Homebirth: An Annotated Guide To The Literature

I: Meta-Analyses and Systematic Reviews

Each paper is linked to either its original abstract on PubMed or the full-text article if available; click on the title to be taken to the abstract/ article.

A) Olsen, O., Clausen, J. A. (2012). Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews, doi: 10.1002/14651858.CD000352.pub2.

An updated systematic review of randomized controlled trials (RCTs) comparing planned home births to planned hospital births among women with uncomplicated pregnancies. The selection criteria were rigorous; only one trial met the inclusion criteria (n=11). The authors report a continued dearth of evidence from RCTs about the safety of home compared to hospital birth. Authors also conclude that evidence from increasingly well-designed observational studies suggests that low-risk women who plan a home birth experience significantly fewer interventions and complications than low-risk women who deliver in hospital. They provide a detailed discourse analysis of differing approaches to risk assessment, including the ethical application of clinically meaningful evidence, and the interaction of model of care with access to choice of birth place. They recommend that all countries facilitate evidence-based integration of home birth services into the health care system and inform all low-risk women of the option of planned home birth.

B) Leslie, M.S., Romano, A. (2007). Appendix: Birth can safely take place at home and in birthing centers. J Perinat Educ, 16(Suppl 1):81S-88S, doi: 10.1624/105812407X173236.  (full text)

A systematic review of home birth and birth center safety studies. The authors followed standard systematic review methods, including reporting levels of evidence, disclosure of inclusion and exclusion criteria and search strategies (detailed in a Methods article by Goer in same journal issue). Drawing on data from numerous studies, the authors compare incidence of interventions and perinatal outcomes between hospital births and home births and between hospital births and birth center births. The evidence for each outcome is graded for quality, quantity and consistency. This review reported that out-of-hospital births had similar perinatal outcomes to hospital births and fewer interventions.

C) Olsen O. (1997). Meta-analysis of the safety of home birth. Birth, 24(1):4-13.

Meta-analysis of observational, comparative, original studies that met criteria for rigorous methodology and investigated differences in perinatal mortality and morbidity between planned home births and planned hospital births. Multivariate statistical analysis controlled for obstetrical background and perinatal factors. Analysis revealed no statistical difference in mortality between planned home and planned hospital birth and the confidence interval did not allow for extreme excess risks in any of the groups (OR=0.87, 95% CI=0.54-1.41). There were significantly fewer medical interventions, fewer severe lacerations, fewer operative births, and fewer low Apgar scores in the home birth groups.

II: Randomized Controlled Trials

A) Hendrix, M., Van Horck, M., Moreta, D., Nieman, F., Nieuwenhuijze, M., Severens, J., Nijhuis, J. (2009). Why women do not accept randomisation for place of birth: feasibility of a RCT in The Netherlands. BJOG 116(4):537-544, doi: 10.1111/j.1471-0528.2008.02103.x.

Based on Dowswell’s findings the authors designed an RCT to compare home and home-like hospital births in the Netherlands for the following outcomes: interventions, satisfaction, referral to obstetricians, and costs. After 6 months, only one woman had enrolled in the study, therefore the trial was discontinued for lack of feasibility. The research team then re-designed their study to investigate the reasons women declined to participate in the RCT. The four main reasons that women indicated were: 1) they had already decided where to give birth prior to learning about the study, 2) they wished to choose their own place of birth 3) they wished to avoid delivering in the ‘wrong’ place for their first child, and 4) they were concerned about receiving an undesired treatment.

B) Dowswell, T., Thornton, J. G., Hewison, J., Lilford, R. J., Raisler, J., Macfarlane, A., Young, G., Newburn, M., Dodds, R. & Settatree, R. S. (1996). Should there be a trial of home versus hospital delivery in the United Kingdom? Measuring outcomes other than safety is feasible. BMJ 312(7033): 753-757.  (full text)

The authors of this small study (n=11) suggested that conducting a trial to assess birth outcomes by birth place (home versus hospital) would be feasible. Eleven subjects were recruited from a pool of 71 women who met the eligibility criteria for a home birth. This ratio suggested that a larger scale trial may be possible. The following outcomes were measured, following an intention to treat analysis: mode of delivery, obstetrical interventions, complications, and infant feeding (breastfeeding versus bottle feeding). However, the authors note that mortality is not an appropriate outcome variable to assess the safety of home birth with a randomized controlled trial because of the extremely large number of subjects required to compare such rare outcomes.

III: Cohort and Population-Based Observational Studies:

North America

A) Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home births with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(6-7):377-83, doi: 10.1503/cmaj.081869.  (full text)

Prospective, five-year long cohort study comparing outcomes among midwife-attended planned home births (n=2802), midwife-attended planned hospital births (n=5984), and physician-attended hospital births (n=5985). Women in all three groups of the study met eligibility criteria for home birth, and thus had comparable maternal and fetal risk profiles. Women in the home birth group who needed intrapartum transfer to the hospital were retained in their original cohort. This study reported similarly low rates of perinatal death in all three cohorts, and similar or reduced rates of adverse outcomes in the planned home birth group. Women in the planned home birth group had significantly fewer intrapartum interventions, including narcotic or epidural analgesia, augmentation or induction of labour, and assisted vaginal or caesarean delivery. In addition, women in the home birth group were less likely to suffer from postpartum hemorrhage, pyrexia, and 3rd or 4th degree tears. Babies of women planning a home birth were less likely to have Apgar scores of < 5 at one minute and the babies were less likely to need drugs for resuscitation. These differences were associated with planned place of birth and persisted regardless of actual place of birth.

