We thank the authors for their comments about our study. We agree with the authors that there are limitations to this study and had discussed them in the Comment section of the manuscript. Despite the fact that vital statistics data have some limitations, this resource is one of the more comprehensive population-based datasets on all births occurring in the United States. As previously stated, we acknowledge that births in 27 states may not be representative of all births in the United States, and thus, results might not be validly inferred for all births in the United States. As such, we do not intend for our paper to serve as conclusive evidence regarding the safety of planned home vs hospital births in the United States.

Our findings highlight the complex trade-off between potential maternal benefit and neonatal risk as women contemplate location of birth. Eventually all states will report birth information using the 2003 revision of the US Standard Certificate of Live Birth, and we plan to reexamine this topic in the near future. We agree with the authors on the need for research validating birth certificate data. Such work will provide important context for our findings and the findings of others.

We were able to examine short-term perinatal data in the current study in which differences in the timing of reporting might bias the finding, as the authors noted. Ideally, we would like to access long-term data on outcomes such as neonatal and infant death, cause(s) of death, and associated neonatal morbidities as they relate to planned home vs hospital births. Currently the National Center for Health Statistics provides the linked birth/infant death datasets for public use up to birth year 2006. When complete linkage of datasets for public use becomes available for all states for more recent years, further investigation regarding planned place of birth and birth attendants and associated perinatal/neonatal/infant outcomes will hopefully elucidate the potential risks and benefits of planned site of birth.

In summary, our data and that of others suggest that planned home births in the United States are likely not without risks. With such, we would like to reiterate the importance of quality and safety of all births, either in or out of the hospital, as a common goal for all obstetric care providers and appropriate counseling for women considering birth location.