Homebirth advocates have been praising and sharing a recent piece by obstetrician Paul Burcher entitled What’s an Ethical Response to Home Birth?
Unfortunately, in offering an answer to the question, Dr. Burcher fails in his most important ethical responsibility. He hasn’t told the whole truth. Since he has held back (or, less likely, is unaware of) important facts, his answer is deeply misleading.
Who is Dr. Burcher ?He is an Associate Professor of Bioethics and Obstetrics and Gynecology at Alden March Bioethics Institute at Albany Medical College.
He previously worked as an obstetrician-gynecologist in Eugene, Oregon, where served as the back up physician for Melissa Cheyney, CPM. Cheyney, as you may recall, had some ethical challenges of her own. She was an embodiment of the ethical problem of “conflict of interest” while she held simultaneous positions as Director of Research of the Midwives Alliance of North America (MANA), the trade organization of homebirth midwives and Chair of the Oregon Board of Direct Entry Midwifery. In her first position she was privy to a large amount of data showing the disastrous outcomes of homebirth in Oregon, which she deliberately refused to share with the state of Oregon.
Burcher collaborated with Cheyney on a commentary in Birth:Issues in Perinatal Care (a journal published on behalf of Lamaze International), A Crusade Against Home Birth that encapsulating in a few words the self-pity, conspiracy theories and mendacity that are at the heart of homebirth midwifery.
Dr. Burcher bases his own piece on a nifty bit of mendacity.
An observational study from The Netherlands that evaluated more than 500,000 births in homes and in hospitals showed no increase in adverse outcomes of any kind with home birth in low-risk women.5 So home birth, in ideal conditions where midwives and physicians work together as a team and where transport to hospitals in an emergency is highly efficient, appears as safe as hospital birth…
But as Dr. Burcher knows (or ought to know if he is keeping up with the scientific literature), that’s not what the paper shows at all. Dr. Burcher neglects to mention two critical pieces of information.
1. The Netherlands, the country with the highest rate of homebirth in the industrialized world, has one of the worst perinatal mortality rates in Europe.
2. The perinatal mortality rates for Dutch midwives caring for low risk women (home or hospital) is HIGHER than that for Dutch obstetricians caring for HIGH risk women. That is a scathing indictment of midwifery in the Netherlands. The paper that Burcher cites doesn’t show that homebirth is safe; it shows that midwives are dangerous.
Dr. Burcher does acknowledge that homebirth in the US has a higher death rate than comparable risk hospital birth:
I would agree … that home birth in America probably incurs a small increase in absolute risk of poor outcomes for newborns delivered at home.
Notably, Dr. Burcher doesn’t dare cite Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009 by Cheyney and MANA purporting to show the safety of American homebirth. Apparently, even he knows that it actually shows that homebirth increases the risk of perinatal death.
The heart of Burcher’s argument is this:
What, then, are our professional obligations as obstetricians working in hospital settings to women who choose to stay home with a midwife for their birth? At the risk of sounding glib by answering a question with a question, do we enhance the safety of childbirth for all women by shunning home birth or by treating midwives collegially? I believe the correct answer is the latter, and since maternal-child safety was one of the founding reasons for ACOG’s existence, I believe we have an ethical obligation at a minimum to accept transports from home with the respect and professional dialogue we afford our colleagues …
That, of course, tells us nothing. Physicians already have an ethical responsibility to care for all patients regardless of how they end up in the emergency room. Dr. Burcher’s glibness is not in answering a question with a question, but rather in the choice of the question he asks.
The real question is “What is an ethical response to a group of laypeople with inadequate education and training, masquerading as midwives behind a fake credential, who have hideous perinatal death rates?”
I would argue that physicians’ ethical obligations are exactly the same as when we are presented with patients who have been harmed by other quacks and charlatans, whether they are peddling cancer “cures,” homeopathy, or cut rate plastic surgery. First, we care for the victims of their incompetence. When patients who have end stage cancer presents after avoiding conventional treatment that might have saved them, we treat them with every ounce of compassion and skill we have at our disposal. But that doesn’t stop us from going after the cure peddlers, or refusing to serve as their regular back up. Failure to put dangerous providers out of business is an ethical lapse, not a virtue. Similarly, when patients who have horrific infections from cut rate plastic surgery present in the emergency room, we treat them with every ounce of compassion and skill we have at our disposal. But that doesn’t stop us from reporting the cut-rate unlicensed providers to the police and regulating agencies or refusing to serve as regular back up for those who prey on the hopes and fears of other human beings. Failure to put dangerous providers out of business is an ethical lapse, not a virtue.
The ethical response of physicians to homebirth ought to be exactly the same. When a patient is transferred into the emergency room from a homebirth, obstetricians are ethically obligated to treat her with every ounce of compassion and skill we have at our disposal. But that shouldn’t stop us from going after these fake “midwives”,” reporting them to the authorities, and demanding strict regulation and harsh penalties for violating those regulations. Failure to put dangerous providers like homebirth midwives out of business is an ethical lapse, not a virtue.
Dr. Burcher, however, reaches a different conclusion:
…[I]t is my assertion that our professional responsibility must include supporting all of the birth options women have and to make each as safe as possible. The Netherlands has shown that safety comparable to a hospital is achievable. We should strive to replicate their results.
Not exactly.
Maybe Dr. Burcher wants to replicate the terrible perinatal outcomes in the Netherlands, but most obstetricians, myself included, do not.
