The metaanalysis by Wax et al resulted in misleading results and conclusions about the safety of home birth.

The authors appropriately found no difference in perinatal mortality rates between planned home and planned hospital births when they included all of the selected studies, which included the very large, high-quality Dutch study that represented >90% of the available data.

However, when they summarized the risk for neonatal death separately, they chose to look only at combined early (0-6 days) and late (7-28 days) neonatal deaths. Because the Dutch study reported only on early neonatal deaths, Wax et al excluded it, thus ignoring neonatal mortality rates for 90% of the available home birth data. If early neonatal deaths had been examined separately, the Dutch study would have been included, and the conclusion would have been that the risk of early neonatal death in home births was no different than that for low-risk hospital births.

Across perinatal/neonatal studies in high resource countries, 65% to 80% of neonatal deaths consistently occur in the first 7 days. There is no reason to expect that the rate of late neonatal mortality in the Dutch study would carry any difference in safety than the early neonatal mortality rates, had it been reported by or requested from the Dutch researchers.

Furthermore, when the high-quality Dutch study is excluded from the neonatal analysis, the American study by Pang et al consequently becomes the largest study that contributed to the neonatal risk estimate. Based on birth certificate records, this study does not meet the quality criteria of more sophisticated approaches of home birth research that, since the 1980s, have required home/hospital birth comparisons to be able to stratify explicitly for whether the home births in the studies were planned and had a midwife or physician in attendance, as the Dutch study does.

Leaving out the study by Pang et al or including the Dutch study would have meant that the authors could not have jumped to the conclusion that less medical intervention or home births create higher neonatal risk. Rather, the more accurate conclusion of the metaanalysis would read, “planned home birth produces the same intrapartum and neonatal outcomes as planned hospital birth with far less intervention.” The international media may not have picked it up so enthusiastically, but the public would not have been misled either.