Clinical Opinion www.AJOG.org

OBSTETRICS Planned home birth: the professional responsibility response Frank A. Chervenak, MD; Laurence B. McCullough, PhD; Robert L. Brent, MD, PhD, DSc (Hon); Malcolm I. Levene, MD, FRCP, FRCPH, F Med Sc; Birgit Arabin, MD

here has been a recrudescence of Tand new support for planned home This article addresses the recrudescence of and new support for -supervised birth in the United States and other de- planned home birth in the United States and the other developed countries in the context veloped countries. The Centers for Dis- of professional responsibility. Advocates of planned home birth have emphasized patient ease Control report that from 2004 to safety, patient satisfaction, cost effectiveness, and respect for women’s rights. We provide 2009 home births in the United States a critical evaluation of each of these claims and identify professionally appropriate re- rose by 29%, increasing from 0.56% to sponses of obstetricians and other concerned physicians to planned home birth. We start 0.72% of all births or 29,650 home with patient safety and show that planned home birth has unnecessary, preventable, births.1 There is also evidence that vagi- irremediable increased risk of harm for pregnant, fetal, and neonatal patients. We docu- nal birth after cesarean delivery is in- ment that the persistently high rates of emergency transport undermines patient safety and creasing at home in the United States.2 satisfaction, the raison d’etre of planned home birth, and that a comprehensive analysis Planned home birth for breech presenta- undermines claims about the cost-effectiveness of planned home birth. We then argue tion has been defended as a legitimate that obstetricians and other concerned physicians should understand, identify, and correct option.3 Private who provide the root causes of the recrudescence of planned home birth; respond to expressions of home birth services have even become interest in planned home birth by women with evidence-based recommendations against “status symbols.”4 it; refuse to participate in planned home birth; but still provide excellent and compassionate Home birth rates in Europe and Aus- emergency obstetric care to women transported from planned home birth. We explain why tralia vary over time and in different obstetricians should not participate in or refer to randomized clinical trials of planned home countries or provinces. In the Nether- vs planned birth. We call on obstetricians, other concerned physicians, midwives lands, home birth has been traditionally and other obstetric providers, and their professional associations not to support planned the first choice for so-called uncompli- home birth when there are safe and compassionate hospital-based alternatives and to cated , performed by mid- advocate for a safe home-birth-like experience in the hospital. wifes or general practitioners. Moreover, Key words: cost-effectiveness, patient safety, planned home birth, professional women have to pay an extra amount responsibility, research ethics (around €250) when deciding for a “nonindicated hospital birth” under the guidance of an obstetrician and even when they decide for a -guided cumentation system (abbreviated as delivery within the hospital. Neverthe- QUAG).8 Seventy-four percent of these less, the home birth rate in the Nether- midwifery units perform less than 70 de- From the Department of and lands has decreased during the past 20 liveries per year, and only 9% perform Gynecology (Drs Chervenak and Brent), Weill years from 38.2% (1989-91) to 23.4% more than 155 per year. According to Medical College of Cornell University, New (2008-10), mostly because of the increas- German law it is even accepted that the York, NY; the Center for Medical Ethics and Health Policy (Dr McCullough), Baylor College ing awareness of the media, patients, and planned delivery of a singleton breech or of , Houston, TX; the Thomas obstetricians about the risks of home twins can take place at home, if an obste- Jefferson University, Alfred I. DuPont Hospital birth.5 In the United Kingdom 3% of to- trician is present at delivery. for Children (Dr Brent), Wilmington, DE; the tal births occur at home, although less Professional organizations in most Division of Pediatrics and Child Health (Dr than half are planned.6 In Sweden, the European countries favor hospital birth Levene), Leeds General Infirmary, United Kingdom; and the Center for Mother and Child estimated proportion of planned home and their insurance systems pay for it. 7 (Dr Arabin), Philipps University, Marburg, births was 0.38 of 1000 of all term births. Nevertheless, planned deliveries within Germany. In Germany, more than 98% of all de- midwifery units or even at home are ac- Received Aug. 2, 2012; revised Sept. 11, liveries occur within , but the cepted and paid for, although the inci- 2012; accepted Oct. 2, 2012. absolute number of deliveries in nonob- dence of these deliveries is in general less The authors report no conflicts of interest. stetric units is rising. Between 2000 and than 2%. Presented at European Congress of Perinatal 2010, the absolute number of home In 2010, the European Court of Hu- Medicine, Paris, France, June 13, 2012. births dropped from 4303 to 3587, but man Rights ruled on a case originating in Reprints are not available from the authors. the number of deliveries in 138 certified Hungary in which it was argued that 0002-9378/$36.00 freestanding midwifery unit settings rose Hungarian law on home birth “dis- © 2012 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2012.10.002 from 4475 to 6775 per year as docu- suaded” health care professionals from mented by the midwifery quality do- assisting home birth in violation of the

