Birth choices, the law, and medicine: balancing individual freedoms and protection of the public's health.

To many Americans, the idea of home birth, the use of a "direct-entry midwife," or both seem archaic. Although much of the professional medical community disapproves of either, state laws regarding birth choices vary dramatically and are not necessarily based on empirical findings of childbirth outcomes. Public health practitioners, policymakers, and consumers view childbirth from the perspectives of safety, cost, freedom of choice, quality of the care experience, and legality, yet the professional, policy, and lay literatures have not offered an unemotional, balanced presentation of evidence. Reviewing the full spectrum of literature from the United States and abroad, we present a Constitutional medical-legal analysis of whether home birth with direct-entry midwives is in fact a safe alternative to physician-attended hospital births, and whether there is a legal basis for allowing alternative health policy choices is such an important yet personal family matter as childbirth. The literature shows that low- to moderate-risk home births attended by direct-entry midwives are at least as safe as hospital births attended by either physicians or midwives. The policy ramifications include important changes in state regulation of medical and alternative health personnel, the allowance of the home as a medically acceptable and legal birth setting, and reimbursement of this lower-cost option through private and public health insurers.