Out-of-hospital birth centers are controversial. A retrospective chart review was performed for 150 consecutive patients who had their prenatal care at The Birthplace, a Seattle birth center with certified nurse-midwives licensed by the state of Washington. Seventy-two percent of the women were nulliparous. Antepartum or intrapartum hospital referral was necessary for 28% of the patients. An additional 17% of the patients would have been transferred if specific written criteria for transfer had been precisely followed. The cesarean section rate was 6% (9 of 150). Nonoptimal 1-minute Apgar scores of 6 or less were more common in nulliparas (20%) than in multiparas (3%) who delivered at The Birthplace (P less than .05). All 5-minute Apgar scores were 7 or more. Three infants had birth weights less than 2500 g. Noncompliance with the transfer criteria was associated with untoward outcome. Patients considering out-of-hospital delivery should be counseled that a high rate of hospital transfer is necessary to minimize risk.