Out-of-hospital births and neonatal outcomes: a retrospective cohort study from a level IV NICU and review of regulatory frameworks.

Out-of-hospital births have increased in the United States, yet their neonatal safety remains debated, particularly in states with lower midwifery integration. This study aimed to describe neonatal outcomes following out-of-hospital births, compare home vs. birth center deliveries, and evaluate birth center features associated with neonatal transfers. We conducted a retrospective cohort study at a Texas Level IV NICU which included 226 neonates admitted post-out-of-hospital births (2020-2024). Analysis included electronic record derived outcomes and resource utilization, supplemented by surveys of six regional birth centers on staffing, equipment, protocols, and transfers. Birth centers had more admissions (48.7% vs. 43.8% home births), but home-born infants showed worse outcomes: median NICU LOS (11.5 vs. 5 days), prolonged antibiotics (median 2 vs. 1d), Mortality (6% vs. 1.8%). Surveys revealed substantial variability: all centers screened for GBS, but only half mandated prophylaxis; 50% had IVs; there was no access to defibrillators. Hospital distance averaged 3.15 miles (travel time ∼12 min), yet transfer delays were common due to late recognition of complications. Neonates from out-of-hospital births exhibited elevated morbidity, mortality, and healthcare utilization. Standardized safety protocols, enhanced regulatory oversight, and improved emergency preparedness are needed, especially in states like Texas with lower midwifery integration.