B) Hutton, E. K., Reitsma, A. H., & Kaufman, K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study.Birth, 36(3):180-89, doi: 10.1111/j.1523-536X.2009.00322.x.

Hutton et al. used the Ontario Ministry of Health Midwifery Program (OMP) database to compare outcomes of all women planning home births from 2003-2006 (n=6692) with a matched sample of women planning a hospital birth (n=6692.) Women with contraindications for home birth were excluded from the hospital sample. The primary outcome was a composite measures of perinatal and neonatal mortality or serious morbidity, i.e. the presence of one or more of the following: death (stillbirth or neonatal death 0–27 days, excluding lethal anomalies and fetal demise before the onset of labor); Apgar score of less than 4 at 5 minutes of age; neonatal resuscitation requiring both positive pressure ventilations and cardiac compressions; admission to a neonatal or pediatric intensive care unit with a length of stay greater than 4 days; or birthweight less than 2,500 g. The home birth group had lower rates of caesarean section (RR 0.64), and neonatal morbidity/mortality (RR 0.84) compared to low risk women who planned a hospital birth. Results suggest that Ontario midwives provide adequate screening and safe care for women planning home births.

C) Schlenzka PF. (1999). Safety of alternative approaches to childbirth [Unpublished Dissertation]. Palo Alto, CA: Department of Sociology, Stanford University.  (full text)

In order to account for errors associated with relying solely on birth certificate data, Schlenzka merged birth certificate and hospital discharge data for California for 1989 and 1990, and by applying a comprehensive risk profile to cases, isolated a cohort of nearly 816,000 low risk births. Outcomes are reported according to planned and actual birth setting. Perinatal mortality was compared with two statistical approaches: indirect standardization using only birth weight, sex, race, age, education, and insurance as risk adjusters, and logistic regression controlling for all risk factors available in the database. No differences in perinatal mortality were found across birth sites, with lower rates of obstetric interventions in out of hospital groups.

IV: Cohort & Population-Based Observational Studies: International

A) Nove A, Berrington A, Matthews Z. Comparing the odds of postpartum haemorrhage in planned home birth against planned hospital birth: results of an observational study of over 500,000 maternities in the UK. BMC Pregnancy & Childbirth. 2012, 12 (1),1-11.

C) Birthplace in England Collaborative Group. (2011). Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 343:d7400.  (full text)

A prospective cohort study in England from April 2008-April 2010 compared perinatal and maternal outcomes and interventions by planned place of birth at the onset of care during labour (planned home birth, freestanding midwifery birth centers, alongside midwifery units and obstetric units). The study included 64,538 low-risk women with a singleton pregnancy at term. The primary study outcome was a Composite Index combining intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, and birth related injuries including brachial plexus injury, fractured humerus or clavicle. Stillbirths before onset of labour were excluded. The researchers found that the incidence of the composite outcome measure was low for the entire sample (4.3/1000 births). In the overall sample, there were no statistically significant differences in the odds of the primary outcome in home, free-standing birth centers or alongside midwifery units when compared with planned birth in obstetric units. However, when the sample was split into nulliparous and multiparous women, the adverse outcome measures during planned home birth were higher than for hospital birth for nulliparous, but not for multiparous women. There was no evidence of a difference in adverse outcomes for freestanding or alongside midwifery units compared to obstetric units. Of women who started labour in obstetrical units, 20% had at least one complicating condition compared with less than 7% in other settings. For low-risk women birthing in an obstetric unit, the odds of receiving augmentation, epidural, spinal analgesia, general anesthesia, vacuum or forceps delivery, caesarean section, episiotomy, and active management of third stage were higher than all other settings. The study concludes that for healthy women with low risk pregnancies, the incidence of adverse perinatal outcomes is low in all settings and therefore the results support offering healthy low-risk nulliparous and multiparous women a choice of birth setting. Given the rarity of events for any of the included perinatal outcomes, and as some of them typically appear as co-morbidities, a composite index might inflate some differences in outcomes as attributable to place of birth. It is unclear how some of the items selected for inclusion in the composite index relate specifically to place of birth causality rather than skill of provider.

D) van der Kooy, J., Poeran, J., de Graff, J. P., Birnie, E., Denktass, S., Steegers, E. A. P., & Bonsel, G. J. (2011). Planned home compared with planned hospital births in the Netherlands: intrapartum and early neonatal death in low-risk pregnancies. Obstet Gynecol 118(5):1037-46.

In this retrospective cohort study, records of 679,952 low risk women from the Netherlands Perinatal Registry (2000-2007) were analyzed to compare intrapartum and early neonatal mortality rates (0-7 days after birth) of planned home versus planned hospital births attended by midwives. Outcomes for a third group of women, for which the planned place of birth was unknown, were also reported. The hospital cohort was used as the comparison group in all analyses. The authors used two methods for analyzing data: a ‘per protocol analysis’, or ‘perfect guideline approach’, which examined outcomes from only those low risk women who were eligible for planned home birth according to Dutch guidelines (n= 602,331) and a ‘natural prospective approach’, which looked at outcomes for all women who planned a home birth under the care of midwives (n=679,952) The per protocol analysis excluded midwifery clients with one or more of the following conditions: intrauterine death, prolonged rupture of membranes, gestational ages < 37 weeks and > 41 weeks. Results revealed a significantly decreased risk of intrapartum and early neonatal mortality in the home birth cohort, using the natural prospective approach (RR = 0.80; 95% CI: 0.71-0.91). When the authors calculated RRs using the perfect guideline approach, and adjusted ORs using either approach, they found no increased risk/odds of intrapartum and early neonatal death in the home versus the hospital setting. These findings align with those reported by De Jonge, et al (2009) using a similar cohort of women (2000-2006). A problematic secondary analysis of data was also reported (See review: Section B, III, A).

