Home birth: The obstetrician's ethical response

Dr. Chervenak is Given Foundation Professor and Chairman, Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, New York.

Dr. Grünebaum is Professor and Director of Obstetrics, Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, New York. 

The increased risks of planned home birth and the appropriate response of the obstetric profession to planned home birth have become a major focus of our international study group, which includes colleagues in obstetrics from Germany (Birgit Arabin, MD, Phillips Universität Marburg), pediatric neurology from the United Kingdom (Malcolm I. Levene, MD, University of Leeds), pediatrics (Robert L. Brent, MD, PhD, Thomas Jefferson University) and ethics (Laurence B. McCullough, PhD, Baylor College of Medicine). This study group was formed because of the recrudescence of planned home birth in the United States, statements from professional societies and the European court that either sanctioned or supported planned home birth,^1,2 and our experience in our medical center with severe complications associated with planned home birth.

Related:Physicians and 'natural birth': the two can co-exist

In March of 2013 we attended a workshop sponsored by the Institute of Medicine and National Research Council titled An Update on Research Issues in the Assessment of Birth Settings.³ Although there were representatives from the American College of Obstetricians and Gynecologists (ACOG), Society for Maternal-Fetal Medicine (SMFM), American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC), and other academicians, one of the authors (FAC) presented results of the first analysis of CDC data⁴ showing the increased risk planned home birth and on the basis of this compelling evidence strongly warned against the dangers of planned home birth.^{3. pp. 134-136} It was clear to all of the members of our international study group that further analysis of CDC birth certificate data is required to establish a reliable scientific account of the outcomes of planned home birth in the United States.

Also read: Planned home births riskier than hospital births, ACOG says

Here we present the results of the work-to-date of our study group and identify their implications for clinical practice. References provide a comprehensive analysis of the relevant scientific and ethics literature.

The outcomes of planned home birth attended by midwives and the outcomes of hospital birth attended by midwives and physicians in term, singleton pregnancies resulting in newborns ≥ 2500 grams birth weight have been analyzed. The comparator groups were midwives attending either planned home birth or hospital deliveries. To date, we have studied neonatal outcomes,^5,6 reliability of Apgar scoring,⁷ and risk assessment.⁸ Before presenting summaries of our findings, we emphasize that all of our analyses to date indicate that midwife-attended hospital births show similar or better outcomes compared to physician-attended hospital births. Our hypothesis was that midwife-attended planned home birth was riskier than midwife attended and physician-attended hospital birth. We rigorously tested this hypothesis by adhering to accepted standards of statistical analysis.

With respect to neonatal outcomes, we have shown that planned home birth by midwives in the United States (figure 1) was associated with significantly increased relative risks (RR) for a 5-minute Apgar score of 0 (1.63/1,000 births; RR 10.55, 95%CI: 8.26–12.93) and neonatal seizures or serious neurological dysfunction (0.86/1,000 births; RR 3.8, 95%CI: 2.8–5.16).⁵ We have also shown that planned home birth by midwives had significantly higher relative risks of total mortality (1.26/1,000 births; RR 3.87, 95%CI: 3.03–4.95), gestational age ≥ 41 weeks (1.84/1,000 births; RR 6.76, 4.42–10.36), and women with first birth (2.19/1,000 birth; RR 6.74, 95%CI: 4.55–9.96). In this article we also report that home birth results in excess total neonatal mortality of 9.32 per 10,000 births and excess early neonatal mortality of 7.89 per 10,000 births.⁶

We have shown that a 5-minute Apgar score of 10 was assigned by midwives at planned home births in 52.44% of all deliveries, as compared to hospital midwives of 3.71% and physicians (3.67%) with an odds ratio (OR) of 28.95 (95%CI: 28.4–29.5). We concluded that this reflects an inexplicable bias of high Apgar scores assigned by midwives at planned home delivery.⁷

We have also demonstrated that midwife-attended planned home births are not low risk, as some have claimed, but have significantly increased risk factors that are not within the clinical criteria established by ACOG and AAP for planned home birth, including breech presentation (1 in 135 births; (OR 3.19, 95%CI: 2.87–3.56); prior cesarean delivery (1 in 22 births; OR 2.08; 95%CI:2–2.17); twin gestation (1 in 156 births; OR 2.06, 95%CI: 1.84–2.31); and gestational age ≥ 41 weeks (1 in 3.54 births; OR 1.71, 95%CI:1.68–1.74). In addition, we found that 2 out of 3 of midwives attending planned home births did not meet ACOG and AAP recommendations for certification by the American Midwifery Certification Board.⁸

Our analyses of the largest, most reliably data base on US births clearly document that midwife-attended planned home birth has significant and marked increase of 5-minute Apgar score of 0, neonatal seizures or serious neurological dysfunction, and early and total neonatal mortality, that midwife-assigned Apgar scores at planned home birth are likely often apocryphal, and that risk assessment by midwives attending planned home birth is, at best, suboptimal. This documented clinical reality of preventable, increased significant adverse neonatal outcomes, biased Apgar scoring, and poor risk assessment cannot and should not be ignored by the professional obstetric community.

