Advocates of planned home birth have emphasized its benefits for patient safety, patient satisfaction, cost effectiveness, and respect for women's rights. A clinical opinion paper published in the American Journal of Obstetrics and Gynecology critically evaluates each of these claims in its effort to identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth.
Throughout the United States and Europe, planned home birth has seen increased activity in recent years. Professional associations and the European Court have publicly supported it, and insurance companies have paid for it.
"These recent statements by professional associations and by the European Court should not be allowed to stand unchallenged," says lead author Frank A. Chervenak, MD, the Given Foundation Professor and chairman of the Department of Obstetrics and Gynecology at Weill Cornell Medical College, and obstetrician and gynecologist-in-chief and director of maternal-fetal medicine at New York-Presbyterian Hospital/Weill Cornell Medical Center. "Positions taken about planned home birth, in our view, are not compatible with professional responsibility for patients….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."
For its evaluation of patient safety, the authors examined evidence of obstetric outcomes and found that planned home birth does not meet current standards for patient safety. Unexpected complications that develop in labor during planned home births can lead to emergency transports and delayed delivery of emergency care. The perinatal mortality rate was reported to be more than 8 times higher when transport from home to an obstetric unit was required.
While the primary motivation for planned home birth is increased patient satisfaction, the authors found this motivation undermined by a high rate of necessary emergency transport, as well as reported inability of the patient to cope with pain, anxiety about losing the baby during transport, and dissatisfaction with caregivers. By creating home-birth-like environments with appropriate staffing in a hospital setting, physicians can improve and ensure patient satisfaction.
In analyzing cost effectiveness, Dr. Chervenak and co-authors refer to a comprehensive Dutch study that calculates a threefold increase of costs that include patient transport and midwife and obstetrician services. Cost analysis must also include professional liability, transport system maintenance, hospital admission, lifetime costs of supporting neurologically disabled children, and more.
Finally, the team examined the relationship between planned home birth and women's rights. It argues that medical professionals should not allow unconstrained rights of pregnant women to control the birth location. To do so would be unethical.
Analytical results of these four claims enabled the authors to provide practical answers to obstetricians' questions regarding their professional responsibility for planned home birth, including addressing the root cause of planned home birth recrudescence, responding to a patient who asks about or requests planned home birth, receiving a patient on emergency transport from planned home birth, and whether to participate in or refer to planned home birth clinical trials.
Professional associations of obstetricians also have a responsibility to promote patient safety, reconsider their statements on planned home birth, and align them with professional responsibility.
"Advocacy of planned home birth is a compelling example of what happens when ideology replaces professionally disciplined clinical judgment and policy," Dr. Chervenak concludes. "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 professional responsibility."
- Frank A. Chervenak, Laurence B. McCullough, Robert L. Brent, Malcolm I. Levene, Birgit Arabin. Planned home birth: the professional responsibility response. American Journal of Obstetrics and Gynecology, 2012; DOI: 10.1016/j.ajog.2012.10.002
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