From Medscape Medical News;
Home Birth Study Findings Raise Controversy, by
Emma Hitt, PhD
July 16, 2010 — A meta-analysis of studies comparing planned home births vs hospital births reported that home births may be associated with an increased neonatal mortality rate; however, the study findings are controversial and have received criticism.

The study, led by Joseph R. Wax, MD, from Maine Medical Center in Portland, and colleagues found that perinatal mortality rates were similar for planned home and hospital births, but that neonatal mortality rates were about 3-fold higher with planned home births than with hospital births.
The study, published online July 1 in the American Journal of Obstetrics and Gynecology and reported by Medscape Medical News at the time, has drawn criticism from 2 major associations for midwives: the National Association of Certified Professional Midwives and the American College of Nurse-Midwives (ACNM).
Midwife Groups Have Concerns About Study Findings
According to Mary Lawlor, CPM, LM, president of the National Association of Certified Professional Midwives, the conclusions are "in direct conflict with a growing international body of quality research that demonstrates the safety of home birth for low-risk women and their infants when attended by trained professional midwives."
"The organization’s principal concerns regarding the study," she told Medscape Medical News, "are the findings’ implications for the safe and effective care of women and their infants, and possible restrictions on women’s access to low-intervention maternity care in all settings by professional midwives, which has been proven to be safe and effective time and again."
According to Lawlor, the analysis of neonatal death rates is flawed and "downplays the fact that the very studies used in Wax’s review demonstrate that mothers choosing home birth have better outcomes in every single measure of maternal and neonatal well-being over mothers having hospital births."
Likewise, Holly Powell Kennedy, CNM, PhD, president of the ACNM, pointed out that some studies have found very positive outcomes for home births, although others assert that home birth is dangerous.
"The important concept for clinicians to recognize is the numerous similarities between planned home birth and planned hospital birth. Regardless of setting, planned home births and hospital births can provide the conditions that have been shown to result in high-quality maternity care outcomes,"’ she told Medscape Medical News.
In a written release from the ACNM, the organization states that they have "several methodological concerns" with the study by Dr. Wax and colleagues. One concern is the inclusion of older studies and studies that did not sufficiently distinguish between planned and unplanned home births. In addition, the analysis does not include certain recent and credible studies on home births. "ACNM cautions against over-interpretation of these findings until there has been further review," they write.
ACOG Opposes Home Births
The American College of Obstetricians and Gynecologists (ACOG), which has more than 52,000 members, declined to offer a direct comment on the study, but provided their position statement on home births.
According to their statement, ACOG believes that "the hospital, including a birthing center within a hospital complex…or freestanding birthing centers…is the safest setting for labor, delivery, and the immediate postpartum period."
The organization notes that large comparative studies of the safety of births in different settings are needed. "Until the results of such studies are convincing, ACOG strongly opposes home births," it writes — although the group acknowledges a woman’s right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or provide home births.
Home Delivery Reasonably Safe for Low-Risk Women
Laura Elizabeth Riley, MD, medical director of labor and delivery at Massachusetts General Hospital in Boston, notes that the study findings verify those from previous publications. "Home births are associated with fewer maternal and neonatal interventions; however, with that comes a modest increase in morbidity and mortality for the newborn," she told Medscape Medical News.
According to Dr. Riley, in general, low-risk women can choose home delivery as a reasonably safe delivery venue provided they understand that there could be some increased risk to the baby. "Maternal mortality is so rare that it could not be assessed in even this large of a sample," she added.
Dr. Riley noted that the strength of the study is the large number of patients, which allows the detection of differences in rather rare outcomes such as neonatal mortality. "The weakness is that the data is not granular enough to allow us to understand the patient factors which may contribute to the outcomes."
The ACOG and the Society for Maternal-Fetal Medicine, which are 2 of the 8 sponsors of the journal in which the article appeared, declined to provide a direct comment about the study findings.
Am J Obstet Gynecol. Published online July 1, 2010.

Authors and Disclosures
Emma Hitt, PhD
Emma Hitt is a freelance editor and writer for Medscape.

Disclosure: Emma Hitt, PhD, has disclosed no relevant financial relationships.
Dr. Hitt does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.
Dr. Hitt does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.