MONTH 2012 American Journal of Obstetrics & Gynecology 1 Clinical Opinion Obstetrics www.AJOG.org plaintiff’s “right to respect for her private The RCOG and RCM Joint Statement tion (3%) is not inconsequential.21 life.” The Court found for her and stated goes further and claims that planned Moreover, the best screening proce- that “the right of the decision to become home birth is a “safe option for many dures, even when optimally performed, a parent includes the right of choosing women.”10 This claim does not with- sometimes fail to detect these high-risk the circumstances of becoming a parent” stand close scrutiny for planned home conditions. Given the severity and fre- and this encompasses professional assis- birth without immediate access to hospi- quency of reasons for transport, even a tance in home birth.9 The implications tal-based care. Such settings are un- very low rate of emergency transport of this court ruling for clinical practice avoidably at risk for transport to the should prompt considerable concern. throughout Europe have not been fully hospital. It is not surprising that the peri- This has been proven by a review of peri- assessed. natal mortality rate was reported to be natal deaths in planned home births in In 2011, the Royal College of Obste- more than 8 times higher when transport Southern Australia where inappropriate tricians and Gynaecologists and the from home to an obstetric unit was inclusion of women with risk factors re- 17 Royal College of Midwives issued the used. As clinicians we have all experi- sulted in inadequate fetal surveillance 17 following statement: “The Royal College enced that unavoidable delay involved in during labor. of Midwives (RCM) and the Royal Col- even the best transport systems from The recent Birthplace in England pro- lege of Obstetricians and Gynaecologists home to hospital and even from labor spective cohort study reported transport (RCOG) support home birth for women and delivery to the operating room re- rates from nonobstetric units to the hos- with uncomplicated pregnancies. There sults in increased risks of mortality and pital of 36 to 45% for nulliparous women morbidity for pregnant, fetal, and neo- and 9 to 13% for multiparous women.22 is no reason why home birth should not 18,19 be offered to women at low risk of com- natal patients. For the primary outcome measure of plications and it may confer consider- Maternal and fetal necessity for trans- perinatal mortality and specific morbid- able benefits for them and their fami- port during labor is often impossible to ities, there was an adjusted odds ratio lies.”10 Also in 2011, the American predict and indications include failure [OR] of 1.59 (95% confidence interval for labor to progress, unbearable labor [CI], 1.01Ϫ2.52) for women “without College of Obstetricians and Gynecolo- pain, fetal malpresentation, increasing any complicating factor at the start of gists (ACOG) stated that “it respects the maternal temperature, suspicious fetal care in labour” for planned home vs right of a woman to make a medically heart-rate tracings, abrupt deterioration planned obstetric unit births. The ad- informed decision about delivery.”11 of fetal heart rate, uterine rupture, acute justed OR was 1.75 (95% CI, 1.07–2.86) These recent statements by profes- bleeding, placental abruption, vasa pre- for the primary outcome for planned sional associations and by the European via, acute sepsis, and cord prolapse. For home vs planned obstetric unit births for Court should not be allowed to stand un- unpredictable, extremely sudden com- nulliparous women, which increased challenged, because the positions taken plications, even rapid transport may not to 2.8 when restricted to nulliparous about planned home birth, in our view, prevent the fetus or pregnant woman women with no complications at the are not compatible with professional re- from death or severe harm, such as sud- start of labor. The 59 to 75% increase in a sponsibility for patients. The advocates den cardiopulmonary arrest, shoulder poor primary outcome is frequently at- of planned home birth emphasize (1) pa- dystocia, or maternal exsaguination.20 tributable to the delay in access to hospi- tient safety, (2) patient satisfaction, (3) Postnatal reasons for transport in- tal care from transport time. Only in the cost-effectiveness, and (4) respect for clude lacerations of the vagina or cervix, online appendix were so called “events” women’s rights. The purposes of this pa- sphincter rupture, uterine atony, and elucidated. In the primary outcome pop- per are to critically evaluate each of these accreta, increta, or percreta. In ulation, intrapartum stillbirths and early claims and to identify professionally ap- patients with severe hemorrhage and neonatal deaths accounted for 13%, neo- propriate responses of obstetricians and placental problems the pregnant woman natal encephalopathy for 46%, meco- other concerned physicians to each may already be in shock when arriving at nium aspiration syndrome for 30%, bra- claim and therefore to planned home a hospital. Even though operative and chial plexus injury for 8%, and fractured birth. shock treatment can be immediately in- humerus or clavicle for 4% of “events.” stituted, death may nevertheless some- It is concluded that these “results sup- Patient safety times occur. port a policy of offering healthy nullipa- Discussion of patient safety is best based Neonatal reasons for transport are rous and multiparous women with low on evidence about obstetric out- myriad and include unexpected very low risk pregnancies a choice of birth set- comes.12-15 ACOG in its statement ac- or very high birthweight, neonatal de- ting.”22 We contend that this view is ir- cepts the finding of Wax et al16 that there pression, signs of respiratory distress, rational and cannot be supported in light is a 2-fold to 3-fold risk of neonatal death unexpected malformations, and acute of the reported adverse outcomes for from planned home vs hospital birth.11 sepsis. In the general population, the in- birth outside of an obstetric service. ACOG takes the view that pregnant cidence of common problems, such as In the Netherlands, there is a long tra- women should be informed about this major malformations (3%), prematurity dition of optimally organized home risk.11 (Ն6%), and severe fetal growth restric- birth, with well-trained midwifes and a

