REPLY
We appreciate the interest in our recent publication, and welcome the opportunity to respond to these concerns, each of
which was addressed in the original article. Exclusions successfully generated a low-risk sample representative of women
considered eligible for home birth. This selection was similar to
that used by Drs Janssen and Klein in 2 of their own studies and
is unrelated to using birth certificate data.1,2
Drs Janssen and Klein reiterate the likely inclusion of unplanned home births that may disproportionately contribute to
observed adverse perinatal outcomes, including depressed
5-minute Apgar scores. Because most excess morbidity among
unplanned home births relates to prematurity, exclusion criteria
minimized such bias. Assuming that the physician or midwife
presence denotes a planned home delivery, we recalculated the
frequencies and odds ratio for 5-minute Apgar scores 7 for
planned home vs hospital births. The prevalence of low scores by
birth location was similar to the original data (1.0% vs 1.2% for
www.AJOG.org
hospital and 2.0% vs 2.3% for home births), as were the odds ratio
(OR) and 95% confidence intervals (CI) (OR, 1.90; 95% CI, 1.58
2.28 vs 1.92; 95% CI, 1.632.25). Thus, concerns regarding internal and external validity are unfounded, and we stand by our conclusions. In addition, the purpose of our article, as clearly stated,
was to evaluate morbidity, not mortality.
We have reservations regarding the proposed new standard for reporting home birth outcomes. Most home births in
the United States are performed by direct entry and lay midwives who are unlicensed, unregulated, or legally banned in
almost half of all states. Thus, although clearly well-intended,
the notion of mandated participation in outcome reporting
by such practitioners is unrealistic.
The authors cite several recent papers as fulfilling their proposed reporting standards, yet their own investigation did not
address intrapartum perinatal deaths, as recommended.2 Moreover, this and another study referenced were underpowered to
detect any differences in maternal, perinatal, or neonatal mortality
by planned delivery location.2,3 This observation is notable, as the
second paper found the neonatal mortality rate tripled among
planned home births of nonanomalous offspring.3 Considering
the criticisms of our investigation, we were chagrined that the
third report meeting the new reporting standard could not provide the intended delivery location for 8.5% of births in an outcome study of planned home vs planned hospital births.4
We appreciate the opportunity to further discuss the topic of
f
home birth and welcome future outcomes studies.
Joseph R. Wax, MD
Michael G. Pinette, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
Maine Medical Center
Portland, ME
REFERENCES
1. Janssen PA, Lee SR, Ryan EM, et al. Outcomes of planned home births
versus planned hospital births after regulation of midwifery in British Columbia. Can Med Assoc J 2002;163:315-23.
2. Janssen P, Saxell L, Page L, Klein M, Liston R, Lee S. Outcomes of
planned home birth with registered midwife versus planned hospital birth
with midwife or physician. Can Med Assoc J 2009;181:277-383.
3. Hutton K, Reitsma A, Kaufman K. 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
2009;363:180-9.
4. de Jonge A, van der Goes BY, Ravelli AC, et al. Perinatal mortality and
morbidity in a nationwide cohort of 529,688 low-risk planned home and
hospital births. BJOG 2009;116:1177-84.
2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.04.041
complete, not current, and did not comment on the first randomized clinical trial evaluating the perinatal outcomes in
obese pregnant women.2 That controlled trial, with appropri-