We congratulate the authors of the publication on selected perinatal outcomes associated with planned home births in the United States that agree with our findings that home births are associated with increased adverse neonatal outcomes. In addition to neonatal outcomes, the authors also examined the following maternal obstetric interventions: operative vaginal delivery (forceps or vacuum-assisted), induction of labor, augmentation of labor, and maternal antibiotic use in labor and showed the differences of these interventions in Table 3 of that article. Purported decreases in obstetric interventions are often cited by home birth advocates to be of significant advantage in home births. We show below that this is not the case.

Table 3 of that article shows the comparisons of obstetric interventions between planned home births and hospital births. Using operative vaginal delivery as an indicator for comparing interventions between hospital and home births is unacceptable, as there are clear indications for operative deliveries but they should never be done at home births. We emphasize that there is no clinical justification for the 10 operative vaginal deliveries reported in the home births group. Rather than celebrating the low incidence of operative vaginal deliveries at home births, these should be eschewed and not used as exemplars.

A combined 3.5% induction and augmentation of labor rate in home births was reported. This prompts an obvious question: How were these inductions done for home births, inasmuch as Pitocin or any other induction agent requires continuous electronic fetal monitoring. Again, a reduction in induction cannot be purported as an advantage of home births, especially considering the increased risk of adverse neonatal outcomes in postdates patients who do not have the option of a safe induction in home births. The recent professional liability case in Maryland where Pitocin was given unmonitored at home by a midwife and there was a subsequent jury award of multimillion dollars against a medical center underscores this point.

A significant decrease in antibiotic use between hospital and home births. (15.2% in the hospital vs 2.6% at home) was also reported. Koumans et al reported a 24.2% incidence of GBS carriage in pregnancy and, according to the CDC recommendations, all women should be screened for GBS and treated with IV antibiotics in labor if positive. The low 2.6% antibiotic use rate in term home births is therefore of concern. Unless there is something inherently different in the home birth population showing a 90% lower incidence of GBS than the general population, it appears that most women with positive GBS status in the home birth group either were not adequately identified or if identified as positive may not have received the recommended dose of antibiotics. The low usage of antibiotics in labor found in this study cannot be used by advocates to point to an advantage of home births, but rather a failure to identify and treat patients adequately and to follow recommended evidence-based guidelines.

Finally, the purported reduced rate of interventions in home births fails to take into consideration the patients with planned home births who were transferred from the home to the hospital. The authors correctly state that this number is likely in excess of 15%. Patients transferred to the hospital are usually transferred because of exhaustion, pain management, abnormal labor, and concerns for fetal distress (eg, Enzo Martinez vs Johns Hopkins Hospital case from Maryland ). Once in the hospital, most of these patients will likely have medically necessary (often overdue) interventions such as operative delivery, augmentation of labor, and epidural anesthesia. Removing these patients from the “planned home birth” category falsely gives the impression that there are less interventions in planned home birth. Put another way, in an intention to treat analysis, which is the appropriate analysis, all interventions and outcomes of planned home births whether the eventual delivery happened at home or the hospital would have been included, leading to an accurate description of the rate of intervention in planned home birth.

We strongly agree with home birth advocates that there is a need to prevent unnecessary obstetric interventions. The challenge for all obstetric providers is to accomplish this important task concomitantly with enhancing patient safety and not undermining it.