It is antithetical to professional responsibility, however, to regard the risks of home birth, however small in the absolute sense, as ethically acceptable. Every life is important. The nature of a pregnant woman’s relationship to her soon-to-be-born child is primarily one of obligation to protect, not freedom. Hence, she does not have an unconditional, systematic right to control her body to the extent that her rights automatically override fetal rights. She does not have an unmitigated right to put her soon-to-be-born child at risk.
Supporting a woman’s autonomy-based rights at the expense of the rights of the fetal or neonatal patient is a form of "rights-based reductionism." Reductionism as an ethical model has an appealing simplicity, but it is ethically incomplete and unprofessional.
As professionals, obstetricians have the obligation, as a matter of professional integrity, to protect the pregnant, fetal, and neonatal patients. Under the ethical model that we call the "professional responsibility model of obstetric ethics," beneficence-based obligations must always be balanced against autonomy-based obligations to the pregnant patient. The obstetrician’s role is to identify and present medically reasonable alternatives for the management of pregnancy – that is, management for which there is evidence of a net clinical benefit. The patient has the right to select from among the medically reasonable alternatives.
Women’s questions about planned home birth should be respectfully addressed in an evidence-based manner. As obstetricians, we must inform women of the high transport rate and of the preventable risks of home birth to herself and the child. Women also should be made aware that emergency transport can be psychologically disruptive, even traumatizing. The risk of long-term harm was documented in a Dutch study in which 17% of all transported women reported having psychological difficulties up to 3 years after giving birth (Birth 2008:35;107-16).
Interestingly, the planned home-birth rate in the Netherlands has decreased from 38% to 23% in the last 20 years, largely because of an increased awareness of the media, patients, and physicians about the risks. This decline has occurred in spite of the fact that women have to pay additional fees for "nonindicated" hospital births.
Our professional response to women’s interest in planned home birth should be compassionate and understanding, taking into consideration some of the legitimate arguments supporting this method of delivery: The desire for empathetic caregivers and the comfort of home, greater control and undisrupted labor, and fewer interventions.
We must work to ensure that delivery in the hospital is safe, respectful and compassionate, as home-like as possible, and free of unnecessary operative deliveries, episiotomies, and other interventions. We need to scrutinize organizational policies and practices, and encourage and further develop collaborative models with nurse midwives, either within the hospital or at home-birth centers with access to full back-up. Simply put, we have to make hospital birth a more humane experience – without jeopardizing outcomes.
We have a clear professional obligation to provide excellent, nonjudgmental emergency care to women who are transported from planned home birth to the hospital. On the other hand, when a woman remains committed to planned home birth despite our communication, we must just say no to our participation, with the explanation that it is ethically unprofessional to participate in substandard care.
Dr. Chervenak is the Given Foundation Professor and chairman of the department of obstetrics and gynecology at Cornell University in New York. Dr. Chervenak reported that he has no disclosures relevant to this Master Class.