Advertisement

Editors' comment

        We have received numerous letters to the editors regarding the article by Wax et al: Maternal and newborn outcomes in planned home birth vs hospital births: a metaanalysis, published in the September, 2010 edition of the Journal. Five of these letters are selected to be published here with the reply from the authors. In response to the concerns that were expressed in the letters, the American Journal of Obstetrics and Gynecology convened an independent review panel to (1) review the article that was published and these letters to the editors and (2) make recommendations to the Journal. The review panel consisted of 3 panelists who are all specialists in maternal fetal medicine, with expertise in metaanalysis and clinical research. The panel was provided a copy of the manuscript that had been submitted (Wax et al
        • Wax J.R.
        • Lucas F.L.
        • Lamont M.
        • et al.
        Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis.
        ) and all of the letters to the editors. In addition, after its initial review, the panel requested additional information from Dr Wax, the corresponding author of the article, that would include the individual summary graphs for each outcome that was presented in the manuscript. Each member of the panel reviewed the information independently, and consensus was reached in a conference call.
        There were a number of issues raised in the letters, many of which the panel believed were subjective and should be debated openly. The issue that the panel focused on was the “numbers” that were included for each outcome in the metaanalysis. The panel reviewed several outcomes and attempted to reconstruct the results of the metaanalysis. In all 3 cases, the results the panel found was slightly different from the result in the manuscript, although there was no difference in (1) the direction of the point estimate of the pooled odds ratio or (2) the overall “statistical significance” of the result. The panel made the following recommendations: (1) The Journal should publish online full summary graphs for each outcome that was assessed in the study, which will allow readers to assess the study findings better, and (2) no retraction of the article is necessary.
        It is clear that we need more rigorous and better designed research on this important safety issue of home birth, given the many confounding factors.

        Reference

          • Wax J.R.
          • Lucas F.L.
          • Lamont M.
          • et al.
          Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis.
          Am J Obstet Gynecol. 2010; 203: 243.e1-243.e8

        Linked Article

        • Study validity questioned
          American Journal of Obstetrics & GynecologyVol. 204Issue 4
          • Preview
            We read with some alarm the article by Wax et al entitled, “Maternal and newborn outcomes in planned home births vs planned hospital birth: a metaanalysis.”1 We agree with several researchers who point out that the method used to select studies for inclusion in this metaanalysis requires serious scrutiny.
          • Full-Text
          • PDF
        • Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis
          American Journal of Obstetrics & GynecologyVol. 204Issue 4
          • Preview
            A recent metaanalysis by Wax et al1 raises several methodologic and analytic concerns. Only 4 studies selected for analysis involved deliveries occurring in the present decade, 7 studies involved fewer than 3000 participants (one with n = 11), and only 1 study was US-based. That study2 accounted for 59% of the neonatal deaths analyzed by Wax et al, and was based on birth certificates that did not explicitly indicate whether the place of birth was planned. Moreover, the analyses of intervention, maternal and infant morbidity involved different studies from those examined for perinatal and infant mortality.
          • Full-Text
          • PDF
        • Home birth metaanalysis: does it meet AJOG's reporting requirements?
          American Journal of Obstetrics & GynecologyVol. 204Issue 4
          • Preview
            We challenge the conclusions of the metaanalysis by Wax et al,1 which reported that planned home births had higher neonatal mortality rates than hospital births and were therefore less safe. The metaanalysis includes poor quality studies, has a high risk of methods bias, and does not meet the Journal's requirement to comply with metaanalysis of observational studies in epidemiology guidelines.2 For example:
          • Full-Text
          • PDF
        • Perinatal mortality and planned home birth
          American Journal of Obstetrics & GynecologyVol. 204Issue 4
          • Preview
            We read with interest the recent systematic review of the safety of home birth.1 The results were alarming, but closer examination revealed reason to suspend judgment.
          • Full-Text
          • PDF
        • Reply
          American Journal of Obstetrics & GynecologyVol. 204Issue 4
          • Preview
            We are utterly dismayed by Drs Zohar and De Vries' citing unnamed detractors and nonspecific unreferenced criticisms of our study. Their characterization of the data as “flawed” is particularly interesting regarding a metaanalysis. We were especially taken aback by the proposed alternative title for our paper. Not only is it disingenuous considering the clearly stated objective, study inclusion criteria, and method of study identification, but it is also an affront to midwives with credentials other than the certified midwife (CM) or certified nurse-midwife (CNM) designation.
          • Full-Text
          • PDF
        • Reply
          American Journal of Obstetrics & GynecologyVol. 204Issue 4
          • Preview
            Thank you for the opportunity to respond to the preceding authors. For most, these submissions simply represent their latest of a series of letters to various editors on the same paper.1-4 At least one of the letters' clear intent is to discredit our study and force its retraction. This goal provides valuable interpretive context, calling the criticisms' severity and validity into question. Harboring no bias, we embarked on the study to examine an important clinical issue. Although our findings may be unpopular in certain quarters, they result from appropriate rigorous scientific methods that have undergone appropriate peer review.
          • Full-Text
          • PDF
        • International data demonstrate home birth safety
          American Journal of Obstetrics & GynecologyVol. 204Issue 4
          • Preview
            The metaanalysis by Wax et al1 resulted in misleading results and conclusions about the safety of home birth.
          • Full-Text
          • PDF
        • “Home birth triples the neonatal death rate”: public communication of bad science?
          American Journal of Obstetrics & GynecologyVol. 204Issue 4
          • Preview
            Current debate and commentaries about the paper by Wax et al1 regarding outcomes of home births have focused on methodological flaws.2 Another serious concern is the selective quoting of results and conclusions in the paper's abstract and the misleading press release from the American Journal of Obstetrics and Gynecology (AJOG) entitled “Planned Home Births Associated with Tripling of Neonatal Mortality Rate Compared to Planned Hospital Births,” that stated “…of significant concern, these apparent benefits are associated with a doubling of the neonatal mortality rate overall and a near tripling among infants born without congenital defects.”3 The news story was picked up by the mass media, and reported uncritically in BMJ and The Lancet.
          • Full-Text
          • PDF
        • Supplemental material of interest to our readers
          American Journal of Obstetrics & GynecologyVol. 204Issue 4
          • Preview
            We appreciate the opportunity provided by the American Journal of Obstetrics and Gynecology to present summary data graphs (forest plots) for our metaanalysis of planned home vs planned hospital births. Figures 1-21 are presented in the order that the data were described in the original manuscripts' Tables 2 and 3 (maternal and neonatal outcomes, respectively). In the course of constructing the graphs we identified minor data entry discrepancies that did not impact any statistical or clinical significance in the overall or sensitivity analyses, each of which was repeated.
          • Full-Text
          • PDF