E) de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., Bennebroek Gravenhorst, J., & Buitendijk, S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG, 116(9):1177-84, doi: 10.1111/j.1471-0528.2009.02175.x.

Retrospective cohort study of 529,688 low-risk women in the Netherlands who were in primary midwife-led care at labour onset. This study compared perinatal mortality and morbidity between planned home births (321,301; 60.7%), planned hospital births (163,261; 30.8%), and unknown place of birth (45,120; 8.5%), using the national perinatal and neonatal registration data from 2000-2006. The following differences between groups were controlled for using logistic regression: parity, gestational age, maternal age, ethnic background, and socio-economic status. Inclusion criteria ensured the subjects were strictly low-risk. The main outcomes were intrapartum death, intrapartum and neonatal death within 24 hours and 7 days after birth, and admission to a neonatal intensive care unit. No significant differences were found between planned home and planned hospital births for any of the main outcomes. The authors concluded that planned home birth in a low-risk population is not associated with higher perinatal mortality rates or an increased risk of admission to a NICU compared to planned hospital birth.

F) Kennare, R. M., Keirse, M. J., Tucker, G. R., & Chan, A. C. (2009). Planned home and hospital births in South Australia 1991-2006: differences in outcomes. Med J Aust, 192(2):76-80.

Retrospective population based-study of all births and perinatal deaths from 1991-2006 in South Australia. 1141 planned home births and 297,192 hospital births were included. Planned home birth was defined as any birth that was intended to occur at home at the time of antenatal booking; 30.6% of the planned home births occurred in hospital. Perinatal outcomes studied were: perinatal death, intrapartum death, intrapartum asphyxiation, Apgar of <7 at 5 minutes, use of pediatric or specialized neonatal care. Maternal outcomes studied were: operative delivery, postpartum hemorrhage and perineal trauma including episiotomy (1998-2006 only). Results: Post-term pregnancy (≥42 weeks) was more common in the home birth group; 58% (n=25/43 post-term pregnancies) delivered at home. Perinatal mortality rates (including intrapartum fetal death and stillbirth) were similar between home and hospital groups (7.9 vs. 8.2 per 1000). There was no statistical difference in perinatal mortality between the home and hospital group (4.6 vs. 6.7 per 1000 respectively). Intrapartum fetal death was higher in the home birth group (1.8 vs .8 per 1000), though the absolute numbers were small. Cases of intrapartum death were not necessarily contingent upon place of birth. Of the 9 perinatal deaths total, 3 were antepartum (occurred after transfer to hospital and were unrelated to antenatal care), 2 were attributable to fetal congenital anomaly, and 4 occurred after the parents refused/delayed transfer or declined intervention after transfer. These deaths might indicate a lack of integration of South Australian midwives into the health care system or an underlying distrust of hospitals for parents. The home birth group had lower rates of caesarean delivery (aOR= .27), instrumental delivery (aOR= .33), and episiotomy (aOR= .14).

G) Chamberlain, G., Wraight, A., & Crowley, P. (Eds.). (1997). Home births: The report of the 1994 confidential enquiry by the National Birthday Trust Fund. Lancaster, UK: Parthenon Publishing Group Ltd.

Comprehensive investigation of the characteristics and outcomes of planned home births across the United Kingdom, endorsed by the Royal Colleges of Obstetricians, Midwives, and General Practitioners. A prospective trial of 6044 planned home births in Great Britain compared mortality and perinatal outcomes with a low risk hospital group and found no significant differences in mortality. The home birth group experienced significantly fewer medical interventions and perinatal complications. The study report is published as a book.

I) Ackermann-Liebrich, U., Voegeli, T., Gunter-Witt, K., Kunz, I., Zullig, M., Schindler, C., Maurer, M., & Zurich Study Team. (1996). Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ, 313(7068):1313-18.  (full text)

Prospective matched cohort study of 489 planned home and 385 planned hospital births. The study design carefully attended to issues of planning status, transfer criteria, and actual place of delivery. The groups were matched according to age, parity, gynecologic and obstetric history, medical history, partner situation, social class, and nationality. The main outcome measures were need for medication and/or intrapartum intervention, duration of labor, severity of lacerations, hemorrhage, neonatal condition and perinatal mortality. They found a lower incidence of interventions, medications, lacerations and higher Apgar scores in the home birth group and no differences in birth weight, clinical condition, or gestational age between groups. There were no differences in mortality between groups.

V: Descriptive Studies & Registry Reports Observational Studies: International

A) Kataoka Y, Eto H, Iida M. Outcomes of independent midwifery attended births in birth centres and home births: A retrospective cohort study in Japan. Midwifery 2013; 29 (8): 965-972.

I: Meta-Analyses and Systematic Reviews

Each paper is linked to either its original abstract on PubMed or the full-text article if available; click on the title to be taken to the abstract/ article.

A) Wax, J. R., Lucas, F. L., Lamont, M., Pinette, M. G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol, 203(3):243.e1-8, doi: 10.1016/j.ajog.2010.05.028.

