Critique of Cochrane systematic review of home-like setting for birth

This paper is a critique of a Cochrane systematic review where the primary objective of the review was to evaluate the effects, on labour and birth outcomes, of care in a home-like birth setting compared with care in a conventional hospital labour ward. The unanticipated finding of that review was a trend towards higher perinatal mortality in the home-like setting group. Our critique focuses on one important question: is the Cochrane review of birth setting based on studies of sufficient scientific rigour to be able to establish whether or not there may be an added risk of perinatal mortality associated with intrapartum care in a home-like setting? In this commentary we critique two aspects of methodological quality in the studies underpinning the Cochrane review: the high levels of non-compliance with the planned treatment, and the low levels of 'treatment fidelity' even if subjects received the planned treatment. Of the 41 deaths in the home-like setting group 35 (85%) were not associated with intrapartum care in a home-like setting. We conclude that the Cochrane review of birth setting cannot be relied upon to make valid statements about whether there may be an added risk of perinatal mortality associated with experiencing intrapartum care in either setting. In the process of our analysis we uncovered what may be two broader problems for Cochrane systematic reviews. The Cochrane Reviewers' Handbook should be expanded to give specific guidance for researchers and reviewers about how to enhance or evaluate research quality in relation to non-compliance with assigned treatment and treatment fidelity.