While the risk of neonatal death is low overall, it may be higher at home births and that is a problem, said Dr. William Barth, Jr., chair of ACOG's committee on obstetrics practice and chief of the division of maternal-fetal medicine at Massachusetts General Hospital
"It's one of those situations where overall the risk is low, but it is increased two to three-fold," he said. "Even though it's a rare outcome, it is a catastrophic outcome. It's preventable in that it is less likely in the hospital."
Explaining his stance, Barth cites a study presented by researchers from Maine Medical Center at the Society for Maternal-Fetal Medicine meeting in Chicago in early February. The study, a meta analysis of research from around the country comparing home births to hospital births, appeared to show a twofold increase in the rare event of neonatal death at a home births.
Declercq said one problem with relying on this study is the results may have been skewed because the researchers relied on the location the birth was planned for rather than where it actually took place.
While the gold standard of clinical research is the double-blind, placebo-controlled, randomized clinical trial, it is impossible to blind a mother to whether she is giving birth at home or in a hospital, and most mothers are unwilling to be randomized to a home birth or hospital birth.
Studies of home versus hospital birth are typically the less reliable cohort study, where women who chose one option or the other but have otherwise similar characteristics are compared.
Barth said that an attempt to run a randomized controlled trial of home versus hospital births had to be canceled because only 11 mothers signed up.
Home birth advocates have cited several studies supporting the safety of home births among low-risk women. However, those studies have taken place in the Netherlands and Canada.
Barth said its unrealistic to apply the findings to the United States.
"Those are highly regulated, highly integrated systems. Their system is prearranged -- it's very different from the systems available in the United States," he said.
Agreeing with that notion, Declercq argued that it is the lack of such a setup that keeps safer home births from being a bigger option in the United States.
"In the United States, people who want to have a home birth have to fight the system," he said, explaining that there is a lack of support for a midwife who decides a patient is too high-risk for a home birth and should be transferred to a hospital.
"I think if you actually move to a system like that, it would be fine in the United States, because the evidence from other countries suggests that it is as well," said Declercq.
Looking at the numbers, he said, adopting such a system probably wouldn't lead to widespread home births in the United States. It would not climb to 30 percent like the Netherlands, but would be closer to the rise to 3 percent seen in the United Kingdom.
But for now, he said, it is likely to remain a highly charged issue, with some advocates of home birth irrationally opposing the choice of a hospital while opponents cite risks of home birth while ignoring complications that can happen at a hospital.
"The mothers who are having these home births are not crazy, unaware people," said Declercq. "They plan carefully, they think about this all the time. They think they're better off not having the interventions that they feel will happen unnecessarily at hospitals."