This article presents a meta-analysis of the safety of planned home versus planned hospital birth. The authors conclude that planned home births are associated with similar maternal outcomes, but with a threefold increase in neonatal mortality. The methodology and statistical analysis employed in this systematic review were flawed. This meta-analysis contains calculation and numerical errors, selective and mistaken inclusion/ exclusion of studies when analyzing specific outcomes, as well as logical flaws in terms of definitions. Many of the odds ratios (ORs) and confidence intervals (CIs) were calculated incorrectly. In some cases, this was the result of errors apparently made in the extraction of data from the original studies. In addition, the software tool used to calculate the statistics had embedded errors that can dramatically underestimate confidence intervals (CIs), and resulted in at least 1 false statistically significant result. Wax et. al defined perinatal death as loss of a newborn of at least 20 weeks or 500 g, or death of a liveborn infant within 28 days of birth. Neonatal deaths were defined as deaths of liveborn infants within 28 days of delivery. This means that neonatal deaths should be reported as a subset of perinatal deaths. However, the paper reports that for planned home births, the neonatal death rates are far higher than the corresponding perinatal death rates. In addition, perinatal death statistics are derived from more than 500,000 births, whereas the neonatal death statistics are drawn from fewer than 50,000 births. Hence the conclusions on comparative neonatal death rates offered by the authors cannot be defended. Most notably, the de Jonge study, which contributed more than 95% of the births used in the analysis, did not define perinatal death according to the same definitions. It is unclear why Wax and colleagues excluded this study from the calculations for neonatal mortality but included the study for perinatal mortality. According to Michal et al. “If that study were removed from the calculations for the 2 outcomes for which it was erroneously included, the total number of births included in the meta-analysis would have been reduced from nearly 550,000 to just 65,000. This dramatic reduction in the size of the dataset would have significantly reduced the impact of any findings of the meta-analysis. On the other hand, if Wax and colleagues had defined perinatal death and neonatal death according to definitions used by de Jonge and associates, the conclusions for these outcomes would have been quite different.”

A more detailed critique of this article, authored by a team of experts in the field (including the principal investigators of studies included in the meta-analysis), is cited in Section C.I.A.

II: Cohort & Population-Based Observational Studies—North America

A) Grünebaum A, McCullough LB, Sapra KJ, Brent RL, Levene MI, Arabin B, Chervenak FA. Apgar Score of Zero at Five Minutes and Neonatal Seizures or Serious Neurologic Dysfunction in Relation to Birth Setting, American Journal of Obstetrics and Gynecology (2013), doi: 10.1016/j.ajog.2013.06.025.

C) Chang, J. J. & Macones, G. A. (2011). Birth outcomes of planned home births in Missouri: A population-based study. Am J Perinatol, 28(7):529-536.

A retrospective cohort study to compare outcomes between planned home births attended by non-CNMs, physicians, and CNMs to outcomes of births in hospitals and birth centers attended by physicians and CNMs. Data was collected from linked Missouri live birth and fetal death files, for the years 1989 through 2005. The study sample included singleton pregnancies, delivered between 36-44 weeks gestation. Pregnancies with major fetal anomalies and breech presentation were excluded. Authors found that planned home birth by non-CNMs, physicians and CNMs was protective against selective obstetric procedures and complications such as fever, moderate to heavy meconium, and dysfunctional labour, but that planned home births attended by non-CNMs were associated with prolonged labour, and fivefold increased odds of newborn seizure. Planned home births attended by all three groups (physicians, CNMs and non-CNMs) held a higher risk of intrapartum death. There are several weaknesses in the design and interpretation of data in this study. The subset of non-CNM attended home births was too small for meaningful analysis of rare perinatal outcomes, and the authors used an unconventional definition of ‘low-risk’, which includes all births from gestational ages of 36-44 weeks. Further, there are multiple issues of data validity using birth record data related to identification of planned home births and type of attendant. Authors suggest the non-CNM group may include certified professional midwives but there were none in practice in Missouri at the beginning of the study period; and the CPM credential was not accepted for licensure in Missouri until 2008. Even today there are not enough Missouri based CPMs to attend the number of births indicated as attended by ‘other midwives’. Prior to legislation families who delivered outside the hospital filled out their own birth certificate record. Several of those births may be misclassified unplanned accidental home births, or attended by someone without credentials. Most importantly, given the sample size and wide confidence intervals, misclassification of even a few records could skew results.

D) Evers, A. C. C, Browers, H. A. A., Hukkelhoven, C. W. P. M., Nikkels, P. G. J., Boon, J., van Egmond-Linden, A., Hillegersberg, J., Snuif, Y. S., Sterken-Hooisma, S., Bruinse, H. W., & Kwee, A. (2010). Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study. BMJ 341:c5639,  doi:10.1136/bmj.c5639.  (full text)

This was not a study of home birth safety but rather focused on primary and secondary care referrals. This cohort study compared the incidences of perinatal mortality and severe perinatal morbidity between low-risk term pregnancies in primary care with a midwife and high-risk secondary care with an obstetrician. The study found that infants of low risk women who started labour under primary care of a midwife had a significantly higher risk of perinatal death than infants of high risk women whose labour started in secondary care under the care of an obstetrician. While NICU admission rates did not differ between groups, infants who were referred to a physician by a midwife during labour had a 3.66 times higher risk of related perinatal death. Infants of nulliparous women had a significantly higher risk of NICU admission than infants of multiparous women. The most common reason for admission was asphyxia. Because data were extracted from a large birth registry database, adjustment for confounders, including appropriate referrals from primary to secondary care before and during the onset of labour, was not possible. These findings do not correspond with any previous studies of the Dutch maternity care system. The results may mostly be a reflection of the interprofessional relationships that are specific to the Utrecht region.

