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.