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Critical Appraisal of the Literature

HOME BIRTH: An annotated guide to the literature ©

Authors: Saraswathi Vedam, Laura Schummers, Kathrin Stoll, Colleen Fulton

Last updated:  Sept 2012


This bibliography is offered as a resource for clinicians and others (researchers, educators and policy makers) who must, within their own context for work, assess the quality of the available evidence on planned home birth, for the purpose of clinical decision making or to contextualize the current international debate on safety, access, ethics, autonomy, and resource allocation with respect to birth place.

This document was originally developed in 1997 for the primary author’s personal use in her clinical and academic work. Over time updated versions (2002, 2004, 2007, 2010) informed the development of clinical practice guidelines for various North American maternity professional associations, and served as a resource in midwifery, medical, and nursing educational institutions. As the requests and self-generated distribution of the document expanded, it became clear that a more comprehensive, formalized approach to updating the literature search and reporting results was necessary. In 2011, additional authors and external reviewers were recruited, and a search strategy for annual updates was formulated. To facilitate continued access by those readers who regularly utilize it, the authors decided to self-publish in electronic and print formats and provide open access to the bibliography.


Click on each section below to explore the studies in that group.  Papers are grouped according to study design and level of evidence, and presented in descending order by publication date.  Each paper is linked to either its original abstract on PubMed or the full-text article if available.

Section A – best available studies on planned home birth and maternal fetal outcomes.

Section B – studies exhibiting problems with the design, analysis or reporting.

Section C – articles dedicated to the critical appraisal of original studies and meta-analyses on planned home birth and maternal fetal outcomes.

Section D – evaluations of women’s choice and satisfaction with home birth.

Section E – a reference list of citations on provider attitudes towards home birth.

Section F – a reference list of citations on policy, economic, legal, and ethical issues related to home birth.

Click here for the PDF of “HOME BIRTH: An annotated guide to the literature”


Search Strategy

Papers were identified through a comprehensive search of the following databases:EBSCO (Academic Search Complete, Medline & CINAHL), PubMed, & Cochrane, along with citation snowballing, and consultations with content experts and key informants. We included articles that were published in English between 1990-2012.

The following search terms were applied:

“home birth” or “home + childbirth” and safety, risk assessment, transfer criteria, outcomes, screening, satisfaction, demand, preference, and perception.

The most recent search (August 2010-March 2012) identified 320 articles for assessment, and resulted in the addition of 22 new citations (see diagram below).


Original studies of outcomes from planned home births in high resource countries were selected for inclusion; studies describing data from developing nations were excluded because they did not meet the definition of planned home birth used for this review which specifies access to qualified attendants and the ability to transfer to a hospital when necessary.

Criteria for assessment

Included papers were independently appraised by three authors according to the algorithm to assess the quality of home birth research outlined by Vedam (2003) below. In addition, studies were assessed for appropriate application of analytic tools (statistics), and the extent to which the conclusions were based on the reported data. Differences were resolved by discussion. Prior to publication, the bibliography was reviewed by 5 external reviewers with expertise in perinatal epidemiology, statistics, and research related to midwifery, obstetrics, bioethics, and health care delivery.

Vedam, S. (2003). Home versus hospital birth: questioning the quality of the evidence on safety. Birth, 30(1), 57-63.

1. Study design should:

Distinguish between planned home births and unplanned out-of-hospital births

Discriminate data from different types of providers

Provide relevant and consistent inclusion criteria for study subjects across comparison groups

Adjust for differences in selection criteria for home birth and perinatal management

Control for differences in transfer criteria and method

Define terms, such as mortality and morbidity

Select relevant and consistent outcome measures.

2. Analysis and discussion should examine the impact of:

Lack of randomization

Small and homogeneous sample sizes>
Retrospective and incomplete data in birth records or certificates

Differences among community standards of care and/or county specific policies and protocols.


Section C describes articles which provide detailed appraisals of studies that are included in Section B.

Section D presents articles that were reviewed and selected by the authors for abstraction or listing if they describe original research, analyzed data from direct patient interviews, focus groups or surveys, and evaluated outcomes related to women’s experience, perception, psycho-social effects or choice with respect to birth place. Publications prior to 2010 were not abstracted.

Papers in Sections E-F were selected for inclusion if they provide an evidence-based discourse analysis or commentary and have the potential to enhance the reader’s understanding of key legal, policy, economic, and ethical issues, and innovative solutions to controversial topics related to home birth.

Authorship by academic and maternity professional experts on birth place was a priority for inclusion.


The authors would like to thank the Transforming Birth Fund for funding the updating and printing of the bibliography and Kerri Blackburn for her assistance in finalizing the bibliography.

Correspondence to the authors may be sent to: or to: B54 2194 Health Sciences Mall; Vancouver, BC V6T 1Z3