The American Journal of Obstetrics and Gynecology has just published a new position paper opposing homebirth and it is deeply disappointing.
It is easy to make a well researched case about the dangers of homebirth, relying on high quality research papers, copious state, national and international statistics and appropriately mindful of women’s right to bodily autonomy. Instead, the AJOG paper is poorly researched, relies on bad studies and is woefully paternalistic.
The paper is Planned home birth: the professional responsibility response by Chervenak et al. Dr. Chervenak is Given Foundation Professor and Chairman of the Department of Obstetrics and Gynecology at Cornell Medical School. He is also the ethics advisor to AJOG, although as far as I can determine, he has no formal training in ethics … and it shows.
Here’s what the authors claim:
This article addresses the recrudescence of and new support for midwife-supervised planned home birth in the United States and the other developed countries in the context of professional responsibility. Advocates of planned home birth have emphasized patient safety, patient satisfaction, cost effectiveness, and respect for women’s rights. We provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth. We start with patient safety and show that planned home birth has unnecessary, preventable, irremediable increased risk of harm for pregnant, fetal, and neonatal patients. We document that the persistently high rates of emergency transport undermines patient safety and satisfaction, the raison d’etre of planned home birth, and that a comprehensive analysis undermines claims about the cost-effectiveness of planned home birth. We then argue that obstetricians and other concerned physicians should understand, identify, and correct the root causes of the recrudescence of planned home birth; respond to expressions of interest in planned home birth by women with evidence-based recommendations against it; refuse to participate in planned home birth; but still provide excellent and compassionate emergency obstetric care to women transported from planned home birth. We explain why obstetricians should not participate in or refer to randomized clinical trials of planned home vs planned hospital birth. We call on obstetricians, other concerned physicians, midwives and other obstetric providers, and their professional associations not to support planned home birth when there are safe and compassionate hospital-based alternatives and to advocate for a safe home-birth-like experience in the hospital.
Here’s what I see as the glaring deficiencies of the paper:
1. In a monumental oversight, the authors never address the fact that there are two types of midwives in the US with very different education, training and outcomes.
Since this is absolutely critical to addressing the issue of homebirth in the US, the only plausible reason why the authors left this out is that they are unaware it. That does not bode well for their understanding of the issue.
2. Despite the existence of many high quality studies demonstrating that homebirth increases the risk of perinatal death, as well as copious state, national and international statistics, the authors choose to rely on low quality studies that have already been amply and accurately criticized.
The Wax study is a poor quality study. It relies in large part on outdated research, tiny studies, and studies that did not discriminate between planned and unplanned homebirth. The Kennare study in Australia is similarly inadequate.
Where is the CDC data on homebirth? Where is the Malloy paper demonstrating that homebirth with a CNM increases the risk of neonatal death? Where is the Evers paper that shows that low risk birth with a Dutch midwife has a higher perinatal mortality rate than high risk birth with a Dutch obstetrician? They, and other similar sources of data are missing. Again, the only plausible reason I can come up with for their absence is that the authors are not well versed in the homebirth literature.
3. The authors simply leave out papers that don’t prove their point.
Any good scientific paper MUST address contradictory data. The authors had an obligation to include and address the deJonge paper from the Netherlands and the 2009 Janssen study from Canada; both are high quality studies that purport to demonstrate the safety of homebirth.
The above problems, while important, are eclipsed by a far more serious problem, the woefully paternalistic attitude of the authors.
For example:
4. The authors are inappropriately dismissive of the repeated finding that women who choose homebirth report higher patient satisfaction. This is a well-established, rock solid finding and the authors give it the back of their hand.
The high rates of transport undercut the raison d’etre of planned home birth.
No, the high rates of transport do not undercut the finding that women who choose homebirth report higher patient satisfaction. There is no evidence that I am aware of that women who are ultimately transferred to the hospital are unsatisfied with their experience at home. When first time mothers are appropriately counseled, they know that the chance of transfer in labor is high, yet choose homebirth anyway. And women who have had previous vaginal deliveries are not transferred in high numbers.
5. The authors’ argument on the ethics of homebirth does not withstand scrutiny.
I have written about Dr. Chervenak’s views before. He takes a position on women’s autonomy that is not shared by non-religious professional ethicists. He presents maternal autonomy and fetal beneficence as equivalent ethical interests, but they are not equivalent. Maternal autonomy trumps fetal beneficence in almost all situations. He insists that women are ethically obligated to choose interventions that will benefit her fetus. That is the Catholic religious position on maternal autonomy and fetal beneficence.
Chervenak is presenting a personal, religious philosophy on maternal autonomy and fetal beneficence and it would have been appropriate for him and his colleagues to acknowledge that their views are not supported by the mainstream medical ethics community. Simply put, in light of American law, and non-religious moral ethics, Chervenak et al. are wrong about the extent of women’s autonomy and women’s ethical obligations toward their unborn children.
6. The authors’ claims about physician responsibilities do not withstand scrutiny. They claim:
Planned home birth should not be considered medically reasonable in professional clinical judgment.
That is both inappropriate and bizarre. It is inappropriate because it is up to the individual clinical to determine what he or she thinks is medically reasonable for a specific patient, and it is bizarre because literally thousands of practicing physicians in the UK, the Netherlands, Canada and Australia have already determined that homebirth is a medically reasonable option for low risk women.
7. The authors proscription of randomized, controlled trials of homebirth is insupportable. They write:
… [A] controlled randomized, controlled clinical trial with home birth as one arm would subject pregnant, fetal, and neonatal patients to preventable, unnecessary risk of mortality, morbidity, and disability when compared with hospital delivery.
Even if you accept, as I do, that homebirth increases the risk of perinatal death and disability, the absolute risk is still small. Therefore, a randomized, controlled clinical trial (assuming that you could get women to participate in it) would be entirely ethical provided that women were informed of the possibility of increased risk.
8. The regrettable paternalism reaches an acme in the concluding words:
We urge obstetricians, other concerned physicians, midwives, and other obstetric providers, and their professional associations to eschew rights-based reductionism in the ethics of planned home birth and replace rights-based reductionism with an ethics based on professional responsibility.
Women’s well established right to medical autonomy is not “rights-based reductionism”; it is a foundation of medical ethics. Professional responsibility never involves forcing patients into doing what you recommend or harranging them for failing to follow your recommendations. Professional responsibility requires informed consent, nothing less and most certainly, nothing more.
