Neonatal Mortality Risk Among Births in Freestanding Birth Centers, 2015 to 2024

Births in freestanding birth centers have grown over the past decade, particularly during the COVID-19 pandemic. Whether the safety profile of birth center births has remained stable as volumes have grown is an open question. This study examines neonatal mortality risk among births in freestanding birth centers compared with births in hospitals over the period 2015 to 2024.

This is a retrospective observational study using public-use US Natality Detail Files from 2015 to 2024. The primary outcome is neonatal death. The sample is restricted to term, singleton, and vertex births without major medical risk factors. Logistic regressions are used to consider the odds of neonatal death by setting (freestanding birth centers relative to birth in hospitals) for each year (2015 to 2024).

Across all 10 years in the sample, the adjusted odds ratio for neonatal death in freestanding birth centers fluctuated around 1.0, and no year showed a statistically significant difference in neonatal death between births in freestanding birth centers and hospitals. During the pandemic years (2020-2021), when birth center volumes increased, odds ratios were below 1.0 (0.43 in 2020; 0.78 in 2021), providing no evidence that higher use of freestanding birth centers raised the risk of neonatal death. The relative safety pattern of birth centers was consistent and stable throughout the study period.

Freestanding birth centers continue to demonstrate neonatal safety comparable with that of hospitals for low-risk pregnancies. This pattern held through a period of substantial growth in birth center use during the COVID-19 pandemic. These findings reinforce birth centers as a safe, evidence-based option for well-qualified low-risk births and support policies that integrate birth centers into mainstream maternity care systems.