2 American Journal of Obstetrics & Gynecology MONTH 2012 www.AJOG.org Obstetrics Clinical Opinion transport system with short distances to leaves room for individual choice where The adverse outcomes described hospitals. Nonetheless, 49% of primipa- other aspects may matter.” The authors above can be reduced in their incidence rous and 17% of multiparous women are had investigated the perinatal outcome by access to timely cesarean delivery. In transported during labor.23 The most of 679,952 low-risk women obtained the United States, there has been a “rule” frequent indications are the need for from the Netherlands Perinatal Registry of 30 minutes from “decision to inci- pain relief (which is subjective and pos- (2000-2007) representing women who sion.”30 ACOG has revised this to state sibly influenced by anxieties to continue had a choice between home and hospital that “when a decision for operative de- with the delivery at home) and pro- birth. After case mix adjustment, there livery in the setting of a Category III EFM longed labor. Women who are trans- was a trend, but nonsignificant, toward tracing is made, it should be accom- 30-32 ferred to a hospital have a significantly increased mortality risk within the group plished as expeditiously as feasible.” higher rate of operative vaginal delivery of intended home birth (OR, 1.05; 95% In Germany, a 20-minute interval from and secondary cesarean delivery (relative CI, 0.91Ϫ1.21). In subgroups, additional decision to delivery is used for quality as- risk [RR], 1.42 and 1.2) and a higher rate mortality arose at home if risk condi- sessment of perinatal centers. of peridural anesthesia (RR, 1.45). Of all tions emerged during birth (up to a 20% None of these standards can be consis- primiparous women transported in the increase).26 tently met if pregnant patients have to be Netherlands to a hospital because of pro- A study from South Australia reported transported. This is true even in the case longed labor, two-thirds need pain that home births between 1991 and 2006 of the Netherlands, where the infrastruc- treatment.24 ture of transport systems is highly devel- 25 accounted for only 0.38% of 300,011 De Neef et al analyzed the intention births despite an average long distance oped and distances within the country to deliver either at home (45%), under from home to a perinatal center. The are small. In the rest of the world the in- guidance of a midwife within a hospital perinatal mortality rate of nonhospital terval for time of transport can be more (44%) or under guidance of an obstetri- deliveries was similar to that for planned lengthy. This will be true, for example, in cian in a hospital (11%) in Dutch pri- hospital births (7.9 vs 8.2 per 1000 countries such as the United States that miparous women in the first trimester. have emergency services but not dedi- births). However, there was a 7-fold The reality was that only 17% of these cated, well developed maternal transport higher risk of intrapartum death (95% women delivered at home, 10% deliv- services. More to the point, the inherent CI, 1.53Ϫ35.87) and a 27-fold increased ered under the guidance of a midwife in problems with transport are in large risk of death from intrapartum asphyxia an obstetric unit, but 73% delivered in a measure irremediable, even with a huge (95% CI, 8.02Ϫ88.83).17 This shows that hospital under the care of an obstetri- investment of capital. Professional re- the perinatal mortality rate may obscure cian. The authors logically conclude that sponsibility is defined prospectively be- significant differences between asphyxia patients have to be informed about these cause of the inherent and unpredictable and intrapartum death resulting from numbers and the high transport rates. risk to maternal, fetal, and neonatal pa- Such information is essential for preg- home birth. Prenatal deaths are obvi- tients in any , including un- nant women to make good decisions ously increased in pregnancies followed complicated pregnancy at the onset of about the site of delivery.25 In Germany, by hospital perinatal centers because of attended labor. midwives are obligated to inform their obligate referral of high-risk patients, in- In summary, planned home birth does patients about the distance from the cluding fetal patients with malforma- not meet current standards for patient freestanding midwifery unit (or home) tions, to these centers. safety in obstetrics, as illustrated by the to the nearest hospital obstetric unit and Reporting from the United States, recent preventable death from hemor- 28 the approximate average time of trans- Ecker and Minkoff focus on the ab- rhage of an Australian midwife home- port. Midwives are also obligated to doc- solute risk of planned home birth, birth advocate while attempting delivery ument this information in the informed rather than the relative risk, and claim of her own child at home.20 There is in- consent form and in the patient’s record. that the “potentially small increment creased relative risk and a persistent ab- Nevertheless, many pregnant women are in absolute risk that a particular pa- solute risk both of which can be reduced not aware of what this might mean in an tient choice carries” is ethically accept- in their incidence by having access to emergency. able. The data above support a differ- professional standards of perinatal care. Some authors from the Netherlands ent clinical and ethical assessment: the To regard these risks as ethically accept- acknowledge and discount the clinical increment is far from small and is not able relegates pregnant and fetal patients significance of an increased risk of ad- ethically acceptable. who experience adverse events to the cat- verse outcomes of planned home vs hos- We therefore emphatically disagree egory of collateral damage. It is antithet- pital birth. Van de Kooy et al,26,27 for ex- with Ecker and Minkoff28 and all others ical to professional responsibility to in- ample, state: “With about 50,000 women who judge the adverse outcomes of tentionally assign any damaged or dead annually starting delivery under supervi- planned home vs hospital birth to be eth- pregnant, fetal, or neonatal patient to sion of a midwife at home, a 5% risk (of ically acceptable. The professional re- this category, even if the number is small. adverse outcome) may be nontrivial. On sponsibility response demands adher- Obstetricians who nonetheless do so an individual level, such a difference ence to accepted standards of care.29 should be subject to peer review and jus-

