In Reply:
Thank you for the opportunity to respond to the preceding authors.
Wax and Pinette suggest that our “perfect guideline analysis” actually underestimates the true perinatal mortality rate among low-risk deliveries. We agree. To demonstrate the potential bias introduced by previous authors who ex post facto excluded high-risk groups, we developed the more natural ex ante prospective approach, reflecting daily practice (Table 2 in our article), and estimated the effect of stepwise consecutive exclusion of categories (subgroups) on the perinatal mortality rate (Fig. 3 in our article). Both may point toward a higher perinatal mortality rate in specific highrisk groups, in agreement with Wax’s study.
Wax and Pinette also emphasize the need for including a risk-adjusted comparison with physician-led care in the hospital. Our primary research goal was to compare planned homebirth with planned hospital birth—both midwife-led—to support policy-making on the optimal setting of care, leaving the midwife’s position as independent professional caregiver unchanged. A comparison of settings naturally includes the gynecologist– hospital combination. However, the Dutch registry data do not allow for such a comparison because low-risk women rarely have their deliveries at the hospital and because too few case-mix data are recorded. Finally, we unintentionally did not refer to the postpublication correspondence of Wax’s study. We generally agree with the views expressed in that correspondence. [...]

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Obstetrics and Gynecology
Department of Gynaecology & Obstetrics

van der Kooy, J, Poeran, V.J.J, de Graaf, J.P, Birnie, E, Denktaş, S, Steegers, E.A.P, & Bonsel, G.J. (2012). Planned home compared with planned hospital births in the Netherlands: Intrapartum and early neonatal death in low-risk pregnancies. Obstetrics and Gynecology, 119(2). doi:10.1097/AOG.0b013e318244c268