E) Malloy, M. H. (2010). Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004. J Perinatol, 30(9):622-27, doi: 10.1038/jp.2010.12.

A retrospective cohort study using linked US birth and death certificate files from the National Center for Health Statistics from 2000-2004, to compare the safety of CNM deliveries at home to CNM deliveries in hospital (data also examined delivery outcomes of ‘other’ midwives’ in hospital and home). Malloy concludes that neonatal mortality rates of certified nurse midwives or ‘other’ midwives are higher in out of hospital settings (home/ birthing center) compared to deliveries at the hospital. Method of selection did not distinguish planned from unplanned home birth nor if hospital birth CNMs were actually in attendance at home births or solely appeared on birth certificates as the certifier of the birth having occurred. Analysis does not distinguish between “other midwife” attendant and no attendant.

F) Wax, J. R., Pinette, M. G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births. Am J Obstet Gynecol 202(2):152.e1-5.  (full text)

A retrospective population-based cohort study to evaluate perinatal mortality by place of birth (hospital, birth center, home) using 2006 U.S. birth certificate data from 19 states available through the CDC. Of 745,690 total births included, 733,143 occurred in hospital, 4661 in freestanding birth centers, and 7427 at home. Excluded from the study were: preterm (<37 weeks), smokers, women with Type I, II or gestational diabetes, either chronic or pregnancy induced hypertension and a prior caesarean section. The authors concluded that home births are associated with less frequent adverse perinatal outcomes (chorioamnionitis, fetal intolerance of labour, meconium staining, assisted ventilation, NICU admissions and birthweights of <2500g), but more frequent abnormal labours and 5-minute Apgar scores of <7 and birth weight >2500g. The study does not differentiate between planned and unplanned home births, and does not provide data about home to hospital transfers.

G) Pang, J., W. Heffelfinger, J. D., Huang, G. J., Benedetti, T. J., & Weiss, N. S. (2002). Outcomes of planned home births in Washington State: 1989-1996. Obstet Gynecol, 100(2):253-59.

Method of selection did not distinguish between planned home births, out-of-hospital births that had no attendant, or births with unknown or unnamed attendants. Premature births occurring before 37 weeks were incorrectly included in the initial analysis. A higher incidence of congenital heart disease in the home birth population could partially explain the higher neonatal mortality and would reflect a difference in populations.

III: Cohort and Population-Based Studies

A) van der Kooy, J., Poeran, J., de Graff, J. P., Birnie, E., Denktass, S., Steegers, E. A. P., & Bonsel, G. J. (2011). Planned home compared with planned hospital births in the Netherlands: intrapartum and early neonatal death in low-risk pregnancies. Obstet Gynecol 118(5):1037-46.  

(The following is a review of the author’s secondary analysis; see review of main study inSection A, IV, B.)

In addition to reporting the usual statistics (RRs and adjusted ORs) to compare perinatal outcomes across birth settings, the authors performed additional analyses, e.g. they divided the crude mortality rates of the home and hospital groups by the prevalence of the ‘Big 4’ (congenital anomalies, IUGR, preterm birth, Apgar < 7; these 4 conditions accounted for 85% of the neonatal mortalities in the sample) to ‘obtain case mix adjustment’. The rationale for this adjustment was to remove clinical determinants of neonatal mortality, and focus on ‘setting’ dependent mortality. Using this approach, the authors reported up to 20% excess mortality in the home setting, leading the authors to conclude that women with certain risk factors (e.g. pregnancy duration more than 41 weeks and having an infant that is small for gestational age) can reduce their risk of intrapartum and early neonatal death by planning a hospital birth. It should be noted that the index does not allow for assessment of statistical significance (and thus more emphasis should be placed on the adjusted ORs reported in tables 2 and 3). As the authors themselves note in post-publication correspondence, “In both RCT and observational designs, post-hoc exclusion of patients or replacement of treatment allocation by the treatment actually received is not allowed under the intention-to-treat principle”; hence, at minimum the analysis and reporting of outcomes should have been limited to their “perfect guideline approach”.

I: Critical Appraisal of Studies in Section B (Studies with Errors in Design, Analysis or Reporting)

Each paper is linked to either its original abstract on PubMed or the full-text article if available; click on the title to be taken to the abstract/ article.

B) Michal, C. A., Janssen, P. A., Vedam, S., Hutton, E. K., de Jonge, A. (2011). Planned home vs hospital birth: A meta-analysis gone wrong. Medscape Ob/Gyn & Women’s Health. (full text)

For a detailed analysis of the 2012 Wax meta-analysis see Section B.I.A. Authors include principal investigators for 3 of the original studies included in the meta-analysis. Each of the significant numerical, statistical and logical errors, errors in definitions, errors in inclusion/exclusion of data for analysis, and mistaken conflation of association with causation, are delineated. Methodological problems and a faulty computational tool are described.

C) Gyte, G., Newburn, M., & Macfarlane, A. (2010). Critique of a metaanalysis by Wax and colleagues which has claimed that there is a three-times greater risk of neonatal death among babies without congenital anomalies planned to be born at home. NCT.  (full text)

Detailed review of Wax’s meta-analysis outlining a range of data reporting errors and methodological weaknesses, which include: insufficient details about choice of included and excluded studies, lack of clarity or consistency about the definition of neonatal mortality, including whether stillbirth data were included. Wax misclassified singleton newborns with a gestational age of 34 wks who were born after transfer from home as ‘planned’ home birth if birth certificate indicated delivery was initially attempted at home. Gyte argues that the authors’ conclusion that “less medication intervention during planned home birth is associated with a tripling of neonatal mortality rate” is unsupported by the poor quality of their data and that the article should not have been accepted by AJOG.

