in the uk. their report noted that intrapartum-related perinatal mortality was low in all settings in the uk, but that in cases of unanticipated obstetric complications, the mortality rate was higher for home births due to the time needed to transfer the mother to an obstetric unit. the uncertain evidence suggests intrapartum-related perinatal mortality (ippm) for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units. if ippm is higher, this is likely to be in the group of women in whom intrapartum complications develop and who require transfer into the obstetric unit. when unanticipated obstetric complications arise, either in the mother or baby, during labour at home, the outcome of serious complications is likely to be less favourable than when the same complications arise in an obstetric unit. a 2002 study of planned home births in the state of washington found that home births had shorter labors than hospital births. in north america, a 2005 study found that about 12 percent of women intending to give birth at home needed to be transferred to the hospital for reasons such as a difficult labor or pain relief. a 2014 survey of american home births between 2004 and 2010 found the percent of women transferred to a hospital from a planned home birth after beginning labor to be 10.9%. both the journal of medical ethics and nice report noted that usage of caesarean sections were lower for women who give birth at home, and both noted a prior study that determined that women who had a planned home birth had greater satisfaction from the experience when compared with women who had a planned birth in a hospital. in 2009 a study of 500,000 low-risk planned home and hospital births in the netherlands, where midwives have a strong licensing requirement, was reported in the british journal of obstetrics and gynaecology. the study concluded that for low-risk women there was no increase in perinatal mortality, provided that the midwives were well-trained and there was easy and quick access to hospitals. further, the study noted there was evidence that "low risk women with a planned home birth are less likely to experience referral to secondary care and subsequent obstetric interventions than those with a planned hospital birth.": 9 the study has been criticised on several grounds, including that some data might be missing and that the findings may not be representative of other populations. in 2012, oregon performed a study of all births in the state during the year as a part of discussing a bill regarding licensing requirements for midwives in the state. they found that the rate of intrapartum infant mortality was 0.6 deaths per thousand births for planned hospital births, and 4.8 deaths per thousand for planned home births. they further found that the death rate for planned home births attended by direct-entry midwives was 5.6 per thousand. the study noted that the statistics for oregon were different for other areas, such as british columbia, which had different licensing requirements. oregon was noted by the centers for disease control and prevention as having the second-highest rate of home births in the nation in 2009, at 1.96% compared to the national average of 0.72%. a 2014 survey of nearly 17,000 voluntarily reported home births in the united states between 2004 and 2010 found an intrapartum infant mortality rate of 1.30 per thousand; early neonatal and late neonatal mortality rates were a further 0.41 and 0.35 per thousand. the survey excluded congenital anomaly-related deaths, as well as births where the mother was transferred to a hospital prior to beginning labor. in october 2013 the largest study of this kind was published in the american journal of obstetrics and gynecology and included data on more than 13 million births in the united states, assessing deliveries by physicians and midwives in and out of the hospital from 2007 to 2010. the study indicated that babies born at home are roughly 10 times as likely to have an apgar score of 0 after 5 minutes and almost four times as likely to have neonatal seizures or serious neurological dysfunction when compared to babies born in hospitals. the study findings showed that the risk of apgar scores of 0 is even greater in first-born babies—14 times the risk of hospital births. the study results were confirmed by analyzing birth certificate files from the u.s. centers for disease control and prevention (cdc) and the national center for health statistics. given the study's findings, dr. amos grunebaum, professor of clinical obstetrics and gynecology at weill cornell medical college and lead author of the study, stated that the magnitude of risk associated with home delivery is so alarming that necessitates the need for the parents-to-be to know the risk factors. another author, dr. frank chervenak, added that the study underplayed the risks of home births, as the data used counted home births where the mother was transferred to a hospital during labor as a hospital birth. when it comes to home births vs hospital births, home births are strongly associated with worse outcomes. the increased rate of adverse outcomes of home births exists despite the reported lower risk profile of home birth. we emphasize that the increased risks of poor outcomes from the setting of home birth, regardless of attendant, are virtually impossible to solve by transport. this is because total time for transport from home to hospital cannot realistically be reduced to clinically satisfactory times to optimize outcome when time is of the essence when unexpected deterioration of the condition of either the fetal patient or pregnant patient occurs.a 2022 study, which examined the introduction of maternity wards in