CORONER John Olle has recommended women planning a home birth undergo a comprehensive risk assessment.
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Mr Olle said the risk assessment could "articulate agreed home birth practice during the course of the pregnancy, together with agreed contingency plan in the event of an emergency."
Mr Olle's comments form part of the findings in the inquest into the death of baby Thomas Freemantle who was delivered in a home birth at a Bendigo property in October 2010.
He was taken by ambulance to hospital but died a short time later.
Mr Olle delivered the inquest findings on Tuesday, stating Thomas Freemantle died from severe hypoxic ischaemic encephalopathy.
Thomas was the third child of Katrina and Garry Freemantle.
The coroner's report identifies pre-existing obstetric risks in the setting of a homebirth as Mrs Freemantle's second child suffered a fractured clavicle during the birthing process.
Mr Olle's report states there were clear and serious risks associated with the Freemantle home birth.
"Katrina's pregnancy posed clear and obvious risks," he said.
"Always, the safety of the child is paramount.
"The decision to home birth did not meet that objective.
"My investigation and finding is not a critique on the merits or otherwise of home birth.
"Rather, high risk pregnancies demand birth occur in the safest setting - namely, a hospital which can provide emergency and timely medical support."
Mr Olle said there were several options for pregnancy and maternity care at Bendigo Health including the Mamta midwife-led program.
"Why the parents chose not to accept the offer of a place in the Mamta program remains a mystery," he said.
"However, in my view, Bendigo Health went to great lengths to meet the needs of the parents."
Mr Olle said both parents held a general distrust of hospitals.
Mr Olle said he was "acutely aware of the devastating loss, suffered by the parents" and did not criticise them.
"Further, I acknowledge the pain and anguish suffered by the clinical staff and individuals who sought to assist the birthing process," he said.
Mr Olle has made his recommendations available to the Department of Health.