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Sunday
Apr242011

Planned Home Birth and the Ethical Obligations of Obstretricians

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by ANaturalAdvocate

 

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. 

 

 

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Reader Comments (14)

Five bucks says that Chervenak, McCullough, and Arabin have at least two more articles printed on this same topic in the next two years.

April 25, 2011 | Unregistered CommenterAngela

...both the woman and the fetus (or “fetal patient and the child it is expected to become”...)

This definition is what concerns me the most. It's that unfortunate off-shoot of the abortion debate. What I hear is that when a woman is pregnant, she can't be trusted to make a safe and appropriate decision on behalf of herself and her child, so she needs to be coerced or even forced into specific birthing practices. The second article even calls the woman unethical if she doesn't birth in a hospital. While I've never had a homebirth, the statistics bear out that low risk women attempting them have positive outcomes. And, really, that 1 in 200 chance of uterine rupture contraindicates a HBAC? These kind of statistics are enough to make homebirth an "unethical" choice by a mother?

And is this truly how interventions are being applied today: “[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...”? Based on which data? I'm assuming these OBs feel that continuous EFM and IV fluids and lack of maternal food consumption, etc., have high benefit and low risk in normal labors, even though all of the little things that restrict labor when summed together may increase non-medically indicated cesareans and even though CEFM especially is not evidence-based at all.

April 25, 2011 | Unregistered CommenterKK

I do want to add that I like how the second article does advise/instruct OBs to provide prenatal care to women who are choosing homebirth against the OBs' wishes.

April 25, 2011 | Unregistered CommenterKK

I think it is key that "Taking Responsibility For the Patient" is such a driver of policy. If there was move away from the authoritarian model of medicine towards a model of care that reflects shared decision making and true informed consent/refusal, this would not be a concern and doctors who wished to assist families choosing homebirth could do so freely with very little fear.

April 25, 2011 | Unregistered CommenterVanessa Manz

I wish more OBs were like mine. He always listened to me and treated me like an equal, not some silly woman who needed to be told what to do. And when I mentioned I'd like a homebirth, he was fully supportive.He understood my desire for one, and even said he "likes" homebirth. We went over my records, his concer over GD and first-time mom expectations. But never once saying it was a contraindication. More in a way that he wanted to understand what I wanted and needed. And he understood why I wanted a homebirth, on all levels.
I think he actually might have attended me at home if it weren't for the backlash he could face from his partner and the hospital (and questions about current state statue that could affect his ability to practice). He made sure my midwife had all my records and walked me out from my last appointment, telling me I was welcome back at any time.
THAT is how and OB should operate. He never once belittled me or reprimanded me for refusing a test or leaving his care. We'd talk. I'd express my reasons, he'd give his opinion and we'd go from there. Not once did I feel like it was a battle or a "bad" choice. No harm to his practice, either. In fact, He's at the top of my OB referral list. And should I ever need and OB or GYN, I won't hesitate to return to him. There's mutual trust.

April 25, 2011 | Unregistered CommenterCW

at least they acknowledge the "psychosocial cost" of hospital birth....

April 25, 2011 | Unregistered CommenterSara

So they note that problems with "integration and transport," i.e. cooperative reception of a home birth transfer at the hospital, make home birth less safe for women and babies. And yet they don't impose an ethical obligation on doctors and hospitals to cooperate with midwives and facilitate home birth transfers. If poor hospital reception of home birth transfers makes home birth a less safe option, thereby enabling doctors to recommend against home birth, then doctors and hospitals are actually incentivized to continue making home birth transfers unsafe.

Nice ethics, ACOG.

April 25, 2011 | Unregistered CommenterHermine

My son died when I attempted a HBA3C. He died after transfer, while in the hospital, but I also know that I made decisions (delaying transfer) that almost certainly contributed to his death. (I didn't rupture, and we don't know what actually killed him. I had an infection, and had received antibiotics, and he died very, very abruptly, which is all we know.) He would be almost 3.5 if he'd lived. I live under the weight of my decisions and what they cost my son every day of my life. That's never going to go away.

I already know I'm not going to be coherent here. I have a really awful cold and I can't think clearly, but....this bothers me on so many levels. I'm deeply bothered by the "directive counseling" stuff. That is the single biggest reason that I no longer feel that I can trust anybody in the medical community - nobody. That's one of the biggest reasons I tried to have the HBA3C in the first place - because I need care providers who understand that this is *my* decision, for good or for bad. I'm sick of the attitude portrayed here - that the doctor has to tell us what to do, because we can't possibly be trusted to make decisions in the best interests of our own children. I've been making such decisions for 18 years, without any "directive counseling" from anybody, and this attitude makes me nuts.

I'm so, so frustrated by the complete lack of understanding demonstrated in the second commentary, in particular. The mindset seems to be that they need to tell us what the risks are and what can happen, But, a huge portion of the obstetrical community seems to be completely unwilling to accept that there are aspects to how labour and birth affect us that don't show up on their monitors, ultrasounds and blood tests. The underlying arrogance behind assuming that the clinical picture is the whole picture drives me crazy. I'm the one living every day with the results of what happened during my "births", but they think they have all the answers. I was told - authoritatively - by a doctor that the large numb areas from c-section number three would go away "within a year". That child turns six in July and I still can't feel a significant chunk of my pelvis and abdomen. That numbness impacts on my health, in indirect ways (primarily the effect on my ability to do exercises involving my core and/or address my diastasis). I haen't had normal bladder sensation in almost six years, and I was also assured that my bladder issues were from *pregnancy" and that the c-section couldn't have had any effect. I have to live with all this, which they won't even admit exists, but I'm supposed to trust them, because they understand all the risks??

