Outcomes of Care for 16,925 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009 Reply

We were pleased to see the recently published data from MANA.1 However, critically reading the report leads to very different conclusions than those of the authors. Absent statistical comparisons, statements regarding “statistical congruence” falsely imply statistical comparability to earlier publications. After indicting birth certificate-based data as unreliable, the authors repeatedly cite such evidence in support of their conclusions. These practices are at best inappropriate and at worst misleading. The authors incorrectly contend that the data show lower cesarean and operative vaginal birth rates than planned hospital births. When low-risk nulliparous women enter labor spontaneously for planned hospital birth, 84% have spontaneous vaginal births, 8% have forceps-assisted births, and 8% have cesareans. The respective figures for multiparas are 98%, 1%, and 1%, virtually identical to the authors’ findings.2 The unexpectedly high rate of postpartum hemorrhage was speculatively attributed to inaccurate estimated blood loss and inconsistent active third stage management. Rather than suggesting a revised definition of postpartum hemorrhage, more appropriate alternative recommendations would include providing home birth midwives with training in estimating blood loss, third stage management, and improved candidate screening for hemorrhage risk.3 The authors state that the rate of successful trial of labor after cesarean (TOLAC) was higher than prior studies “with no significant increase in early or overall neonatal mortality.” The latter likely reflects the unexpectedly high number of intrapartum fetal deaths observed with TOLAC, dismissed as too few to reliably analyze. Three deaths in 1052 TOLACs starkly contrast 2 deaths among 15,338 in-hospital TOLACs, a highly significant difference (P = .002). Notably, more than 73%ofwomen attempting in-hospital TOLACgave birth vaginally.4 The intrapartum fetal and neonatal death rates are excessive. Even after excluding high-risk women and lethal anomalies, the intrapartum fetal death rate, 1.3 per 1000, is almost 10-fold that of low-risk women entering labor for a planned hospital birth, representing an absolute increased risk of more than one death per 1000 births. The neonatal mortality rate, 0.76 per 1000, is 2.5 times greater than that for low-risk planned hospital births.2 Contrary to the authors’ interpretation, the data show that planned home birth incurs significant avoidable intrapartum fetal and neonatalmortalitywhile offering nomeasurable maternal benefit. The outcomes demand an immediate reappraisal and improvement of home birth client selection as well as intrapartum fetal and neonatal care. Women considering their birth options, and their offspring, deserve no less.