Oops, I did too much direct copying of the text for copyright purposes....here's the edited version...read the study for the original text.
Basically, only three possibly preventable deaths occurred in homebirths in the study, and two of those had risk factors.
Okay, here's the important part of the study, where they look at actual deaths:
"There were nine deaths in the planned home birth group — a rate of 7.9 per 1000 births, compared with 8.2 per 1000 births for planned hospital births."
So the homebirth cohort -- including those who were planning a homebirth but for some reason or another started labor in the hospital -- had a slightly lower rate of death. However, the hospital group included pregnancies that were high risk from the start due to maternal health issues, multiple pregnancies, etc (the homebirth group did, however, include preemies).
Among the two deaths that occurred at home without a transfer, one was a planned "homedeath" in which the parents know the baby will not survive and simply try to make the baby's short time on earth gentle and painless. The other death that occurred at home looks like it could have been preventable with better monitoring.
In the transfers, two were high risk to start. In the first, the mother had been planning a homebirth but labor actually was induced and started in the hospital, so it doesn't illustrate the safety of homebirth. In the second, one of the twins died. There is a lot of debate regarding whether or not it's safe to homebirth twins. In this case, maybe better monitoring on the part of the midwife would have saved the baby.
In the final five deaths which occurred in a hospital, but which are characterized as homebirths because the mother was getting prenatal care with a homebirth midwife (they don't actually say if labor started at home or in a hospital), three were congenital abnormalities in which the baby would have died no matter what, one was a baby whose mother went into premature labor and died because he was too little to survive, and the final was a mother who went very post-term, refused fetal monitoring and induction and the baby died.
"Nonetheless, in the 16-year study period there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth, or timing of transfer to hospital might have made a difference to the outcome. Characteristics of these births were post-term pregnancy, twin pregnancy, and inadequate fetal surveillance during labour."
So basically, of all those deaths, three might be considered preventable. Most midwives will transfer a mother to a hospital after 42 weeks, or at least require NST, so I'd be hesitant to include that one. There are two -- the waterbirth and the twin birth -- that might have been prevented with a more careful midwife or a choice of hospital birth. Note that there were no deaths from things like placental abruption, cord prolapse, etc.
They also mention that postpartum hemorrhage rates were similar in home and hospital births, and note it may be because midwives carry pitocin to use in case of hemorrhage.
"Integration of home birth practitioners into the health system with supervision and backup may help to dissuade women from undertaking high-risk home births and reduce avoidable adverse outcomes.
"Although it is not anticipated that large numbers of women will opt for home birth, women’s autonomy in choosing reproductive behaviour is a fundamental human right enshrined in Australian law.4 Respecting their choices and achieving the best outcome for all concerned is likely to remain a challenge that will require more light and less heat than it has received thus far."
This study isn't anti-homebirth, it's anti unsafe homebirth. It makes two very good points -- one, if a woman with high risk factors chooses to have a homebirth, there is risk involved and the woman needs to have good information and have a transfer plan in place. The study authors want homebirth more integrated into the medical system. And two, proper fetal monitoring is essential during homebirth. That's where you need a highly skilled and careful midwife. I especially like the last line about needing "more light and less heat."
Australia has been very homebirth unfriendly and came very close to banning homebirth altogether.
One other thing I was thinking of -- it doesn't address cause of death in the hospital. But of course you have to ask how many of those hospital deaths were preventable, occurring because of physician error, side effects from unnecessary interventions, infections contracted in the hospital, etc.
And huge omission, unlike the recent Canadian study and the 2007 North American study, it doesn't actually note whether or not the births are attended by midwives. That would be highly relevant information.
I have only just skimmed this study so don't really have any comments to make on it specifically but, to answer the other questions...