I think my issues were actually summed up by an ultrasound technician. I was pregnant with my fifth, and last, child. I'd already had a "we can't find a heartbeat" scare at 14 weeks, which was addressed by ultrasound to confirm a living fetus (at that point, I'd had three miscarriages, as well as my previous pregnancy being the one that ended in the stillbirth of my son). When I went in for the later ultrasound, I only agreed because 1) I was burned out on fighting with doctors and, more importantly 2) I was terrified of the possibility that I would have a placenta accreta. I'd already had four c-sections, and the earlier u/s had confirmed tha I had an anterior placenta. I'd been caught on the wrong side of the odds too often in my reproductive life to be completely reassured by the fact that my absolute risk of an accreta was fairly small. So, I asked the tech if she could tell me whether my placenta was over the scar (I know the techs aren't allowed to say much and have to have someone else talk to the patient). Her response was clasic medpro: "You should trust your doctor and stop reading too much". Oh, yeah - because my doctor could wave her magic OB/GYN wand and make it so I didn't have an accreta, right? The whole mindset makes me want to hurl....and simultaneously makes me want to hit someone. I'm done having children, but I want my daughters to be able to make their decisions about prenatal and labour care providers based on what they feel to be in their best interests, from a health and safety standpoint, not based on fear of how they'll be treated by said providers. :(

April 25, 2011 | Unregistered CommenterLisa

KK: That definition concerns me as well, yes, although a big concern is also the "not unreasonable clinical risks" statement. "Unreasonable" as defined by WHOM? What is unreasonable to me may be perfectly reasonable to you; just in talking to other laypeople we can determine that. Is the "unreasonable" as defined by the physician? In that case, are we really expected to turn over our own thoughts when being treated? I do appreciate, though, that they stayed strictly on the "ethical" side and did not attempt to stray to the "legal" side.

Vanessa:: Agreed. I know many physicians who would be much more willing to assist in or provide backup for home births, if they didn't know what would happen. I particularly liked the first commentary, which flat-out stated that sometimes your patients will choose things you disagree with, and that's just something you have to deal with.

CW: I'd love to know that OB! It always helps to have good names to pass around as well.

Sara: ...if they then minimize it. :)

Hermine: I agree. It seems that a lot of the difficulty in transports is because doctors refuse to participate. I think it is necessary to note that both articles stated that patients should be given appropriate prenatal AND emergency care, as needed/requested.

Lisa: I'm very sorry for your loss, and thank you for being willing to talk here. I understand that physicians are concerned about being held responsible for the decisions of patients, and perhaps we do need to work to protect them better when honest informed consent and refusal has been made. However,a s you describe, it is so difficult to trust the information given from the physicians when we know there is a goal in mind and that the choice is potentially being influenced improperly. As I stated above, my decision given a set of circumstances may be different from your decision - and yet neither decision is "wrong."

April 25, 2011 | Registered CommenterANaturalAdvocate

<<So they note that problems with "integration and transport," i.e. cooperative reception of a home birth transfer at the hospital, make home birth less safe for women and babies. And yet they don't impose an ethical obligation on doctors and hospitals to cooperate with midwives and facilitate home birth transfers. If poor hospital reception of home birth transfers makes home birth a less safe option, thereby enabling doctors to recommend against home birth, then doctors and hospitals are actually incentivized to continue making home birth transfers unsafe.

Nice ethics, ACOG.>>

I second this. Have been screaming this for a few years now.

<<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.>>

This is funny. MOST homebirths I've heard of did not end in trasnfer, but the ones that did, including one of the two I've planned, did not necessarily result in psychosocial burdens of disappointment, etc. as described here. The biggest indicator I can identify of whether this will occur, from the stories I've heard, is how the women were treated at the hospital and how much decision making power they felt they had (when appropriate...ie, in a true emergency, there wouldn't be alot of that as people have to act fast). If homebirth transfers were to be treated well across the board, there would be little or no second-guessing about transfer on the part of the mother or midwife (Monday morning quarterbacking possibly, but no second-guessing b/c of concerns about how they'd be treated at the hospital).

I can certainly say that while I did have some stress transferring to the hospital, it was more over worry about how I would be treated once there and also dealing with the institution and the likelihood I would need a c/section for my ascending breech baby. My bp spiked in hospital and stayed high while I was there, but at my 6 wk checkup wtih the midwife was just barely above normal for me. So yes, there was some stress. But I also feel every bit as empowered from that birth as I do from my homebirth, because the hospital personnel were (mostly) respectful, understanding, attentive, etc., and left me alone when I needed them to. There are some insititutional things I would change, but well, nothing's perfect. No psychosocial burdens here. And frankly, if every hb transfer was handled as professionally as mine was (by the hospital staff as well as the midwife) we would barely be talking about this side of it. The way I see it, mine was not a "failed" hb, but an absolutely successful one...that happened to end in a hospital with a c/sec, the way the baby clearly indicated he needed to be born.

The way to overcome women's feelings of stress/disappointment/etc., is not to belittle them for attempting a homebirth, but to support them when they determine they need additional intervention. If this were done more frequently, and if hospitals could be more flexible with their policies (such as EFM, no birth tubs for broken waters, NPO, etc.) we could probably have a real dialogue on this whole issue. Mutual respect is what it comes down to.

Even though I don't like the patriarchal tone of the second article, I do like that both articles seem to come down on the side of mutual respect (although I have HUGE issues w/being called unethical for planning a hb, article #2).

Ok ~ rambling. It's obvious I still have new mom brain.

April 26, 2011 | Unregistered CommenterRachel
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