Master Class

Planned Home Births


 

In the last decade, there has been new and renewed support for planned home birth in the United States and in Europe. From 2004 to 2009, home births in the United States rose by 29%, increasing from 0.56% to 0.72% of all births, according to the Centers for Disease Control and Prevention. For non-Hispanic white women, planned home births rose by 36% from a rate of 0.80% in 2004 to 1.09% in 2009.

Although planned home birth for women with a prior cesarean delivery is still rare, there is CDC evidence that VBAC at home is increasing in the United States as well (Obstet. Gynecol. 2012;119:737-44).

Dr. Frank A. Chervenak

Although these increases may be considered small, the changes are part of a congruence of events in the United States and other developed countries that demand our attention and professional response. One such event is a 2010 ruling by the European Court of Human Rights that states that the decision to become a parent includes the right of "choosing the circumstances of becoming a parent." This right includes the right to professional assistance at home birth, according to the ruling.

The full ramifications of this court decision, which originated in Hungary when a pregnant woman alleged that she was not able to give birth at home because health professionals were dissuaded by law from assisting her, remain to be seen. However, recent statements from professional associations favor the woman’s right to choose planned home birth.

The Royal College of Obstetricians and Gynecologists (RCOG) and the Royal College of Midwives (RCM) issued a statement in 2007 in support of planned home birth for women with uncomplicated pregnancies, saying there is "no reason why home birth should not be offered to women at low risk of complications." Home birth in such cases may confer "considerable benefits" for the mother and her family, increasing the likelihood of a birth that is "both satisfying and safe," the statement says.

In addition, the American College of Obstetricians and Gynecologists said in a 2011 committee opinion (#476) that while it believes hospitals and birthing centers are the safest setting for birth, "it respects the right of a woman to make a medically informed decision about delivery." In doing so, ACOG qualified its previous statement, which recommended against home birth (Obstet. Gynecol. 2011;117:425-8).

In the meantime, articles in the consumer press have focused on the benefits of planned home birth, indicating that home birth has become fashionable and that the midwife is increasingly regarded as a status symbol.

Planned home birth has been debated for decades, but this recent recrudescence of support-motivated ethicist Laurence B. McCullough, myself, and a team of physicians – a U.S. neonatologist and a pediatric neurologist and perinatologist from Europe – to review the change in the context of professional responsibility (Am. J. Obstet. Gynecol. 2013:208;31-8).

Advocates for planned home birth emphasize patient satisfaction, patient safety, cost effectiveness, and respect for women’s rights. Yet, as we have described in detail, none of these reasons or causes of support for home birth can or should stand unchallenged. Most importantly, planned home birth does not meet current obstetric standards for patient safety. One of the largest and most current studies, for instance, shows a two- to threefold increased risk of neonatal death with planned home birth, compared with hospital birth.

Some advocates of planned home birth accept this finding as well as other studies showing adverse outcomes and maintain that the level of risk is ethically acceptable. However, we feel that such views are antithetical to our professional responsibility. As obstetricians, our professional responsibility is to both the pregnant woman and the fetal patient. An overwhelming emphasis on maternal rights over fetal rights – a form of rights-based reductionism – is ethically incomplete, clinically inadequate, and therefore unprofessional.

Safety issues

A systematic review published in 2010 identified a doubling of the overall rate of neonatal mortality, and a tripling of the neonatal mortality rate among nonanomalous neonates, in planned home birth vs. planned hospital birth. Dr. Joseph R. Wax and his associates called these findings "especially striking" because women planning home births were "of similar and often lower obstetric risk than those planning hospital births."

The meta-analysis, which included 12 studies from the United States, Canada, Europe, and Australia, showed that women who chose home birth are "in large part successful in achieving their goal of delivering with less morbidity and medical intervention than experienced during hospital-based childbirth," but at a significant cost, the authors said (Obstet. Gynecol. 2010:203;243.e1-8).

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