Clinical opinion
Obstetrics
Planned home birth: the professional responsibility response

Presented at European Congress of Perinatal Medicine, Paris, France, June 13, 2012.
https://doi.org/10.1016/j.ajog.2012.10.002Get rights and content

This article addresses the recrudescence of and new support for midwife-supervised planned home birth in the United States and the other developed countries in the context of professional responsibility. Advocates of planned home birth have emphasized patient safety, patient satisfaction, cost effectiveness, and respect for women's rights. We provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth. We start with patient safety and show that planned home birth has unnecessary, preventable, irremediable increased risk of harm for pregnant, fetal, and neonatal patients. We document that the persistently high rates of emergency transport undermines patient safety and satisfaction, the raison d'etre of planned home birth, and that a comprehensive analysis undermines claims about the cost-effectiveness of planned home birth. We then argue that obstetricians and other concerned physicians should understand, identify, and correct the root causes of the recrudescence of planned home birth; respond to expressions of interest in planned home birth by women with evidence-based recommendations against it; refuse to participate in planned home birth; but still provide excellent and compassionate emergency obstetric care to women transported from planned home birth. We explain why obstetricians should not participate in or refer to randomized clinical trials of planned home vs planned hospital birth. 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.

Section snippets

Patient safety

Discussion of patient safety is best based on evidence about obstetric outcomes.12, 13, 14, 15 ACOG in its statement accepts the finding of Wax et al16 that there is a 2-fold to 3-fold risk of neonatal death from planned home vs hospital birth.11 ACOG takes the view that pregnant women should be informed about this risk.11

The RCOG and RCM Joint Statement goes further and claims that planned home birth is a “safe option for many women.”10 This claim does not withstand close scrutiny for planned

Patient satisfaction

The raison d'etre for planned home birth is increased patient satisfaction. The RCOG-RCM statement emphasizes that the focus should not be exclusively on the physical safety of planned home birth. It is also important to “acknowledge and encompass issues surrounding emotional and psychological well-being.” Birth for women is a rite of passage and a family life event, as well as being the start of a lifelong relationship with her infant.”10

The RCOG-RCM statement is correct to emphasize the

Cost-effectiveness

In the United States and throughout the world fiscal responsibility and accountability have become essential components in clinical practice and organizational leadership.44 It might at first appear that planned home birth offers the potential for cost-savings by avoiding a relatively more expensive hospital admission. The Birthplace in England national cohort study “priced” planned home birth, birth in freestanding midwifery units, “alongside” midwifery units, and obstetric units at,

Respect for women's rights

There are 2 ways in which respect for women's rights can be understood. The first starts with the right of the woman to make decisions and control what happens to her body. The physician is bound to acknowledge and implement the patient's preferences, without constraint. This is a purely contractual model of the physician-patient relationship in which the woman protects herself by the exercise of her autonomy-based rights. “In a democratic society, a woman has the right to choose where she

What should obstetricians do to address the root cause of the recrudescence of planned home birth?

The first professional responsibility of obstetricians is to ensure that hospital delivery is safe, respectful, and compassionate.53, 54, 55, 56 Current, inappropriate practices may be fueling the recrudescence of planned home birth. Physician leaders need to closely scrutinize organizational policies and practices and should see to it that staffing is competent and adequate. Well-trained, compassionate in-house attending obstetric and anesthesia coverage should be required for all hospitals

Conclusion

Advocacy of planned home birth is a compelling example of what happens when ideology replaces professionally disciplined clinical judgment and policy. 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 on professional responsibility.

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    The authors report no conflicts of interest.

    Reprints are not available from the authors.

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