MONTH 2012 American Journal of Obstetrics & Gynecology 3 Clinical Opinion Obstetrics www.AJOG.org tifiably incur professional liability and reasons were the necessity of transport the hospital or home-birth centers with ac- sanction from state medical boards. Pol- from home to the hospital, the inability cess to full back-up, have recently been re- icy makers who do so should be exposed to cope with pain, the unexpected in- ported.40-43 We fully support and endorse as threats to professional responsibility. creased rate of operative deliveries, anx- professionally responsible midwifery but iety about losing the infant during trans- reject professionally irresponsible home- Patient satisfaction port, and the dissatisfaction with birth midwifery and advocacy of it. The raison d’etre for planned home birth caregivers. This paper documents that is increased patient satisfaction. The planned home birth, often unpredict- Cost-effectiveness RCOG-RCM statement emphasizes that ably and suddenly, fails to fulfill what is In the United States and throughout the the focus should not be exclusively on promised to pregnant women and there- world fiscal responsibility and account- the physical safety of planned home fore expected by them. Unfortunately, ability have become essential compo- birth. It is also important to “acknowl- none of the other studies has systemati- nents in clinical practice and organiza- edge and encompass issues surrounding cally investigated satisfaction/dissatis- tional leadership.44 It might at first emotional and psychological well-be- faction with planned birth in an inten- appear that planned home birth offers ing.” Birth for women is a rite of passage tion-to-treat model. the potential for cost-savings by avoid- and a family life event, as well as being It also has been demonstrated in the ing a relatively more expensive hospital the start of a lifelong relationship with Netherlands that among low-risk women admission. The Birthplace in England na- her infant.”10 the rate of operative deliveries is higher tional cohort study “priced” planned The RCOG-RCM statement is correct when they are managed by an obstetri- home birth, birth in freestanding mid- to emphasize the biopsychosocial im- cian instead of a midwife.36 This is ex- wifery units, “alongside” midwifery units, portance of planned home birth.29,33 Its plained by the high rate of continuous and obstetric units at, respectively, £1066, biopsychosocial advantages include con- fetal heart rate monitoring and impa- 1435, 1461, and 1631, and concluded that tinuity of an empathetic caregiver, the tience of the obstetrician to tolerate a “for multiparous women at low risk of comfort of home, greater control by the longer labor time. complications, planned home birth is the pregnant woman, fewer interventions, Much can and should be done to cre- most cost-effective option. For nullipa- and less defensive medicine. These ad- ate a home-like, psychologically, and so- rous low-risk women, planned birth at vantages become even more salient if the cially supportive hospital birth to support home is likely to be the most cost-effec- hospital birth option includes provision the legitimate expectations of women for a tive option but associated with an in- of care by nonobstetric physicians or humane, safe, and undisrupted labor ex- crease in adverse perinatal outcomes.”45 poorly supervised trainees and physi- perience with full back-up immediately This is selective and a defective cost- cians new to practice, lack of in-house available.37 Hospital managers and ob- effectiveness analysis. A more compre- anesthesia or neonatal care, and in- stetricians should be aware of the fact hensive Dutch report calculates a general creased intervention rates driven by de- that a home-like equipped delivery room 3-fold increase of costs in patients trans- fensive medicine or unprofessional self- can reduce the woman’s need for pain ported during labor, when the costs of interest to avoid lengthy attendance at relief, even reduce the rate of operative the midwife, the transport system, and labor. deliveries or episiotomies and increase the obstetricians are included. Even The high rates of transport undercut patient satisfaction.38 It is also useful if more important, Svensson46 exposed the the raison d’etre of planned home birth. pregnant women and their partners are failure to include the lifetime costs for Emergency transport, even in its most already familiar with the delivery rooms support of disabled children, which he humane forms, is psychologically and within a hospital and all possibilities of estimates to be £5 million per handi- socially disruptive for the pregnant pain relief. A Cochrane review has stated capped child. In addition, the potential woman whose expectation to deliver at that a continuous 1-to-1 care during de- increased cost of professional liability home has suddenly been dashed. The ex- livery can reduce per se operative inter- must be considered.47 A comprehensive pectation of normal vaginal delivery at ventions at the second stage of labor.39 and reliable cost-effectiveness analysis home without intervention is put at risk In summary, planned home birth of- would have also to take into account the by the higher rates of operative and ce- ten does not satisfy its raison d’etre, im- cost of maintaining an adequate trans- sarean deliveries compared with women proved patient satisfaction. Professional port system, hospital admission for the who labor in the hospital.34 It is therefore responsibility requires physician leaders pregnant women, admissions to the neo- not surprising that a study of Dutch to take measures to improve patient natal intensive care unit, the lifetime women revealed that the self-reported, satisfaction, by creating home-birth-like costs of supporting the neurologically persistent levels of frustration including environments that are appropriately disabled children who will result from serious psychologic problems in trans- staffed not only to ensure patient safety, planned home birth, and potentially in- ported women compared with those which is the paramount professional re- creased professional liability costs. who labored in a hospital persisted even sponsibility, but also to ensure patient In summary, selective cost-effective- up to 3 years after birth in 17% of all satisfaction.38 Successful collaborative ness analysis is not consistent with pro- transported women.35 Most relevant experience with midwives, either within fessional responsibility and may seri-