D) Keirse, M. J. (2010). Home birth: Gone away, gone astray, and here to stay. Birth, 37(4):341-46.

Commentary on Wax JR et al. Maternal and newborn outcomes in a planned home birth vs. planned hospital birth. Keirse highlights the weakness and results of Wax et al.’s meta-analysis of home birth. Keirse examines which studies Wax included and excluded from his meta-analysis in order to conclude that home birth is related to a 2.6 increase of maternal mortality and a tripling of neonatal mortality. Keirse also cites either statistical errors or reporting errors of data present in the study that contribute to his results. Wax’s meta-analysis refers only to planned home birth but includes statistics from U.S. birth certificates that do not differentiate between planned and unplanned home birth, and this inclusion significantly contributes to the higher rate of neonatal mortality. Although useful when randomized control trials are unavailable, meta-analyses need to consider the impact culture, geography, and health care systems have on data when consolidating smaller studies.

E) Vedam, S. (2003). Home versus hospital birth: questioning the quality of the evidence on safety. Birth, 30(1):57-63.

Detailed review of Pang’s study, including well acknowledged errors in methodology and definitions. Outlines flaws associated with using birth certificate data to study outcomes of planned home births and includes an algorithm for evaluating quality of studies on home birth safety. Studies must adhere to following study design criteria in order to avoid errors and bias: 1) differentiate between planned and unplanned home births, 2) accurately discriminate between provider types, 3) use consistent inclusion criteria across groups, 4) adjust for home birth selection criteria, 5) control for transfer criteria and 6) select consistent outcome measures. Compares the methodology used by Pang with the methodology of other commonly cited home birth studies, with examples of reliable and unreliable designs.

I: Studies of Patient Demand & Satisfaction, Autonomy & Experience

Each paper is linked to either its original abstract on PubMed or the full-text article if available; click on the title to be taken to the abstract/ article.

A) Jackson, M., Dahlen, H., & Schmied, V. (2012). Birthing outside the system: Perceptions of risk amongst Australian women who have freebirths and high risk homebirths. Midwifery, 28(5):561-7, doi: 10.1016/j.midw.2011.11.002.

A qualitative study using open ended questions examined 20 Australian women over 18 years of age who chose to have an unattended home birth (freebirth), or an attended high risk home birth despite having medically defined risk factors, or care provider recommendations for a hospital birth. Of note in this study is the participants’ average age (34) and level of education, where more than 70% of the women had tertiary qualifications. All were living in urban settings within 30 minutes of emergency care. 17 of 20 women were multiparous. Researchers found that the women who chose an unattended birth attributed this choice to a previous traumatic hospital birth or because of a belief that the interventions and interruptions of hospitals increase risk. The study found that women who freebirth tend to perceive risk differently, and that these women believe they are making a choice to protect their babies. For these women, birth in the hospital is less safe than birthing at home. The women in this study directly connected their experiences during labour and birth to their experience of mothering both immediately and long term. This study also aims to dispel a belief that women who freebirth are poorly informed and undereducated because study participants were more educated than the Australian public and had attended formalized training in obstetric emergencies and neonatal resuscitation.

B) Blix, E. (2011). Avoiding disturbance: Midwifery practice in home birth settings in Norway. Midwifery, 27(5):687-692.

Qualitative study of 17 Norwegian midwives to examine how midwifery care promotes and supports normal labour and birth and why these births are associated with lower rates of interventions compared with hospital births. The study highlights the connection between the calm, undisturbed environment available to women at home with fewer interventions in childbirth. Strengths of this study include its detailed discussion of how the home and its particular setting might augment “normal birth”.

C) Catling-Paull, C., Dahlen, H., & Homer, C. S. (2011). Multiparous women’s confidence to have a publicly-funded homebirth: a qualitative study. Women Birth, 24(3):122-8, doi: 10.1016/j.wombi.2010.09.001.

A qualitative study of 10 multiparous Australian women who chose a publicly-funded, planned home birth with the St. George Hospital Homebirth Program. The study found that multiparous women who have had at least one previous normal birth feel a strong confidence to birth at home. The women cite hospital back up, trust in the skill of their midwives, and their own personal strength as sources of confidence to have a normal birth at home. None of the women felt that they were at an increased risk of birth complications due to having a baby at home.

D) Stramrood, C. A., Paarlberg, K. M., Huis In ‘t Veld, E. M., Berger, L. W., Vingerhoets, A. J., Schultz, W. C., & van Pampus, M. G. (2011). Posttraumatic stress following childbirth in homelike- and hospital settings.J Psychosom Obstet Gynaecol, 32(2):88-97, doi: 10.3109/0167482X.2011.569801.

A qualitative cross-sectional study of 428 Dutch women who completed surveys 2-6 months post-partum to compare the rate of post-traumatic stress disorder (PTSD) in home-like settings to the hospital. The study found that women who had home deliveries had the lowest rate of PTSD symptoms compared to women who were either transferred to care in the hospital during labour but who remained in primary care (under the care of a midwife) or to those who gave birth in secondary or tertiary care (either under the care of an OB/GYN or at a university referral centre). Home deliveries also had a lower rate of PTSD compared to those with pregnancy or delivery complications at the hospital. However, no difference was found in the scores between women who delivered in primary care with a midwife either at home (planned home birth) or the hospital (planned hospital birth). The study also found a strong association between the development of PTSD and the reported intensity of labour pain, leading researchers to speculate whether there is a difference between women requesting pain medication and the role this might play in the development of PTSD for certain women.