The response of obstetricians, hospital managers, and politicians concerned with healthcare should be guided by the professional responsibility model of obstetric ethics. Based on the landmark work in medical ethics by the Scottish physician-ethicist John Gregory (1724–1773) and the English physician-ethicist Thomas Percival (1740–1804), the professional responsibility model of obstetric ethics requires the identification and deliberative balancing of 3 ethical obligations: beneficence-based obligations to the pregnant patient; autonomy-based obligations to the pregnant patient; and beneficence-based obligations to the fetal patient. ⁹

The professional responsibility model of obstetric ethics provides a powerful antidote to maternal rights-based reductionism, ie, the view that the rights of pregnant women are absolutely determinative in the ethics of obstetric practice. Using this approach to obstetric ethics, the obstetrician should engage only in nondirective counseling about alternative birth settings. Nondirective counseling means that the obstetrician should present information about the outcomes of planned home birth and planned hospital birth but refrain from expressing evaluation of them and therefore form making any recommendations, to avoid interference with “the right of a woman to make a medically informed decision about delivery.”

The professional model of obstetric ethics, guided by the evidence that we have summarized above, rejects a maternal right-based reductionist approach as inconsistent with professional integrity. Instead, an obstetrician treating a pregnant woman who is interested in planned home birth should not only inform the woman about home birth’s markedly increased adverse outcomes, but also strongly recommend against it based on evidence about its outcomes and quality. Because these outcomes are preventable only in the hospital setting, the obstetrician should explain that his or her participation in planned home birth is not consistent with professionally responsible obstetric care. The obstetrician should also explain that, if the woman elects planned home birth and either she or her newborn baby are brought by emergency transport to the hospital, both will be provided nonjudgmental, appropriate care. Because clinical equipoise does not exist in the case of home birth, the ethics of protection of human subjects prohibits randomized trials of planned home birth versus planned hospital birth. Obstetricians therefore have a strict professional responsibility not to inform pregnant women about such trials if they exist.

We emphasize that this strongly directive approach implements respect for every pregnant woman’s right to make an informed and voluntary decision about herself and her birth setting. The autonomy-based professional responsibility of the obstetrician in the informed consent process is to empower every pregnant woman with the evidence-based information needed to exercise meaningful autonomy. This includes evidence-based recommendations for hospital birth and against the home setting for birth. Evidence-based recommendations do not interfere with the voluntariness of the woman’s decision-making process, as is clear from routine recommendations to all pregnant women that they refrain from smoking and consumption of alcoholic beverages. Put more precisely, evidence-based recommendations do not constitute medical paternalism, because such recommendations do not interfere with, but enhance the exercise of every pregnant woman’s autonomy.

Obstetricians have the inescapable professional responsibility to address the root causes of the recrudescence of planned home birth in the United States. It is imperative that interventions be as evidence-based as possible, which is the means to assiduously avoid unnecessary interventions. We have shown that the cesarean delivery rate can be responsibly decreased by creating and sustaining a strong culture of patient safety.^11,12 It is also imperative that obstetricians create a home-birth-like setting in the hospital and encourage collaboration with certified nurse-midwives as valued and respected professional members of the obstetric care team.⁹

In summary, obstetricians have the professional responsibility to explain the documented, preventable increased neonatal risk and questionable quality of planned home birth and to recommend against it, especially in light of the inadequacy of the home birth setting to respond quickly and effectively to obstetric emergencies. At the same time, obstetricians should create and sustain a strong culture of safety committed to a home-birth-like experience in the hospital. If obstetricians fulfill these professional responsibilities, the recrudescence of planned home birth in the United States should reverse in favor of hospital births, which will prevent the increased perinatal mortality and morbidity attendant planned home birth.

References

1. Chervenak FA, McCullough LB, Brent RL, Levene MI, Arabin B. Planned home birth: the professional responsibility response. Am J Obstet Gynecol. 2013;208:31–38.

2. Chervenak FA, McCullough LB, Arabin B. Obstetric ethics: an essential dimension of planned home birth. Obstet Gynecol. 2011;117:1183–1187.

3. Institute of Medicine and National Research Council. As Update on Research Issues in the Assessment of Birth Settings. Washington, DC: The National Academies Press, 2013.

4. National Center for Health Statistics. Vital Statistics Data Available Online: Birth Data Files. Accessed February 28, 2015. Available at: http://www.cdc.gov/nchs/data_access/VitalStatsOnline.htm.

5. Grünebaum A, McCullough LB, Sapra KJ, et al. Apgar score of zero at five minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol. 2013;209:e1–323. e6

6. Grünebaum A, McCullough LB, Sapra KJ, et al. Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009. Am J Obstet Gynecol. 2014;211:390.e1-7.

7. Grünebaum A, McCullough LB, Brent RL, Levene MI, Arabin B, Chervenak FA. Justified skepticism about Apgar scoring in out-of-hospital births. J Perinat Med. 2014 Apr 16. pii: /j/jpme.ahead-of-print/jpm-2014-0003/jpm-2014-0003.xml. doi: 10.1515/jpm-2014-0003. [Epub ahead of print]

8. Grünebaum A, McCullough LB, Brent RL, Levene MI, Arabin B, Chervenak FA. Perinatal risks of planned home births in the United States. Am J Obstet Gynecol. 2014 Oct 15. pii: S0002-9378(14)01063-1. doi: 10.1016/j.ajog.2014.10.021. [Epub ahead of print]

9. Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of obstetric ethics: avoiding the perils of clashing rights. Am J Obstet Gynecol. 2011;205:315.e1–5.

10. ACOG Committee Opinion No. 476: Planned home birth. ACOG Committee on Obstetric Practice. Obstet Gynecol. 2011;117:425–428.

11. Grünebaum A, Chervenak F, Skupski D. Effect of a comprehensive patient safety program on compensation payments and sentinel events. Am J Obstet Gynecol. 2011;204:97–105.

12. Grünebaum A, Dudenhausen J, Chervenak FA, Skupski D. Reduction of cesarean delivery rates after implementation of a comprehensive patient safety program. J Perinat Med. 2013;41:51–55.