Maternal and Peri/Neonatal Mortality and Morbidity in Midwife‐Assisted Low‐Risk Birth Outside Hospital Compared to Obstetric Team‐Assisted Low‐Risk Hospital Birth: A Systematic Review and Meta‐Analysis

AIM: To compare outcomes of planned home or freestanding midwifery unit (FMU) with obstetric unit births in high-income countries. METHODS: We conducted a systematic review and meta-analysis of systematic reviews, randomised controlled trials, cohort studies, case series, and case reports. Medline, Embase, CINAHL and the Cochrane Library were searched up to 8 April 2026 (PROSPERO: CRD42024570558). Outcomes included maternal and peri/neonatal mortality, severe morbidity, hospital transfers and health economics. Certainty of evidence was assessed using GRADE. RESULTS: Nine cohort studies (n = 1 261 312), 18 case series, and three case reports were included. All cohort studies had a risk of bias. Planned home/FMU births were associated with fewer maternal intensive care admissions (adjusted odds ratio [AOR] 0.41, 95% confidence interval [95% CI] 0.19-0.89), increased peri/neonatal mortality (OR 1.70, 95% CI 1.05-2.74), fewer severe perineal tears (AOR 0.64, 95% CI 0.45-0.93), and lower intrapartum caesarean section rates (AOR 0.29, 95% CI 0.26-0.33). Transfers occurred in 9%-33% of births. Cost savings for home/FMU births disappeared when emergency standby capacity was considered. CONCLUSION: Evidence certainty was low or very low. Planned home/FMU births may reduce some maternal complications but may increase peri/neonatal mortality, although absolute risks remain low. The cost-effectiveness of home/FMU birth remains uncertain.