Planned Home Birth and the Ethical Obligations of Obstretricians
In January of this year, the American College of Obstetricians and Gynecologists released their latest opinion on planned home birth, and The Unnecesarean’s breakdown of the opinion can be found here. According to the opinion, “The College believes that hospitals and birthing centers are the safest place for labor and delivery.” In addition, ACOG states that VBACs are “an absolute contraindication” and that postterm, twin, and breech births should also not take place at home. It is also considered important for women to determine if they have access to an “integrated” system where women can transfer quickly as needed.
Despite ACOG’s statement that an institutional (hospital or birth center) birth is safer and that planned home births are not supported, it “emphasizes that women who decide to deliver at home should be offered standard components of prenatal care.” The Committee on Obstetric Practice also stated that is “respects the right of a woman to make a medically informed decision about delivery.” The question becomes, then, what is a physician’s obligation to a woman planning a home birth? Is the physician ethically required to continue treatment of the woman as requested?Or rather is s/he to warn of the risks and then end the relationship if the plans for a home birth continue? Anecdata about obstetricians and their actions surrounding planned home birth abound, from physicians willing to assist in potentially complicated home births to physicians who drop patients at term after an expressed desire for a home birth.
In the upcoming issue of the American Journal of Obstetricians and Gynecologists, two articles discuss the physician’s ethical responsibilities when a patient chooses a planned home birth.
- Home Birth: What Are Physicians’ Ethical Obligations When Patient Choices May Carry Increased Risk? (Ecker and Minkoff)
“Our intention in this commentary is not to advocate for or against home births. Rather, we recognize that home birth is but one example of a patient choice that might differ from what a provider feels is in a women’s best interest.”
The focus of this commentary appears to be on physician interaction with a patient when the patient is choosing a course of action that the physician does not support. The authors recognize the conflict between patient autonomy and recommended (or even permitted) choices and admit the “imperfect” information available regarding the risks of home birth.
A major component of this commentary is a discussion on absolute risk as compared to relative risk. Available information all suggest that the absolute risk of bad outcomes (in numbers or percentages alone) of home birth is low; the question is instead what is the relative risk (or the risk compared to hospital birth, etc.). The commentary discusses a number of studies regarding the risk, including the Wax paper and the de Jong study, concluding that absolute risk in both was low and that the de Jong study indicated a low relative risk as well, although the authors have concern about the differences in integration and transport available that would make the results less applicable to birth in the US.
The authors also compares the ACOG statement to statements by the Royal College of Obstetricians and Gynecologists, which appear not only concerned with physical safety but “also to acknowledge and emcompass issues surrounding emotional and psychological wellbeing. Birth for a woman is a rite of passage and a family life even, as well as being the start of a lifelong relationship with her baby.”
Liability is also covered, both on the part of physicians and that of midwives. Physicians, according to the commentary, worry about having to take on responsibility for patients who attempted a home birth against advisement. In addition, midwives may worry about judgments undertaken by hospital staff and would therefore potentially delay transfers to the hospital when needed, both for concerns about liability and the treatment of the women they transport.
“In sum, physicians are obliged to use their skills to minimize risks, even for women who have shunned physicians’ recommendations and advice. When choices are associated with a low absolute risk, [the authors] argue for dialogue rather than intractable opposition. … For those interest in encouraging hospital birth, dialogue and creating hospital practices appealing to those inclined to home birth are more appropriate than campaigning to restrict access to home delivery.” [emphases added]
- Obstetric Ethics: An Essential Dimension of Planned Home Birth (Chervenak, McCullough, and Arabin)
The focus of the second commentary, however, is on obstetric ethics which “concerns the ethical obligations of the obstetrician to both the pregnant patient and the fetal patient.” The authors state that the obstetrician must act in a manner to seek good over potential harms, rather than simply avoiding harm, for both the woman and the fetus (or “fetal patient and the child it is expected to become” as referenced by the commentary). In addition, the commentary reaches to the woman’s ethical obligation as “[w]hen a clinical intervention is reliably expected to benefit the fetal patient and child it is expected to become and there are not unreasonable clinical risks to the pregnant woman, she is ethically obligated to authorize and accept such intervention.” [emphasis added] The commentary describes three obligations of the obstetrician when faced with a patient desiring a planned home birth.
First, the physician must give adequate disclosure of risks. The authors reference both the Wax paper and a recent article about perinatal mortality in the Netherlands, concluding that, despite the fact that both articles have been disputed, women must be informed that they indicate a “twofold to threefold increased risk of neonatal death” and that the figures are probably inaccurate in underestimating the risks in the US because of increased distances and the lack of health care integration. In addition, “pregnant women planning a home birth must be informed about the increased mortality and morbidity risks of transport from the site of home birth.” The ACOG statement regarding home birth is considered by the authors to be “ethically inadequate” because the information available is not sufficiently transferable to the US population.
Second, the physician must engage in “directive counseling,” not only providing information but also recommending a particular course of action with the goal of “influence not control.” The authors conclude that the physician has a “beneficence-based” obligation to counsel against home birth as the “psychosocial cost” of hospital birth is outweighed by its many benefits, including preventing risks to the fetal patient “who is utterly incapable of consenting to them and that can be prevented without requiring the pregnant woman to accept unreasonable clinical risks to herself.” They also determine that women with planned home births will suffer from “psychosocial burdens of disappointment, frustration, and the increased stress and anxiety of emergency transport during labor, which occurs in many planned home births.” Due to these analyses, the authors conclude that a physician has an obligation to recommend against home birth and for hospital-based birth, and that a woman has an ethical obligation to accept these recommendations. They conclude this section with, “The College statement is ethically inadequate with respect to the role for directive counseling, an ethically essential aspect of respecting the pregnant woman’s autonomy and right to make a medically informed decision.”
Finally, the authors state that obstetricians must not participate in planned home birth, although it is the woman’s right to refuse hospital-based birth and choose home birth. They suggest that assisting in a planned home birth is “not compatible with professional integrity” and that the physician must explain this to the patient. However, the authors also suggest that the obstetrician has an obligation to provide “respectful and professional” prenatal and emergency care to the woman, even should she continue on her plan for a home birth. “Specifically, the obstetrician should not denigrate the woman’s decision to have a planned home birth, Such behavior is unprofessional and risks undermining efforts at respectful persuasion.”
Both commentaries acknowledge the woman’s right to autonomy in her care, and in the ethical obligation of the obstetrician to support a patient with respectful prenatal and emergency care - even if that patient chooses a planned home birth. However, they differ in the physician’s obligations to the patient, and, in fact, in defining who the patient is (as woman v. woman-and-fetal-patient). More importantly, they differ in tone and how much authority and understanding should be given to the woman seeking care. In addition, Ecker and Minkoff rely on respectful providing of information and changing the attitude and atmosphere of hospitals to encourage women to birth in hospital, while Chervenak, McCullough, and Arabin rely on “directive counseling” to convince a woman of the danger of home birth.