No Place Like Home: A Retrospective Analysis of Increasing Home Birth Rates in North Dakota’s Maternity Desert (2015–2024)

For centuries, giving birth at home in attendance of family and midwives was considered the standard. This paradigm shifted in the early 20th century as physician-attended hospital deliveries became more common, especially among affluent women. By the mid-1970s, nearly all U.S. births occurred in hospitals or accredited birthing centers. Today, however, home births are once again gaining popularity. According to the Centers for Disease Control and Prevention (CDC), national home birth rates increased by 22% in 2019 and an additional 12% in 2020. There are several reasons why women may choose to deliver at home, including reduced medical intervention, increased autonomy during labor, familiarity and comfort, and dissatisfaction with hospital care. Economics may also play a substantial role, with some reports indicating hospital-based vaginal delivery may come with a fourfold increased price tag when compared to deliveries at home. The safety and potential adverse outcomes of home delivery have also been debated. While several retrospective analyses suggest planned home births are safe for low-risk individuals attended by certified nurse midwives, organizations such as the American College of Obstetricians and Gynecologists (ACOG) maintain that hospitals and accredited birthing centers are the safest, particularly considering increased risks for adverse neonatal outcomes, including seizures and mortality. Regardless, risk mitigation for adverse obstetric and neonatal outcomes alike hinges on the idea that emergent, high-level care is readily accessible in a timely fashion; a luxury those living in exceedingly rural or impoverished areas may not afford. While national level data of home birth rates have been well documented, recent, state-level patterns (especially rural regions) remain underexplored. North Dakota presents a unique case, as 74% of its counties are classified as maternity care deserts, more than double the national average of 35%, ranking it #1 in the nation for least access to maternity care by far. As such, understanding updated trends in home birth rates is essential for equipping local providers, emergency responders, and public health officials with the data needed to anticipate needs, allocate resources, and safeguard maternal and neonatal outcomes in North Dakota. The purpose of this study was to explore home birth rate trends in the state of North Dakota over the last decade. This retrospective analysis utilized public birth record data from the North Dakota Department of Health and Human Services for the years 2015–2024. Home births were defined as all deliveries occurring outside of hospitals or accredited birth centers. Annual home birth rates were then calculated and simple linear regression analysis was performed to assess trends over time. Home birth rates in North Dakota were found to rise from 1.06% in 2015 to 1.73% in 2024. Linear regression models demonstrated a statistically significant absolute increase in home birth rates by about 0.08% per year (F(1,8)= 22.624, p = 0.001, adjusted R² = 0.706), mirroring national trends. These findings underscore the urgent need to strengthen rural maternal care infrastructure and incorporate obstetric-friendly emergency transfer systems, ensuring that all birthing individuals, regardless of geography, have access to safe, timely, and equitable care.