E) Symon, A., Winter, C., Donnan, P. T., & Kirkham, M. (2010). Examining autonomy’s boundaries: A follow-up review of perinatal mortality cases in UK independent midwifery. Birth, 37(4):280-7. doi: 10.1111/j.1523-536X.2010.00422.x.

A qualitative review using thematic analysis and grounded theory to examine the case notes of midwives involved in 15 instances of perinatal mortality at home births in the UK between 2002 and 2005. Researchers noted that in 13 of the 15 cases significant antenatal risk factors were present (4 sets of twins, 3 VBAC, 3 Breech, 5 maternal illness) and 8 of 15 women had declined some, or all, routine antenatal screening. Strengths of this study are that it provides a detailed examination into perinatal deaths at home and examines why some women might choose high-risk home births even after antenatal risk factors have been identified, or care providers have encouraged a transfer to the hospital. It illustrates the challenge that independent midwives face balancing informed consent/ refusal with providing care. This study also examines how issues regarding transfer of care, inter-professional communication, and a deep mistrust of NHS by some women can led to a delay in care and poorer outcomes. Limitations of this study are its small sample size, but also that it is only a study of the midwives’ notes and does not include hospital notes or family accounts.

F) Hendrix, M., Pavlova, M., Nieuwenhuijze, M. J., Severens, J. L., & Nijhuis, J. G. (2010). Differences in preferences for obstetric care between nulliparae and their partners in the Netherlands: A discrete-choice experiment. J Psychosom Obstet Gynaecol, 31(4):243-51, doi: 10.3109/0167482X.2010.527400.

A prospective cohort study to examine the differences between low-risk pregnant women and their partners’ preferences regarding obstetric care and place of birth and the extent to which these preferences are influenced by obstetric care and socio-economic factors. The study employed a method of “discrete choice” to assess preference. Data were collected at 32 weeks from 321 pregnant women and 212 of their partners. This study found that overall women prefer to be assisted by a midwife during birth and they also prefer to give birth in a home-like setting. Women also place importance on having influence over the decision making process and the possibility of pain relief (though the study does not specify what kind of pain relief). Their partners’ preferences where similar; high value was placed on a midwifery assisted birth in a home-like setting, and control over decision-making. Partners had a preference for no out-of pocket payments and a higher preference for access to pain relief.

G) Hildingsson, I., Rådestad, I., & Lindgren, H. (2010). Birth preferences that deviate from the norm in Sweden: Planned home birth versus planned cesarean section. Birth, 37(4):288-95, doi: 10.1111/j.1523-536X.2010.00423.x.

Descriptive and comparative study using data from questionnaires of women who had a planned home birth (n=671) and women who had an elective caesarean section (n=126) between 1997 and 2008. In Sweden, the current medical context neither promotes home birth nor elective caesarean section. The study found significant socioeconomic differences between the two groups of women. Compared to women who chose an elective caesarean, women who chose planned home birth were more educated, had a lower BMI, were less likely to smoke, felt less threat to baby’s life during the birth, felt more in control, and were more satisfied with their overall birth experience. Women in the home birth group reported a higher intensity of pain, but a more positive experience of that pain than women who gave birth via caesarean.

H) Lindgren, H. & Erlandsson, K. (2010). Women’s experiences of empowerment in a planned home birth: A Swedish population-based study.Birth, 37(4):309-17, doi: 10.1111/j.1523-536X.2010.00426.x.

Descriptive study using questionnaires of women who had one or more planned home births between 1992 and 2005 (n=735). Birth stories were analyzed using content analysis and descriptive statistics. Women who birthed at home felt empowered by their environment and the people who supported them (midwives, partners, family). Birth stories rarely mentioned pain or suffering and stressed the importance of an undisturbed space and sense of control. Surveys highlighted the importance of support, guidance and trust in their attendants to feel safe. Feeling disempowered was related to a poor choice of attendants and the absence of partner support. The response rate of the study was 99%. Limitations: small scale study might not be generalizable to general Swedish population or international context.

I) Lindgren, H. E., Radestad, I. J., Christensson, K., Wally-Bystrom, K., & Hildingsson, I. M. (2010). Perceptions of risk and risk management among 735 women who opted for a home birth. Midwifery, 26(2):163-72, doi: 10.1016/j.midw.2008.04.010.

Using data from a national survey of all women who birthed at home in Sweden between 1992 and 2005, this study aims to describe women’s perceptions of risk and risk management related to childbirth. Categories of perceived risk related to hospital and home births emerged. Perceived risks of hospital births included loss of autonomy, impersonal care, and subjection to interventions. Perceived risks of home birth centered around difficulty accessing emergency care in a worst-case scenario. The study found that women avoided discussing risks with care providers (other than their homebirth midwife) as a strategy to manage perceived risks.

R) Janssen, P. A., Henderson, A. D., & Vedam, S. (2009). The experience of planned home birth: views of the first 500 women. Birth, 36(4):297-304, doi: 10.1111/j.1523-536X.2009.00357.x.

S) Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery & Wom Health, 54(2):119-126, doi: 10.1016/j.jmwh.2008.09.006.

