Critical appraisal of the proposed defenses for planned home birth

Abstract

Two prominent proposed defenses have been offered of planned home birth. The first focuses on the very low absolute risk of planned home birth, which is considered to be safe because it is so low, irrespective of its significantly elevated relative risk. The second invokes an analogy between trial of labor after cesarean delivery and planned home birth. Because trial of labor after cesarean delivery and planned home birth have similar, very low absolute risks and because the former is an acceptable clinical practice, defenders of planned home birth argue that the latter should be considered acceptable. This article presents a critical appraisal of these 2 proposed defenses of planned home birth. Question 1: Are proposed defenses of planned home birth focused on its low absolute risks consistent with the commitment to patient safety? This commitment to patient safety requires the identification of variation in the processes of patient care and reduction of variation when reduction improves outcomes. Relative, as well as absolute, risks therefore must be identified. Compared with hospital midwives, planned home births have a significantly higher relative total neonatal mortality risk of 3.87 (1.26 vs 0.32 per 1000 births; P<.001) and a significantly higher relative risk of 5-minute Apgar score of zero of 18.11 (1.63 vs 0.0/1000 births; P<.001). Planned hospital birth prevents these risks. It follows that planned home birth as a variant in birth setting is not consistent with the commitment to patient safety. Question 2: Is the analogy to trial of labor after cesarean delivery consistent with the philosophic rules of analogic reasoning? The long-established philosophic rules for analogic reasoning require that the 2 cases that are compared are similar in all relevant respects and that all relevant analogies have been considered. The 2 cases are dissimilar because the perinatal risks of planned home births are approximately 3 times higher than trial of labor after cesarean delivery. At least 8 clinical analogies to other situations of very low absolute, but unacceptable, risks are ignored. The clinical implication of the results of this critical appraisal is that obstetricians should respond to expressions of interest in planned home birth based on these proposed defenses with a respectful explanation of the inadequacies, the failure to commit to patient safety, and a recommendation for planned hospital birth.