In a recent opinion piece, “Planned home birth: the professional responsibility response,” Chervenak et al argue against the ethics of home birthing stating that advocates of planned home birth have emphasized 4 points: patient safety, patient satisfaction, cost-effectiveness, and respect for women’s rights. “We provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth.”

Regarding patient safety, the authors say, “Maternal and fetal necessity for transport during labor is often impossible to predict.” Home birth women by definition are selected based on their health. They labor as nature intended without interventions. In experienced hands, transport is rarely “impossible” to predict. The authors state the most common reasons for transport are pain relief and prolonged labor, neither being unsafe. The argument against home birth in the United States continues by presenting safety data from South Australia, a system that has no resemblance here.

The authors state, “It is antithetical to professional responsibility to intentionally assign any damaged or dead pregnant, fetal, or neonatal patient to this category, even if the number is small.” Yet ample evidence exists that similar cohorts of normal women delivered out of hospital vs a hospital have cesarean section rates of 6% and 24%, respectively. By that standard the increased morbidity of the hospital model if held to the same standard would be professionally irresponsible.

Regarding patient satisfaction, the authors assume the high rates of transport undercut the raison d’être of planned home birth. A Dutch study from 2008 showing persistent levels of frustration for up to 3 years in 17% of transported women is cited. That implies an 83% satisfaction rate. A fairer comparison would be the satisfaction rate of US women with successful home vs hospital births. I disagree with the solution of supporting “homebirth-like” environments in the hospital setting.

Minimal savings in cost comparison data from Britain are cited, vs US cost comparisons. The cost of a typical home birth in the United States is about 35% of that in hospitals. Savings over a cesarean birth approach 80%. When cesarean section rates approaching 35% are factored in, the savings is even more significant.

Regarding women’s rights, the authors avoid using the beneficence-based model of ethics which, as with vaginal birth after cesarean, supports a woman’s reasonable choice. Instead it is stated, “From the perspective of the professional responsibility model, insistence on implementing the unconstrained rights of pregnant women to control the birth location is an ethical error and therefore has no place in professional perinatal medicine.” But home birth advocates do not support unconstrained rights or rights-based reductionism.