title: Investigating the debate of home birth safety: A critical review of cohort studies focusing on selected infant outcomes.
abstract: OBJECTIVE
  There is a debate within the medical community regarding the safety of planned home births. The presumption of increased risk of maternal and infant morbidity and mortality at home due to limited access to life-saving interventions is not clearly supported by research. The aim of the present study was to assess strengths and limitations of the methodological approaches of cohort studies that compare home births with hospital births by focusing on selected infant outcomes.
  
  
  METHODS
  Studies were identified that assess the risk for at least one of three infant outcomes (mortality, Apgar score, and admission to the neonatal intensive care unit [NICU]) of home births compared with hospital births.
  
  
  RESULTS
  Fifteen cohort studies were included. Two studies of low-risk births and two including higher risk births found home births to be at an increased risk of neonatal mortality. However, mortality is rare in developed nations and may not be the best measure of safety. When studies focused on low-risk pregnancies, planned birth location, and well-trained birth attendants, there was no difference in neonatal morbidity (Apgar score and NICU admission).
  
  
  CONCLUSIONS
  Many methodological challenges were identified among these studies. This review contributes to the home birth published work by identifying key strengths and limitations that need to be accounted for in the interpretation of study findings and the development of future studies. Based on this review, the key variables that would strengthen future studies are birth attendant identification, documented planned birth location, and specification of the birth risk level. Uniformity of data collection and minimizing missing data are also critical.
authors.affiliation: Department of Public Health Sciences, University of Rochester, Rochester, New York, USA.
authors.forename: Heather R
authors.initials: HR
authors.lastname: Elder
authors.affiliation: Department of Public Health Sciences, University of Rochester, Rochester, New York, USA.
authors.forename: Amina P
authors.initials: AP
authors.lastname: Alio
authors.affiliation: Department of Clinical Sciences, Temple University School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Susan G
authors.initials: SG
authors.lastname: Fisher
mesh_terms: D001034:Apgar Score; D015331:Cohort Studies; D005260:Female; D006700:Home Childbirth; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D010343:Patient Admission; D061214:Patient Safety; D011247:Pregnancy; D011256:Pregnancy Outcome
keywords: home birth; infant mortality; methods; safety