With home births and other such arrangements becoming more popular in the United States, debate is intensifying over an important question: Just how safe is it to have a baby outside a hospital?
A study published recently in the New England Journal Of Medicine provides some of the clearest information on the subject to date.
The study, which analysed nearly 80,000 pregnancies in Oregon, found that when women had planned out-of-hospital deliveries, the probability of the baby dying during birth or in the first month after - though slight - was 2.4 times greater than for women who had planned hospital deliveries.
Out-of-hospital births also carried greater risk of neo-natal seizures, and increased the chances that newborn babies would need ventilators or mothers would need blood transfusions.
PRIORITIES AND RISKS
The question is what is most important to you and what risks are you willing to accept.
DR MICHAEL GREENE, chief of obstetrics at Massachusetts General Hospital
However, out-of-hospital births were far less likely to involve Caesarean sections - 5.3 per cent compared with 24.7 per cent in a hospital. They also involved fewer interventions to augment labour, and mothers had fewer lacerations.
In the often-polarised debate over home birth, the study has been embraced by advocates on all sides.
Dr Joseph Wax, the vice-chairman of the American College of Obstetricians and Gynaecologists' committee on obstetric practice, said the study showed "there's clearly pros and cons to the different available birth settings, both with benefits and risks to mums and babies".
A tiny fraction of US births occur outside hospitals, but they have been increasing, partly because some women want to avoid interventions like induced labour or Caesarean sections.
In 2012, according to federal data, births at home and birth centres comprised 1.28 per cent of all American births, up from 0.79 per cent in 2004.
That growth has drawn attention to issues of safety, midwife training and licensing, coordination between midwives and doctors, as well as arrangements for transferring women to hospitals if problems arise.
The study team, based at Oregon Health and Science University, also adjusted for women's race, age and pregnancy risks like diabetes or hypertension, so those factors could be ruled out as explanations for delivery problems.
Dr Jonathan Snowden, an epidemiologist who was the lead author, and his colleagues analysed 79,727 births in 2012 and 2013 in Oregon.
They excluded births involving twins, birth defects, breech or premature delivery.
Of those, 75,923 women delivered in a hospital as planned; 3,203 delivered outside a hospital as planned, including almost 2,000 at home; and 601 women planned out-of-hospital births but were transferred to hospitals.
Severe complications were rare in all locations, but in planned out-of-hospital births, 3.9 out of 1,000 cases resulted in a baby's death during birth or within four weeks after, compared with 1.8 deaths out of 1,000 in planned hospital births.
"The question is what is most important to you and what risks you are willing to accept," said Dr Michael Greene, the chief of obstetrics at Massachusetts General Hospital and an associate editor of The New England Journal Of Medicine.
Ms Ellen Tilden, a certified nurse midwife who was an author of the study, said she hoped the results "will be used to think about decreasing risk in all birth settings".
Ms Erin Dietrich would welcome that. The 35-year-old had her first child in 2011 at a midwife's house in isolated Otis, Oregon.
She said she loved the "hippy kind of alternative birth thing", but suffered a "pretty bad tear" that the midwife did not treat. "I was in a lot of pain for a long time until I finally saw a regular doctor."
For her second child, she chose a big Portland hospital with a bathtub-equipped birthing suite and a nurse midwife. But when she arrived, she had to wait for a room and received notably less individual attention, she said.
Still, when she had a tear, "they stitched me right up, I healed so quickly and I felt great", she said.
NEW YORK TIMES