Midwives' clinical decision-making in planned out-of-hospital birth: A systematic review and conceptual synthesis.

PROBLEM: Planned out-of-hospital birth services are expanding, requiring midwives to make complex clinical decisions in environments characterised by limited immediate support, increasing governance requirements, and heightened scrutiny of adverse outcomes. BACKGROUND: Despite strong evidence supporting the safety of planned out-of-hospital birth for women having a low-risk pregnancy, existing research has predominantly focused on outcomes, with limited synthesis of how midwives make clinical decisions in these contexts. Increasing medicalisation, risk-oriented paradigms, and reliance on standardised decision-support tools may further shape clinical judgement and the interpretation of physiological labour. AIM: To map and synthesise evidence on factors influencing midwives' clinical decision-making in planned out-of-hospital birth. METHODS: A systematic review was conducted and reported in accordance with PRISMA guidelines. Electronic databases were searched, and 13 studies met the inclusion criteria. FINDINGS: Clinical decision-making was conceptualised as a dynamic, relational, and context-sensitive process. Three key themes were identified: Physiological Orientation & Embodied Assessment, Enabling Conditions, Confidence and Environment, Autonomy, Accountability and Transfer. Decision-making extended beyond measurable clinical parameters to include embodied, relational, and contextual forms of knowledge. DISCUSSION: This review advances a conceptualisation of decision-making as a coalescent process that integrates biophysical data, experiential knowledge, and contextual awareness. Current clinical decision tools may not fully capture this complexity. CONCLUSION: Re-envisioning clinical decision-making frameworks to reflect, integrate, and be context-sensitive is essential to supporting safe, woman-centred out-of-hospital birth and strengthening midwifery agency. STUDY REGISTRATION: PROSPERO CRD420261399685.