sweden, found that the wards substantially reduced home deliveries and early neonatal mortality, as well as positive long-term effects on labour income, unemployment, health-related disability and schooling for individuals born in maternity wards. study design randomized controlled trials are the "gold standard" of research methodology with respect to applying findings to populations; however, such a study design is not feasible or ethical for location of birth. the studies that do exist, therefore, are cohort studies conducted retrospectively by selecting hospital records and midwife records. by matched pairs (by pairing study participants based on their background characteristics), in february 2011 the american congress of obstetricians and gynecologists identified several factors that make quality research on home birth difficult. these include "lack of randomization; reliance on birth certificate data with inherent ascertainment problems; ascertainment of relying on voluntary submission of data or self-reporting; a limited ability to distinguish between planned and unplanned birth; variation in the skill, training, and certification of the birth attendant; and an inability to account for and accurately attribute adverse outcomes associated with transfers". quality studies, therefore, need to take steps in their design to mitigate these problems in order to produce meaningful results. the data available on the safety of home birth in developed countries is often difficult to interpret due to issues such as differing home-birth standards between different countries, and difficult to compare with other studies because of varying definitions of perinatal mortality. additionally, it is difficult to compare home and hospital births because only the risk profiles are different between the two groups, according to the cdc: people who choose to give birth at home are more likely to be healthy and at low risk for complications. there are also unquantifiable differences in home birth patients, such as maternal attitudes towards medical involvement in birth. methods of scientific inquiry modern scientific inquiry into home birth takes place in the fields of anthropology, epistemology, ethnology, history, jurisprudence, medicine, midwifery, public health, sociology, and women's studies. research of home birth is complicated by ancient and modern biases about the nature of women and birth, manifested in the language and ideas that are used to refer to women, women's bodies, and what women do. it has been demonstrated that reports of research of physiological phenomena, such as conception, transmit deep-seated biased cultural notions of women and women's bodies. most 20th- and 21st-century researchers of home birth view the phenomenon through two broad perspectives that are closely tied to the ideas and perceptions of birth itself – social and biomedical. insurance and licensing issues while a woman in developed countries may choose to deliver her child at home, in a birthing center, or at hospital, health coverage and legal issues influence available options. australia in april 2007, the western australian government expanded coverage for birth at home across the state. other state governments in australia, including the northern territory, new south wales and south australia, also provide government funding for independent, private home birth. the 2009 federal budget provided additional funds to medicare to allow more midwives to work as private practitioners, allow midwives to prescribe medication under the medicare benefits schedule, and assist them with medical indemnity insurance. however, this plan only covers hospital births. there are no current plans to extend medicare and pbs funding to home birth services in australia. as of july 2012, all health professionals must show proof of liability insurance. in march 2016, the coroners court of victoria found against midwife gaye demanuel in the case of the death of caroline lovell. "coroner white also called for a review of the regulation of midwives caring for women during home births, and for the government and health authorities to consider an offence banning unregistered health practitioners from taking money for attending home births." canada public health coverage of home birth services varies in canada from province to province, as does the availability of doctors and midwives providing home birth services. the provinces of ontario, british columbia, saskatchewan, manitoba, alberta, and quebec currently cover home birth services. united kingdom there are few legal issues with a home birth in the uk. woman cannot be forced to go to a hospital. the support of the various health authorities of the national health service may vary, but in general the nhs will cover home births – the parliamentary under-secretary of state for health, lord hunt of king's heath has stated that "as i understand it, although the nhs has a legal duty to provide a maternity service, there is not a similar legal duty to provide a home birth service to every woman who requests one. however, i certainly hope that when a woman wants a home birth, and it is clinically appropriate, the nhs will do all it can to support that woman in her choice of a home birth." united states practicing as a direct-entry midwife was illegal in states shown here in red in 2006 27 states license or regulate in some manner direct-entry midwife, or certified professional midwife (cpm). in the other 23 states there are no licensing laws, and practicing midwives can be arrested for practicing medicine without a license. it is legal in all 50 states to hire a certified nurse midwife, or cnm, who are trained nurses, though most cnms work in hospitals.