We appreciate the letter by Illuzzi et al concerning our publication that showed the incremental increased neonatal mortality risks in out-of-hospital births.

The authors of the letter cite a study that purportedly shows in accredited birthing centers a lower neonatal mortality rate than we reported for free-standing birthing centers. However, that study was based on voluntary data and was not comprehensive. The authors themselves state in their publication that their data are not generalizable. Therefore, the data they cite do not support their claim that birthing centers, even when accredited, generally have low neonatal mortality rates.

Our study used the Centers for Disease Control and Prevention (CDC) birth certificate database, which is comprehensive and includes all births in the United States. The CDC category for birthing centers included only free-standing birthing centers. Outcomes of hospital-based birthing centers in the CDC data are included in hospital outcomes.

We believe that it is the absence of essential services, personnel, expeditious access to cesarean deliveries, and sufficiently trained pediatricians and neonatologists, and advanced equipment as well as the extended time transporting patients to the hospital that unnecessarily increase neonatal risks in out-of-hospital births, whether births occur in free-standing birthing centers or homes.

Physicians and other health care providers have a professional responsibility to understand, identify, and address the root causes motivating patients’ desire for out-of-hospital birth by providing evidence-based, compassionate hospital care, improving hospital settings, addressing obstetric interventions, and providing excellent, supportive, and nonjudgmental hospital care to women transported from a planned home or birthing center birth.