4 American Journal of Obstetrics & Gynecology MONTH 2012 www.AJOG.org Obstetrics Clinical Opinion ously mislead public officials in policy integrity justifiably limits the woman’s come an essential part of training. Phy- deliberations about permitting and rights by limiting the scope of clinically sician leaders must be especially watchful funding planned home birth. If we re- reasonable alternatives. This limitation for trends of clinically unjustified in- gard the increased “event” of perinatal or does not exist in the rights-based reduc- creased intervention that results from in- even maternal deathϪwhich appears in tionist model of women’s rights. appropriate self-interest in reducing lia- the British Birthplace study only in an In the professional responsibility bility, convenience, or financial gain.44,60 appendixϪthese calculations become model of decision making, the patient This focus on maternal and fetal safety even more problematic, inasmuch as the has the right to select from among the should be complemented with an em- least expensive patient is a dead patient. medically reasonable alternatives. If she phasis on compassionate care that re- rejects them all and also remains a pa- spects pregnant women as persons by ac- Respect for women’s rights tient, then her refusal is not a simple ex- knowledging and striving to meet their There are 2 ways in which respect for ercise of a negative right to noninterfer- psychosocial needs. Home birth centers women’s rights can be understood. The ence. Her refusal is more complex, with immediate access to cesarean deliv- first starts with the right of the woman to because it is coupled with a positive right ery, as well as collaborative practice models make decisions and control what hap- to the services of clinicians and the re- between obstetricians and nurse midwives pens to her body. The physician is bound sources of health care organizations and should be encouraged.38-43 The goal to acknowledge and implement the pa- society.51 In all ethical theories positive should be effective integration of clini- tient’s preferences, without constraint. rights come with limits. In the clinical cally competent and empathetic obstet- This is a purely contractual model of the setting ethically justified limits originate ric care as presaged by the Scottish phy- physician-patient relationship in which in professional integrity, because profes- sician-ethicist John Gregory,61 more the woman protects herself by the exer- sional integrity prohibits provision of than 2 centuries ago, who called for phy- cise of her autonomy-based rights. “In a clinical management that is not safe.52 sicians to be scientifically excellent and democratic society, a woman has the In summary, from the perspective of to exhibit “gentleness of manners, and a right to choose where she might undergo the professional responsibility model, compassionate heart,” what Shakespeare one of the most important experiences of insistence on implementing the uncon- calls “the milk of human kindness.”61 her life, and where she will begin to bond strained rights of pregnant women to with a child she will raise lovingly.”48 control the birth location is an ethical er- How should obstetricians respond This is rights-based reductionism, in ror and therefore has no place in profes- when a woman raises the topic of which the patient’s rights systematically sional perinatal medicine. An editorial in planned home birth? override professional responsibility. In Lancet succinctly summarized this point: The increased risk of planned home the resulting contractual relationship the “Women have the right to choose how birth is preventable by planned hospital physician’s obligation to protect the and where to give birth, but they do not delivery. Planned home birth should not pregnant woman, much less the fetal and have the right to put their baby at risk.”6 be considered medically reasonable in neonatal patient is completely subordi- professional clinical judgment. This nated to the woman’s rights.29 Professionally appropriate responses clinical judgment should be respectfully In a professional relationship the phy- What should obstetricians do to communicated and the woman’s ques- sician and other obstetric providers do address the root cause of the tions addressed in an evidence-based have an independent obligation, as a recrudescence of planned home birth? fashion. Women should be informed of matter of professional integrity, to pro- The first professional responsibility of the high transport rate and the increased, tect pregnant, fetal, and neonatal pa- obstetricians is to ensure that hospital preventable risks to herself, her fetus, tients.29,49 These beneficence-based ob- delivery is safe, respectful, and compas- and her infant, as well as the psychosocial ligations must in all cases be balanced sionate.53-56 Current, inappropriate harms of emergency transport. The ob- against autonomy-based obligations to practices may be fueling the recrudes- stetrician and other obstetric provider the pregnant patient. Beneficence-based cence of planned home birth. Physician should recommend strongly against and autonomy-based obligations com- leaders need to closely scrutinize organi- planned home birth and obtain in- bine to create the professional responsi- zational policies and practices and formed consent for delivery in a safe and bility to empower the pregnant woman should see to it that staffing is competent compassionate hospital environment or to make informed decisions about the and adequate. Well-trained, compas- a birth center with immediate hospital management of her pregnancy and care sionate in-house attending obstetric and access. of her newborn child.29,50 The physi- anesthesia coverage should be required cian’s role is to identify and present med- for all hospitals offering planned hospi- ically reasonable alternatives for the tal delivery. Unnecessary obstetric inter- How should obstetricians respond management of pregnancy, ie, clinical ventions need to be assiduously pre- to a woman’s request to participate management for which there is an evi- vented by adherence to evidence-based in planned home birth? dence base of net clinical benefit. In a guidelines. 57-59 Teaching of noninvasive For a woman who is nonetheless com- professional relationship, the physician’s care and mode of delivery should be- mitted to planned home birth, the obste-

