An immutable truth: planned home births in the United States result in avoidable adverse neonatal outcomes

Abstract

ObjectiveHome births in the United States are associated with increased patient-risk profiles, neonatal injury, and death.1Grünebaum A. McCullough L.B. Orosz B. Chervenak F.A. Neonatal mortality in the United States is related to location of birth (hospital versus home) rather than the type of birth attendant.Am J Obstet Gynecol. 2020; 223: 254.e1-254.e8Abstract Full Text Full Text PDF Scopus (12) Google Scholar Recently, research was published that showed that home births in the State of Washington have no increased adverse perinatal outcome.2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar This study aimed to evaluate the risk profiles and outcomes for US planned home births for the years 2016 to 2020.Study DesignThis was a retrospective population-based cohort study that used the Centers for Disease Control and Prevention WONDER online natality online database for the years 2016 to 2020.3Centers for Disease Control and PreventionAbout natality, 2016-2019 expanded.http://wonder.cdc.gov/natality-expanded-current.htmlDate: 2021Date accessed: October 30, 2021Google Scholar We included planned home births and compared the outcomes with and without certain risk factors, including breech presentations, twin deliveries, previous cesarean deliveries, deliveries at ≥42 weeks’ gestation, nulliparity, and a composite of at least 1 risk factor: diabetes mellitus (prepregnancy or gestational), hypertension (prepregnancy or gestational), eclampsia, previous preterm births, pregnancies that resulted from infertility treatment, and mothers that had a previous cesarean delivery. Adverse neonatal outcomes included 5-minute Apgar scores of 0 to 3, infant mortalities, seizures, and infant transfers. Statistical analysis included chi-square testing and was displayed as odds ratios (ORs) and 95% confidence intervals (CIs).ResultsA total of 18,954,274 births was investigated between 2016 and 2020, of which 153,123 were planned home births (0.81%) that accounted for the study population. The Table shows the risk factors and outcomes. Most deliveries with risk factors had significantly higher odds of adverse outcomes compared with those with no risk factors. The highest odds were for births with breech presentations and twin deliveries. Deliveries with breech presentations had an OR of 8.88 (95% CI, 7.7–10.3), and deliveries with twins had an OR of 2.8 (95% CI, 2.2–3.4) for at least 1 abnormal outcome. Moreover, the ORs for births with breech presentations with a 5-minute Apgar score of 0 to 3 (which according to the American College of Obstetricians and Gynecologists may be one of the first indications of encephalopathy and confers an increased relative risk of cerebral palsy), infant mortalities, and infant seizures were 16.10 (95% CI, 12.1–21.4), 14.12 (95% CI, 9.7–20.5), and 16.16 (95% CI, 8.6–20.3), respectively.TableRisks and outcomes of intended home births in the United States (2016–2020)Risks5-min Apgar of 0–3Infant mortalityInfant seizureInfant transportAt least 1 abnormal conditionaThis field indicates whether any abnormal conditions was reported for the newborn for assisted ventilation, neonatal intensive care unit admission, surfactant replacement therapy, antibiotics for suspected neonatal sepsis, or seizures or serious neurologic dysfunctionNo risk factor (n=139,870)3.09 (432)1.42 (199)0.64 (90)14.95 (2089)32.24 (4509)At least 1 riskbThis field indicates at least 1 of the risk factors checked: diabetes mellitus (prepregnancy or gestational), hypertension (prepregnancy or gestational), eclampsia, previous preterm births, pregnancies that resulted from infertility treatment, and mothers that had a previous cesarean delivery. (n=12,103)4.05 (49)2.48 (30)0.91 (11)23.80 (288)58.58 (709)OR (95% CI)1.31 (0.99–1.76)1.75 (1.19–2.56)1.41 (0.76–2.65)1.61 (1.40–1.80)1.82 (1.70–2.10)No breech (n=151,169)2.95 (446)1.94 (294)0.61 (92)15.15 (2290)33.14 (5010)Breech (n=1209)45.49 (55)25.64 (31)9.10 (11)93.47 (113)196.00 (237)OR (95% CI)16.10 (12.10–21.40)14.12 (9.70–20.50)16.16 (8.60–20.30)7.31 (6.00–8.90)8.88 (7.70–10.30)No previous cesarean delivery (n=145,330)3.19 (463)1.41 (205)0.63 (92)15.35 (2231)33.46 (4863)Previous cesarean delivery (n=6643)5.72 (38)3.61 (24)1.35 (9)21.98 (146)53.44 (355)OR (95% CI)1.80 (1.30–2.50)2.57 (1.70–3.90)2.15 (1.09–4.27)1.45 (1.22–1.71)1.65 (1.50–1.80)No twins (n=151,914)3.23 (491)1.44 (219)0.65 (98)15.36 (2333)33.89 (5148)Twins (n=1205)10.79 (13)11.62 (14)4.15 (5)58.09 (70)82.16 (99)OR (95% CI)2.36 (2.90–5.80)8.20 (4.80–14.10)6.57 (2.70–16.20)4.00 (3.20–5.20)2.80 (2.20–3.40)Gestational age at 37–41 wk (n=144,723)2.96 (428)1.10 (159)0.64 (920)14.45 (2091)32.75 (4740)Gestational age at <37 wk (n=1457)24.71 (36)31.57 (46)2.75 (4)137.27 (200)161.98 (236)OR (95% CI)8.54 (6.10–12.10)29.60 (12.10–41.30)4.30 (1.60–11.80)10.85 (9.30–12.70)5.71 (5.00–6.60)Gestational age at >42 wk (n=5522)5.43 (30)2.35 (13)0.91 (5)15.76 (87)45.64 (252)OR (95% CI)1.84 (1.30–2.70)2.12 (1.20–3.80)1.44 (0.60–3.50)1.10 (0.90–1.40)1.45 (1.30–1.70)Multiple pregnancy (n=123,853)2.96 (367)1.24 (154)0.52 (64)13.46 (1667)30.84 (3820)Nulliparous (n=26,556)4.97 (132)2.37 (63)1.43 (38)26.47 (703)51.62 (1371)OR (95% CI)1.68 (1.40–2.10)1.90 (1.40–2.60)2.80 (1.90–4.10)2.00 (1.80–2.20)1.71 (1.60–1.80)The “n” indicates the incidence per 1000 births, and the reference indicates the absence of condition.CI, confidence interval; OR, odds ratio.Grünebaum. Planned home births in the United States resulting in avoidable adverse neonatal outcomes. Am J Obstet Gynecol 2022.a This field indicates whether any abnormal conditions was reported for the newborn for assisted ventilation, neonatal intensive care unit admission, surfactant replacement therapy, antibiotics for suspected neonatal sepsis, or seizures or serious neurologic dysfunctionb This field indicates at least 1 of the risk factors checked: diabetes mellitus (prepregnancy or gestational), hypertension (prepregnancy or gestational), eclampsia, previous preterm births, pregnancies that resulted from infertility treatment, and mothers that had a previous cesarean delivery. Open table in a new tab ConclusionOur study findings were consistent with previous reports and indicated several important realities regarding planned home births in the United States. Many midwives did not follow guidelines meant to exclude high-risk patients at planned home births,2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar,4Grünebaum A. McCullough L.B. Brent R.L. Arabin B. Levene M.I. Chervenak F.A. Perinatal risks of planned home births in the United States.Am J Obstet Gynecol. 2015; 212: 350.e1-350.e6Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar,5Grünebaum A. McCullough L.B. Chervenak F.A. Most intended home births in the United States are not low risk: 2016-2018.Am J Obstet Gynecol. 2020; 222: 384-385Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar resulting in significant numbers of planned home births with increased risks and adverse neonatal outcomes. The recent study by Nethery et al2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar concluded that planned home births in the State of Washington have good neonatal outcomes by focusing on results of low-risk patients. In Britain, nulliparous patients are considered to be at high risk for planned home births. At least 8.7% of planned home births in our US study (≥25% when including nulliparous patients) and 7.3% in Nethery’s study (≥40% including nulliparous patients) were high risks. This suggested that the experience in the States of Washington, when the “excluded conditions” (Midwife Association of Washington State guidelines2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar) are included, is similar to home births in the United States overall and that significant numbers of high-risk patients are being delivered in planned home births. Nethery et al2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar reported an increased neonatal mortality rate of more than 8 times in high-risk patients compared with low-risk patients (OR, 8.52; 95% CI, 2.4–30.3)2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar but failed to comment on this important finding. By focusing on low-risk deliveries, Nethery et al2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar misrepresented their conclusion that planned home births in the United States have good outcomes.It is the professional responsibility of all healthcare providers, obstetricians, and midwives to present unbiased information. Focusing the reporting of outcomes on low-risk deliveries underreports true adverse outcomes in US home births and provides biased information to patients considering planned home births. It is an immutable truth that planned home births in the United States result in avoidable risks of increased adverse neonatal outcomes. ObjectiveHome births in the United States are associated with increased patient-risk profiles, neonatal injury, and death.1Grünebaum A. McCullough L.B. Orosz B. Chervenak F.A. Neonatal mortality in the United States is related to location of birth (hospital versus home) rather than the type of birth attendant.Am J Obstet Gynecol. 