We read with interest the recent systematic review of the safety of home birth. The results were alarming, but closer examination revealed reason to suspend judgment.

The reported similarity in the perinatal death rate whether birth was planned to occur at home or in hospital, accompanied by an increased neonatal death rate when planned to occur at home, implies that there were fewer stillbirths in the planned home birth group. Analysis of the numbers provided in the paper indicates strong evidence that this is indeed the case, although this was not mentioned. Whether the death occurs before or after birth is not the primary criterion most would use to judge the safety of management of birth, rather the fact of the death. So the perinatal mortality should be the primary focus of the paper, not the neonatal mortality without also reporting fetal deaths.

The authors highlighted the consistency of findings related to neonatal deaths, but excluded papers (including the largest) that reported only perinatal deaths, not neonatal deaths separately. Is there some reasonable explanation for this?

The paper suggests that the true risk may be higher than reported due to the self-selection of low-risk women to planned home birth. This is a curious comment given that women in both groups in this systematic review were “low risk,” or matched on risk factors.

A quick glance reveals a number of apparent errors in the tables. For example the odds ratio for postpartum hemorrhage is said to be 0.66, but using the numbers provided in the table results in an odds ratio of 0.99. There are several others. Whether these errors result from miscalculation, typographical errors, or some other factor, they have the unfortunate effect of lowering confidence in the accuracy of the paper as a whole.