MONTH 2012 American Journal of Obstetrics & Gynecology 5 Clinical Opinion Obstetrics www.AJOG.org trician should explain that professional cannot protect themselves. Random- constraints on the rights of patients have responsibility prohibits participation in ized controlled clinical trials of played a major role in the reasoning of US or facilitation of substandard clinical planned home vs planned hospital state and federal courts about end-of-life care. The simple fact that a pregnant pa- birth violate research ethics. It is there- decision making because the landmark de- tient has made a request does not by itself fore impermissible for an obstetrician cision In re Quinlan. Professional organi- create a professional responsibility to to participate in or refer patients to zations should also reconsider their state- implement that request, especially when such trials. ments on planned home birth and bring the request is for clinical management them into line with professional responsi- that is substandard.52 How should professional associations bility, to prevent rights-based reduction- of obstetricians respond to the ism in obstetric ethics and practice. recrudescence of planned home birth? How should obstetricians respond ACOG and RCOG should continue their Conclusion when a patient is received on important efforts to enhance patient Advocacy of planned home birth is a emergency transport from a planned safety and compassionate care for all compelling example of what happens home birth? hospital births and birth centers with im- when ideology replaces professionally There is a strict professional obligation mediate access to cesarean delivery. disciplined clinical judgment and policy. to provide excellent medical care in all ACOG and RCOG should continue to We urge obstetricians, other concerned obstetric emergencies. Without hesita- support collaborative physician-mid- physicians, midwives, and other obstet- tion, therefore, the obstetrician should wife practices and strive for a home birth ric providers, and their professional as- provide excellent, compassionate, emer- experience within the hospital. Profes- sociations to eschew rights-based reduc- gency obstetric care to all pregnant sional associations should also support tionism in the ethics of planned home women transported from planned home policy changes and try to get an impact birth and replace rights-based reduc- birth. Obstetricians have a compassion- on health care politicians as demon- tionism with an ethics based on profes- based obligation to be aware to and ad- f strated by the Steering Committee of sional responsibility. dress the psychosocial harms of such Perinatal Care in the Netherlands. The transport, in an attempt to ameliorate Dutch minister of Health and Sports un- REFERENCES their long-term effects. derstood that 7 topics are essential to im- 1. MacDorman MF, Mathews TJ, Declercq E. prove perinatal care in the Netherlands: Home births in the United States, 1990-2009. US Centers for Disease Control and Prevention. Should obstetricians participate in or “(1) to organize perinatal care with NCHS Data Brief no. 74. January 2012. Availa- refer patients to a randomized mother and child in the center, (2) to in- ble at: http://www.cdc.gov/nchs/data/databriefs/ controlled clinical trial of planned troduce a proactive instead of a reactive db84.htm. Accessed June 24, 2012. home vs planned hospital birth? care, (3) to inform women about the im- 2. MacDorman MF, Declercq E, Mathews TJ, Analysis of the safety data on home birth portance of preconceptional heath, (4) Stotland N. Trends and characteristics of home vaginal birth after cesarean delivery in the shows that there is an unacceptable risk to promote collaborative practice, im- United States and selected states. Obstet Gy- to pregnant, fetal, and neonatal patients. prove the quality of collaborative deliv- necol 2012;119:737-44. Equipoise, an important ethical condi- ery, to make plans for the delivery if 3. Shapiro SM. Mommy wars: the prequel. New tion for initiating randomized con- appropriate by a case-manager and in- York Times Sunday Magazine, May 23, 2012. trolled trials implies genuine uncertainty crease visits at home after birth, reduce Available at: http://www.nytimes.com/2012/ 05/27/magazine/ina-may-gaskin-and-the-battle- as to whether one treatment is better home delivery, (5) to support national for-at-home-births.html?_rϭ1&pagewantedϭall. than another. For home birth, equipoise programs for prevention and care of Accessed June 24, 2012. does not exist, because a controlled clin- women with poor psychosocial condi- 4. Pergament D. The midwife as status symbol. ical trial with home birth as one arm tions, (6) to not leave women alone from New York Times, June 15, 2012. Available at: would subject pregnant, fetal, and neo- the first moment of delivery to the end, http://www.nytimes.com/2012/06/17/fashion/ the-midwife-becomes-a-status-symbol-for-the- natal patients to preventable, unneces- and (7) that a woman can be reassured hip.html. Accessed June 24, 2012. sary risk of mortality, morbidity, and that at any time of the day or night any 5. Central Bureau voor de Statistiek, Den Haag, disability when compared with hospital intervention that is necessary can be ini- 2012. delivery. The fundamental ethical im- tiated within 15 minutes.”63 This last 6. Home birth–proceed with caution. Lancet perative in research with human subjects goal cannot now or in the foreseeable fu- 2010;376:303. 7. Hildingsson IM, Lindgren HE, Haglund B, is to protect them from impermissible ture ever be met by a home delivery. Rådestad IJ. Characteristics of women giving 62 harm. This imperative would be vio- Professional organizations should be birth at home in Sweden: a national register lated by a randomized controlled clin- willing to file amicus briefs in cases like study. Am J Obstet Gynecol 2006;195: ical trial. This conclusion is made all the one decided by the European Court 1366-72. the stronger when one realizes that fe- of Human Rights discussed earlier to en- 8. Society for Quality in Outpatient Obstetrics homepage. Available at: www.quag.de. Ac- tal and neonatal patients are vulnera- sure that courts take into account profes- cessed Aug. 1, 2012. ble subjects of research because they sional responsibility and integrity. Pro- 9. Case of Ternovszky v. Hungary (Application no. are incapable of consent and therefore fessional integrity and its implications for 67545/09). European Court of Human Rights.