T) Christiaens, W., Gouwy, A., & Bracke, P. (2007). Does a referral from home to hospital affect satisfaction with childbirth? A cross-national comparison. BMC Health Services Research, 7(109), doi:10.1186/1472-6963-7-109.  (full text)

U) Jannssen, P. A., Carty, E. A., & Reime, B. (2006). Satisfaction with planned place of birth among midwifery clients in British Columbia. J Midwifery Womens Health, 51(2):91-7.

V) Hildingsson, I., Waldenstrom, U., & Radestad, I. (2003). Swedish women’s interest in home birth and in-hospital birth center care. Birth, 30(1):11-22.

Each paper is linked to either its original abstract on PubMed or the full-text article if available; click on the title to be taken to the abstract/ article.

A) Vedam, S., Schummers, L., Stoll, K., Rogers, J., Klein, M. C., Fairbrother, N., Dharamsi, S., Liston, R., Chong, G. K., & Kaczorowski, J. (2012). The Canadian Birth Place Study: describing maternity practice and providers’ exposure to home birth. Midwifery, 28(5):600-8, doi: 10.1016/j.midw.2012.06.011.

B) Freeze, R. A. S. (2010). Attitudes towards home birth in the USA. Expert Rev Obstet Gynecol, 5(3):283-299.   (full text)

C) Vedam, S., Stoll, K., White, S., Aaker, J., & Schummers, L. (2009). Nurse-midwives’ experiences with planned home birth: impact on attitudes and practice. Birth, 36(4):27482, doi: 10.1111/j.1523-536X.2009.00354.x.

D) Klein, M. C., Kaczorowski, J., Hall, W., Fraser, W., Liston, R. M., Eftekhary, S., Brant, R., Masse, L. C., Rosinski, J., Mehrabadi, A., Baradaran, N., Tomkinson, J., Dore, S., McNiven, P. C., Saxell, L., Lindstrom, K., Grant, J., & Chamberlaine, A. (2009). The attitudes of Canadian maternity care practitioners towards labour and birth: Many differences but important similarities. JOGC, 31(9):827-840.

I: Policy

Each paper is linked to either its original abstract on PubMed or the full-text article if available; click on the title to be taken to the abstract/ article.

A) Vedam, S. (2012). In search of a common agenda for planned home birth in America. J Perinatal Education, 21(2):67-71, doi:10.1891/1058-1243.21.2.67.  (full text)

B) Dahlen, H., Schmied, V., Tracy, S. K., Jackson, M., Cummings, J., & Priddis, H. (2010). Home birth and the National Australian Maternity Services Review: Too hot to handle? Women and Birth, 24(4):148-155, doi: 10.1016/j.wombi.2010.10.002.

C) O’Brien-Pallas, L., Baumann, A., Donner, G., Murphy, G. T., Lochhaas-Gerlach, J., & Luba, M. (2001). Forecasting models for human resources in health care. J Advanced Midwifery, 33(1):120-129.

D) Campbell, R. & MacFarlane, A. (1994). Where to be born? The debate and the evidence, 2nd ed. Oxford: National Perinatal Epidemiology Unit.

II: Cost Effectiveness

A) Schroeder, E., Petrou, S., Patel, N., Hollowell, J., Puddicombe, D., Redshaw, M., & Brocklehurst, P. (2012). Cost effectiveness of alternative planned places of birth in woman at low risk of complications: Evidence from the Birthplace in England national prospective cohort study. BMJ, 344:e2292, doi:10.1136/bmj.e2292.  (full text)

B) Henderson, J. & Petrou, S. (2008). Economic implications of home births and birth centers: a structured review. Birth, 35(2):136-46, doi: 10.1111/j.1523-536X.2008.00227.x.

C) Anderson, R. E. & Anderson, D. A. (1999). The cost effectiveness of home birth. J Nurse Midwifery, 44(1):30-5.

III: Legal

A) Dimond, B. (2000). Is there a legal right to a home confinement? Br J Midwifery, 8(5):316-9.

B) Hafner-Eaton, C. & Pearce, L. K. (1994). Birth choices, the law, and medicine: balancing individual freedoms and protection of the public’s health. J Health Polit Policy Law, 19(4):813-35.

IV: Ethics

A) De Vries, R. & Buitendijk, S. E. (2012). Science, safety and place of birth – lessons from the Netherlands. European Obstet & Gynaecol, 7(Suppl 1):13-17.  (full text)

B) Plante, L. (2011). Obstetric ethics: an essential dimension of planned home birth. Obstet & Gynecol, 118(2 Pt 1):357, doi: 10.1097/AOG.0b013e31822678ed.

C) Walsh, D. J. (2010). Childbirth embodiment: problematic aspects of current understandings. Sociol Health Illn, 32(3):486-501, doi: 10.1111/j.1467-9566.2009.01207.x.

D) Torres, J. & De Vries, R. G. (2009). Birthing ethics: What mothers, families, childbirth educators, nurses, and physicians should know about the ethics of childbirth. Perinat Educ, 18(1):12–24, doi: 10.1624/105812409X396192.  (full text)

E) Kukla, R., Kuppermann, M., Little, M., Lyerly, A. D., Mitchell, L. M., Amstrong, E. M., & Harris, L. (2009). Finding autonomy in birth. Bioethics, 23(1): 1-8, doi: 10.1111/j.1467-8519.2008.00677.x.  (full text)

F) Bell, A. F. (2007). Nurse-midwife and scientist: stuck in the middle? J Obstet Gynecol Neonatal Nursing, 36(1):71-3.

V: Available After Press