2020; 223: 254.e1-254.e8Abstract Full Text Full Text PDF Scopus (12) Google Scholar Recently, research was published that showed that home births in the State of Washington have no increased adverse perinatal outcome.2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar This study aimed to evaluate the risk profiles and outcomes for US planned home births for the years 2016 to 2020. Home births in the United States are associated with increased patient-risk profiles, neonatal injury, and death.1Grünebaum A. McCullough L.B. Orosz B. Chervenak F.A. Neonatal mortality in the United States is related to location of birth (hospital versus home) rather than the type of birth attendant.Am J Obstet Gynecol. 2020; 223: 254.e1-254.e8Abstract Full Text Full Text PDF Scopus (12) Google Scholar Recently, research was published that showed that home births in the State of Washington have no increased adverse perinatal outcome.2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar This study aimed to evaluate the risk profiles and outcomes for US planned home births for the years 2016 to 2020. Study DesignThis was a retrospective population-based cohort study that used the Centers for Disease Control and Prevention WONDER online natality online database for the years 2016 to 2020.3Centers for Disease Control and PreventionAbout natality, 2016-2019 expanded.http://wonder.cdc.gov/natality-expanded-current.htmlDate: 2021Date accessed: October 30, 2021Google Scholar We included planned home births and compared the outcomes with and without certain risk factors, including breech presentations, twin deliveries, previous cesarean deliveries, deliveries at ≥42 weeks’ gestation, nulliparity, and a composite of at least 1 risk factor: diabetes mellitus (prepregnancy or gestational), hypertension (prepregnancy or gestational), eclampsia, previous preterm births, pregnancies that resulted from infertility treatment, and mothers that had a previous cesarean delivery. Adverse neonatal outcomes included 5-minute Apgar scores of 0 to 3, infant mortalities, seizures, and infant transfers. Statistical analysis included chi-square testing and was displayed as odds ratios (ORs) and 95% confidence intervals (CIs). This was a retrospective population-based cohort study that used the Centers for Disease Control and Prevention WONDER online natality online database for the years 2016 to 2020.3Centers for Disease Control and PreventionAbout natality, 2016-2019 expanded.http://wonder.cdc.gov/natality-expanded-current.htmlDate: 2021Date accessed: October 30, 2021Google Scholar We included planned home births and compared the outcomes with and without certain risk factors, including breech presentations, twin deliveries, previous cesarean deliveries, deliveries at ≥42 weeks’ gestation, nulliparity, and a composite of at least 1 risk factor: diabetes mellitus (prepregnancy or gestational), hypertension (prepregnancy or gestational), eclampsia, previous preterm births, pregnancies that resulted from infertility treatment, and mothers that had a previous cesarean delivery. Adverse neonatal outcomes included 5-minute Apgar scores of 0 to 3, infant mortalities, seizures, and infant transfers. Statistical analysis included chi-square testing and was displayed as odds ratios (ORs) and 95% confidence intervals (CIs). ResultsA total of 18,954,274 births was investigated between 2016 and 2020, of which 153,123 were planned home births (0.81%) that accounted for the study population. The Table shows the risk factors and outcomes. Most deliveries with risk factors had significantly higher odds of adverse outcomes compared with those with no risk factors. The highest odds were for births with breech presentations and twin deliveries. Deliveries with breech presentations had an OR of 8.88 (95% CI, 7.7–10.3), and deliveries with twins had an OR of 2.8 (95% CI, 2.2–3.4) for at least 1 abnormal outcome. Moreover, the ORs for births with breech presentations with a 5-minute Apgar score of 0 to 3 (which according to the American College of Obstetricians and Gynecologists may be one of the first indications of encephalopathy and confers an increased relative risk of cerebral palsy), infant mortalities, and infant seizures were 16.10 (95% CI, 12.1–21.4), 14.12 (95% CI, 9.7–20.5), and 16.16 (95% CI, 8.6–20.3), respectively.TableRisks and outcomes of intended home births in the United States (2016–2020)Risks5-min Apgar of 0–3Infant mortalityInfant seizureInfant transportAt least 1 abnormal conditionaThis field indicates whether any abnormal conditions was reported for the newborn for assisted ventilation, neonatal intensive care unit admission, surfactant replacement therapy, antibiotics for