6 American Journal of Obstetrics & Gynecology MONTH 2012 www.AJOG.org Obstetrics Clinical Opinion

Dec. 14, 2010. Available at: http://sim.law.uu.nl/ 25. de Neef T, Hukkelhoven CW, Franx A, van 43. DeJoy S, Burkman RT, Graves BW, et al. sim/caselaw/Hof.nsf/1d4d0dd240bfee7ec12568 Everhardt E. Uit de lijn der verwachting. Nederl Making it work: successful collaborative prac- 490035df05/30b9a2d7ebbbd8c4c12577f9004a Tijdschrift Obstet Gynaecol 2009;122:34-342. tice. Obstet Gynecol 2011;118:683-6. a476?OpenDocument. Accessed June 24, 26. Van de Kooy J, Poeran J, de Graaf JP, et al. 44. Chervenak FA, McCullough LB. The moral 2012. Planned home compared with planned hospital foundation of medical leadership: the professional 10. Royal College of Obstetricians and Gynaeco- birth in the Netherlands: intrapartum and early virtues of the physician as fiduciary of the patient. logists and Royal College of Midwives Joint State- neonatal death in low-risk pregnancies. Obstet Am J Obstet Gynecol 2001;184:875-80. ment no. 2. April, 2007. Home births. Available at: Gynecol 2011;118:1037-46. 45. Schroeder S, Petrou S, Patel N, et al. Cost http://www.rcog.org.uk/files/rcog-corp/uploaded- 27. Van de Kooy J, Poeran J, de Graaf JP, et al. effectiveness of alternative planned places of files/JointStatmentHomeBirths2007.pdf. Ac- Planned home compared with planned hospital birth in woman at low risk of complications: ev- cessed June 24, 2012. birth in the Netherlands: intrapartum and early idence from the Birthplace in England national 11. American College of Obstetricians and Gyne- neonatal death in low-risk pregnancies. In reply. prospective cohort study. BMJ 2012;244: cologists. Committee Opinion no. 476. Commit- Obstet Gynecol 2012;119:388-9. e2292. doi 10.1136/bmj.e2292. tee on Obstetric Practice. Planned home birth. 28. Ecker J, Minkoff H. What are physicians’ 46. Svensson G. Re: Perinatal and maternal Obstet Gynecol 2011;117 (no. 2, part 1):425-8. ethical obligations when patient choices may outcomes by planned place of birth for healthy 12. Kyser KL, Lu X, Santillan DA, et al. The as- carry risk? Obstet Gynecol 2011;117:1179-82. women with low risk pregnancies: the Birth- sociation between hospital obstetrical volume 29. Chervenak FA, Brent RL, McCullough LB. place in England national prospective cohort and maternal postpartum complications. Am J The professional responsibility model of obstet- study. BMJ Group. Privacy Policy Website Obstet Gynecol 2012;207:42.e1-17. ric ethics: avoiding the perils of clashing rights. T&Ca. Revenue Sources Highwine press; 2011. 13. Bailit JL, Srinivas SK. Where should I have Am J Obstet Gynecol 2011:205:315.e1-5. 47. Wegner Y, Rector K. Jury awards Waverly my baby? Am J Obstet Gynecol 2012;207:1-2. 30. American College of Obstetricians and Gyne- family $55 million in Hopkins malpractice case. 14. Knox GE, Simpson KR. Perinatal high reli- cologists. Committee Opinion no. 116. Practice Baltimore Sun June 26, 2012. Available at: ability. Am J Obstet Gynecol 2011;204:373-7. Bulletin. Management of intrapartum fetal heart http://articles.baltimoresun.com/2012-06-26/ 15. Schuchat A. Reflections on pandemics, rate tracings. Obstet Gynecol 2010;116: health/bs-md-ci-malpractice-award-20120626_ past and present. Am J Obstet Gynecol 1232-40. 1_malpractice-awards-in-state-history-gary- 31. 2011;204(Suppl 1) S4-6. Nageotte MP, Vander Wal B. Achievement stephenson. Accessed Aug. 1, 2012. of the 30-minute standard in obstetrics—can it 16. Wax JR, Lucas L, Lamont M, et al. Maternal 48. Zohar N, quoted in Even D. Health ministry be done? Am J Obstet 2012;206:104-7. and newborn outcomes in planned home birth delaying delivery of new restrictions on at-home 32. Boehm FH. Decision to incision: time to re- vs. planned hospital births: a metaanalysis. births. Haaretz Jan. 3, 2012. Available at: consider. Am J Obstet Gynecol 2012;206:97-8. Am J Obstet Gynecol 2010;203:243.e1-8. http://www.haaretz.com/print-edition/news/ 33. Engel G. A unified concept of health and 17. Kennare RM, Keirse MJ, Tucker GR, Chan health-ministry-delaying-delivery-of-new- disease. IRE Trans Med Electr 2009;10.1109/ AC. Planned home and hospital births in South restrictions-on-at-home-births-1.405164. Ac- IRET-ME.1960.5008004. Originally appeared Australia, 1991-2006: differences in outcomes. cessed June 24, 2012. in Persp Biol Med 1960;13:48-57. Med J Aust 2010;192:76-80. 49. Chervenak FA, McCullough LB, Arabin B. 34. Stichting Perinatale Registratie Nederland. 18. Chervenak, McCullough, Brent RL. The perils Obstetric ethics: an essential dimension of Available at http://perinatreg.nl. Accessed June of the imperfect expectation of the perfect baby. planned home birth. Obstet Gynecol 2011; 24, 2012. Am J Obstet Gynecol 2010;203:101.e1-5. 117:1183-7. 