We thank the authors for their comments about our study. Our study reported on both maternal and neonatal outcomes associated with planned home births compared with hospital births with the aim of providing comprehensive short-term perinatal outcomes associated with these birth settings. The study used information recorded on birth certificates, with ongoing quality control procedures by trained National Center for Health Statistics staff.

Although we agree with the authors that induction and augmentation of labor with pharmacologic agents should best be carried out in the hospital setting, in some cases artificial rupture of the membranes, or amniotomy, can serve as a safe means to induce and/or augment labor both in planned home births as well as hospital births. As we did not have information regarding methods of induction and augmentation, we could not make assumptions regarding the safety of induction/augmentation in planned home births. We speculate that a combined 3.5% induction and augmentation of labor incidence rate in the home birth cohort was partly because women who had planned home births tend to be low-risk. Regardless if this was due to self-selection by low-risk parturient or patient transfer to hospitals, our study highlights that planned home birth is associated with adverse neonatal outcomes, even among this low-risk population.

In our study, we acknowledged the limitation that women who intended to have home birth but subsequently delivered in hospitals were analyzed as hospital births, leading to underestimation of actual risk associated with planned home births. We reiterate our findings that planned home births involve complex tradeoffs between potential maternal benefit and neonatal risks such that women who are contemplating location of birth should be fully informed about both in order to enable an informed choice.

Finally, we agree with the authors that it is incumbent upon us all to establish means to improve the quality and safety of all births, either in- or out-of-hospital. To that end, we would point to health systems like that of the Netherlands where a large proportion of the population plan for a home birth, and protocols for risking out are in place, so that the system serves to seamlessly assure that high-risk women will deliver in hospital. There are no particular economic pressures to either deliver at home or in hospital. This is not the case in the US where it appears that high-risk patients such as those with a prior cesarean, breech presentation, or twins may deliver at home.