suspected neonatal sepsis, or seizures or serious neurologic dysfunctionNo risk factor (n=139,870)3.09 (432)1.42 (199)0.64 (90)14.95 (2089)32.24 (4509)At least 1 riskbThis field indicates at least 1 of the risk factors checked: diabetes mellitus (prepregnancy or gestational), hypertension (prepregnancy or gestational), eclampsia, previous preterm births, pregnancies that resulted from infertility treatment, and mothers that had a previous cesarean delivery. (n=12,103)4.05 (49)2.48 (30)0.91 (11)23.80 (288)58.58 (709)OR (95% CI)1.31 (0.99–1.76)1.75 (1.19–2.56)1.41 (0.76–2.65)1.61 (1.40–1.80)1.82 (1.70–2.10)No breech (n=151,169)2.95 (446)1.94 (294)0.61 (92)15.15 (2290)33.14 (5010)Breech (n=1209)45.49 (55)25.64 (31)9.10 (11)93.47 (113)196.00 (237)OR (95% CI)16.10 (12.10–21.40)14.12 (9.70–20.50)16.16 (8.60–20.30)7.31 (6.00–8.90)8.88 (7.70–10.30)No previous cesarean delivery (n=145,330)3.19 (463)1.41 (205)0.63 (92)15.35 (2231)33.46 (4863)Previous cesarean delivery (n=6643)5.72 (38)3.61 (24)1.35 (9)21.98 (146)53.44 (355)OR (95% CI)1.80 (1.30–2.50)2.57 (1.70–3.90)2.15 (1.09–4.27)1.45 (1.22–1.71)1.65 (1.50–1.80)No twins (n=151,914)3.23 (491)1.44 (219)0.65 (98)15.36 (2333)33.89 (5148)Twins (n=1205)10.79 (13)11.62 (14)4.15 (5)58.09 (70)82.16 (99)OR (95% CI)2.36 (2.90–5.80)8.20 (4.80–14.10)6.57 (2.70–16.20)4.00 (3.20–5.20)2.80 (2.20–3.40)Gestational age at 37–41 wk (n=144,723)2.96 (428)1.10 (159)0.64 (920)14.45 (2091)32.75 (4740)Gestational age at <37 wk (n=1457)24.71 (36)31.57 (46)2.75 (4)137.27 (200)161.98 (236)OR (95% CI)8.54 (6.10–12.10)29.60 (12.10–41.30)4.30 (1.60–11.80)10.85 (9.30–12.70)5.71 (5.00–6.60)Gestational age at >42 wk (n=5522)5.43 (30)2.35 (13)0.91 (5)15.76 (87)45.64 (252)OR (95% CI)1.84 (1.30–2.70)2.12 (1.20–3.80)1.44 (0.60–3.50)1.10 (0.90–1.40)1.45 (1.30–1.70)Multiple pregnancy (n=123,853)2.96 (367)1.24 (154)0.52 (64)13.46 (1667)30.84 (3820)Nulliparous (n=26,556)4.97 (132)2.37 (63)1.43 (38)26.47 (703)51.62 (1371)OR (95% CI)1.68 (1.40–2.10)1.90 (1.40–2.60)2.80 (1.90–4.10)2.00 (1.80–2.20)1.71 (1.60–1.80)The “n” indicates the incidence per 1000 births, and the reference indicates the absence of condition.CI, confidence interval; OR, odds ratio.Grünebaum. Planned home births in the United States resulting in avoidable adverse neonatal outcomes. Am J Obstet Gynecol 2022.a This field indicates whether any abnormal conditions was reported for the newborn for assisted ventilation, neonatal intensive care unit admission, surfactant replacement therapy, antibiotics for suspected neonatal sepsis, or seizures or serious neurologic dysfunctionb This field indicates at least 1 of the risk factors checked: diabetes mellitus (prepregnancy or gestational), hypertension (prepregnancy or gestational), eclampsia, previous preterm births, pregnancies that resulted from infertility treatment, and mothers that had a previous cesarean delivery. Open table in a new tab A total of 18,954,274 births was investigated between 2016 and 2020, of which 153,123 were planned home births (0.81%) that accounted for the study population. The Table shows the risk factors and outcomes. Most deliveries with risk factors had significantly higher odds of adverse outcomes compared with those with no risk factors. The highest odds were for births with breech presentations and twin deliveries. Deliveries with breech presentations had an OR of 8.88 (95% CI, 7.7–10.3), and deliveries with twins had an OR of 2.8 (95% CI, 2.2–3.4) for at least 1 abnormal outcome. Moreover, the ORs for births with breech presentations with a 5-minute Apgar score of 0 to 3 (which according to the American College of Obstetricians and Gynecologists may be one of the first indications of encephalopathy and confers an increased relative risk of cerebral palsy), infant mortalities, and infant seizures were 16.10 (95% CI, 12.1–21.4), 14.12 (95% CI, 9.7–20.5), and 16.16 (95% CI, 8.6–20.3), respectively. The “n” indicates the incidence per 1000 births, and the reference indicates the absence of condition. CI, confidence interval; OR, odds ratio. Grünebaum. Planned home births in the United States resulting in avoidable adverse neonatal outcomes. Am J Obstet Gynecol 2022. ConclusionOur study findings were consistent with previous reports and indicated several important realities regarding planned home births in the United States. Many midwives did not follow guidelines meant to exclude high-risk patients at planned home births,2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar,4Grünebaum A. McCullough L.B. Brent R.L. Arabin B. Levene M.I. Chervenak F.A. Perinatal risks of planned home births in the United States.Am J Obstet Gynecol. 