35. Rijnders M, Baston H., Schönbeck Y, et al. 19. Rayburn WF, Richards ME, Elwell EC. 50. Chervenak FA, McCullough LB. The profes- Perinatal factors related to negative or positive re- sional responsibility model of respect for auton- Drive times to hospitals with perinatal care in call of birth experience in women 3 years postpar- the United States. Obstet Gynecol 2012; tum in the Netherlands. Birth 2008;35:107-16. omy in decision making about cesarean deliv- 119:611-6. 36. Maassen MS, Hendrix MJC, van Vugt HC, ery. Am J Bioeth 2012;12:1-2. 20. Shears R. Woman, 36, who campaigned for Veersema S, Smits F, Nijhuis JG. Operative de- 51. Chervenak FA, McCullough LB. Justified home births dies having baby daughter at liveries in low-risk pregnancies in the Nether- limits on refusal of intervention. Hastings Cent home. Daily Mail online. Jan. 31, 2012. Avail- lands: primary versus secondary care. Birth Rep 1991;21:12-8. able at: http://www.dailymail.co.uk/health/ 2008;35:277-82. 52. Brett AS, McCullough LB. Addressing re- article-2094348/Caroline-Lovell-Home-birth- 37. Kerr SM. Homebirth in the hospital: inte- quests by patients for nonbeneficial interven- advocate-dies-delivering-baby-daughter-home. grating natural with modern medicine. tions. JAMA 2012;307:149-50. html. Accessed Aug. 1, 2012. Boulder, CO: Sentient Publications; 2008. 53. Knox GE, Simpson KR. Perinatal high re- 21. Brent RL. The role of the paediatrician in the 38. Hodnett ED, Downe S, Edwards N, Walsh liability. Am J Obstet Gynecol 2011;204: effort to prevent congenital malformations. Pe- D. Home-like versus conventional institutional 373-7. diatric Rev 2011;32:411-22. settings for birth. Cochrane Database Syst Rev 54. Pettker CM, Thung SF, Raab CA, et al. A 22. Birthplace in England Collaborative Group. 2005;1:CD000012. comprehensive obstetrics patient safety pro- Perinatal and maternal outcomes by planned 39. Hodnett ED, Gates S, Hofmeyr GJ, Sakala gram improves safety climate and culture. Am J place of birth for healthy women with low risk C. Continuous support for women during child- Obstet Gynecol 2011;204:216.e1-6. pregnancies: the Birthplace in England national birth. Cochrane Database Syst Rev 2007; 55. Grunebaum A, Chervenak F, Skupski D. Ef- prospective cohort study. BMJ 2011;343: 3:CD003766. fect of a comprehensive patient safety program d7400. doi: 10.1136/bmj.d7400. 40. Shaw-Battista J, Fineberg A, Boehler B, et on compensation payments and sentinel events. 23. Amelink-Verburg MP, Verloove-Vanhorick al. Obstetrician and nurse-midwife collabora- Am J Obstet Gynecol 2011;204:97-105. SP, Hakkenberg RM, Veldhuijzen IM, Benne- tion. Obstet Gynecol 2011;118:663-72. 56. Rosenstein AH. Managing disruptive be- broek Gravenhorst J, Buitendijk SE. Evaluation 41. Darlington A, McBroom K, Warnick S. A havior in the health care setting: focus on ob- of 280,000 cases in Dutch midwifery practices: Northwest collaborative practice model. Obstet stetric services. Am J Obstet Gynecol 2011; a descriptive study. BJOG 2008;115:570-8. Gynecol 2011;118:673-7. 204:187-92. 24. Amelink-Verburg MP, Rijnders ME, Bui- 42. Hutchison MS, Ennis L, Shaw-Battista J, et 57. Arabin B, Chervenak FA. RE: Perinatal and tendijk SE. A trend analysis in referrals during al. Great minds don’t think alike: collaborative maternal outcomes by planned place of birth for pregnancy and labour in Dutch midwifery care maternity care at San Francisco General Hos- healthy women with low risk pregnancies: the 1998-2004. BJOG 2009;116:923-32. pital. Obstet Gynecol 2011;118:678-82. Birthplace in England national prospective

MONTH 2012 American Journal of Obstetrics & Gynecology 7 Clinical Opinion Obstetrics www.AJOG.org cohort study. BMJ 2012 Jan. 18, online States: 1995-2008. Obstet Gynecol 2012; Netherlands: Kluwer Academic Publishers; publication. Available at: http://www.bmj.com. 119:657-8. 1998:161-245. ezproxyhost.library.tmc.edu/rapid-response/ 60. Chervenak FA, McCullough LB, Brent RL. 62. Brody BA, McCullough LB, Sharp RR. Con- 2012/01/17/re-perinatal-and-maternal-outcomes- The professional responsibility model of physi- sensus and controversy in clinical research eth- planned-place-birth-healthy-women-low-r. cian leadership. Am J Obstet Gynecol 2012 ics. JAMA 2005;294:1411-4. Accessed Aug. 1, 2012. March [Epub ahead of print]. 63. Klink A (Dutch Minister of Health and 58. Blanchette H. The rising cesarean delivery 61. Gregory J. Lectures on the duties and qual- Sports). Letter to the chairman of the second rate in America. Obstet Gynecol 2011;118: ifications of a physician. London: W. Strahan parliament Postbus 20018 2500 EA DEN 687-90. and T. Cadell, 1772. Reprinted in McCullough HAAG, Jan. 6, 2010. Betreft: Advies Stuur- 59. Arabin B, Kyvernitakis I, Liao A, et al. Trends LB, ed. John Gregory’s writings on medical eth- groep zwangerschap en geboorte. CZ/EKZ- in cesarean delivery for twin births in the United ics and philosophy of medicine. Dordrecht, 2978049.

8 American Journal of Obstetrics & Gynecology MONTH 2012