care unit, one of the largest in the country, caring for critically ill and extremely preterm newborns referred from across North Texas.

His scholarly work sits at the intersection of neonatal clinical outcomes and health policy, with a focus on how the systems surrounding a birth shape what happens to the infant. He is the senior and corresponding author of a five-year retrospective cohort study of neonates transferred to a Level IV NICU after out-of-hospital birth, paired with a structured survey of regional freestanding birth centers examining staffing, emergency preparedness, and transfer protocols. That work documents substantial neonatal morbidity, mortality, and resource utilization following community birth, and makes the case for minimum safety standards and closer integration of out-of-hospital birth settings into regional perinatal systems.