2015; 212: 350.e1-350.e6Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar,5Grünebaum A. McCullough L.B. Chervenak F.A. Most intended home births in the United States are not low risk: 2016-2018.Am J Obstet Gynecol. 2020; 222: 384-385Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar resulting in significant numbers of planned home births with increased risks and adverse neonatal outcomes. The recent study by Nethery et al2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar concluded that planned home births in the State of Washington have good neonatal outcomes by focusing on results of low-risk patients. In Britain, nulliparous patients are considered to be at high risk for planned home births. At least 8.7% of planned home births in our US study (≥25% when including nulliparous patients) and 7.3% in Nethery’s study (≥40% including nulliparous patients) were high risks. This suggested that the experience in the States of Washington, when the “excluded conditions” (Midwife Association of Washington State guidelines2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar) are included, is similar to home births in the United States overall and that significant numbers of high-risk patients are being delivered in planned home births. Nethery et al2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar reported an increased neonatal mortality rate of more than 8 times in high-risk patients compared with low-risk patients (OR, 8.52; 95% CI, 2.4–30.3)2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar but failed to comment on this important finding. By focusing on low-risk deliveries, Nethery et al2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar misrepresented their conclusion that planned home births in the United States have good outcomes.It is the professional responsibility of all healthcare providers, obstetricians, and midwives to present unbiased information. Focusing the reporting of outcomes on low-risk deliveries underreports true adverse outcomes in US home births and provides biased information to patients considering planned home births. It is an immutable truth that planned home births in the United States result in avoidable risks of increased adverse neonatal outcomes. Our study findings were consistent with previous reports and indicated several important realities regarding planned home births in the United States. Many midwives did not follow guidelines meant to exclude high-risk patients at planned home births,2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar,4Grünebaum A. McCullough L.B. Brent R.L. Arabin B. Levene M.I. Chervenak F.A. Perinatal risks of planned home births in the United States.Am J Obstet Gynecol. 2015; 212: 350.e1-350.e6Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar,5Grünebaum A. McCullough L.B. Chervenak F.A. Most intended home births in the United States are not low risk: 2016-2018.Am J Obstet Gynecol. 2020; 222: 384-385Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar resulting in significant numbers of planned home births with increased risks and adverse neonatal outcomes. The recent study by Nethery et al2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar concluded that planned home births in the State of Washington have good neonatal outcomes by focusing on results of low-risk patients. In Britain, nulliparous patients are considered to be at high risk for planned home births. At least 8.7% of planned home births in our US study (≥25% when including nulliparous patients) and 7.3% in Nethery’s study (≥40% including nulliparous patients) were high risks. This suggested that the experience in the States of Washington, when the “excluded conditions” (Midwife Association of Washington State guidelines2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar) are included, is similar to home births in the United States overall and that significant numbers of high-risk patients are being delivered in planned home births. Nethery et al2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar reported an increased neonatal mortality rate of more than 8 times in high-risk patients compared with low-risk patients (OR, 8.52; 95% CI, 2.4–30.3)2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar but failed to comment on this important finding. By focusing on low-risk deliveries, Nethery et al2Nethery E. Schummers L. Levine A. Caughey A.B. Souter V. Gordon W. Birth outcomes for planned home and licensed freestanding birth center births in Washington State.Obstet Gynecol. 2021; 138: 693-702Crossref PubMed Scopus (7) Google Scholar misrepresented their conclusion that planned home births in the United States have good outcomes.