Frank A. Chervenak, MD

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).

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).

A population-based study from South Australia on all births and perinatal deaths between 1991 and 2006 – one of the studies included in the review – reported that the overall perinatal mortality rate of nonhospital deliveries was similar to that for planned hospital births. However, there was a 7-fold higher risk of intrapartum death and a 27-fold higher risk of death from intrapartum asphyxia (Med. J. Austr. 2010:192;76-80).

A key complicating factor in planned home birth is the frequent need for transport to the hospital. Maternal and fetal reasons for transport during labor include failure for labor to progress, unbearable labor pain, fetal malpresentation, abrupt deterioration of fetal heart rate, uterine rupture, acute bleeding, placental abruption, acute sepsis, and cord prolapse.

Neonatal reasons for transport include signs of respiratory distress, unexpected very low or very high birth weight, and acute sepsis. Indeed, in the 2010 meta-analysis, respiratory distress and failed resuscitation contributed disproportionately to neonatal deaths among planned home births.

The 2010 review concluded that more data are necessary before drawing any conclusions regarding maternal mortality in planned home vs. planned hospital delivery. Although rare, preventable maternal death may nevertheless sometimes occur. Just recently, an Australian midwife and home-birth advocate died from postpartum hemorrhage after attempting to deliver her second child at home.

These complications and high-risk conditions are often impossible to predict, even with the best possible prenatal screenings, risk assessments, and fetal surveillance during labor. Women need immediate access to in-hospital care and emergency cesarean delivery.

Even studies that generally support home birth have reported high rates of transport. For example, the recent Birthplace in England prospective cohort study reported transport rates from nonobstetric units to the hospital of 36%-45% for nulliparous women and 9%-13% for multiparous women (BMJ 2011:343;d7400).

Adverse outcomes were similarly much higher in this study in women having their first baby at home. For women "without any complicating factor at the start of care in labour," the adjusted odds ratio of a primary outcome event for births planned at home, compared with planned obstetric unit births, was 1.59. The primary outcome in this study was defined as a composite measure of perinatal mortality and intrapartum-related neonatal morbidities (which include early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, and brachial plexus injury).

This adjusted odds ratio of an adverse event increased to 1.75 in a subgroup analysis of nulliparous women, and to 2.8 when the sample was restricted to nulliparous women with no complications at the start of labor. Although the authors did not elucidate on the issue of transport, the 59%-75% increase in a poor primary outcome may largely be attributed to the delay in access to hospital care from transport time.

In the Netherlands, where there is a long tradition of organized home birth with well-trained midwives, 49% of primiparous and 17% of multiparous women are transported during labor (BJOG 2008:115:570-8). Research done in the Netherlands also shows that women who are transferred to a hospital have a significantly higher rate of operative vaginal and secondary cesarean delivery.

In the United States, women tend to envision that any complications can be easily mitigated by a rapid and seamless transport and transition to the hospital, but in reality, even the best of transport systems experience unavoidable delays that can result in increased mortality and morbidity.

The standard of care in the United States is that "decision to incision" should take no more than 30 minutes, and ACOG has said in a recent practice bulletin that once a decision for operative delivery has been made in the context of a Category III EFM tracing, it should be accomplished as expeditiously as possible. The standards outside the United States are much the same, if not stricter. In Germany, for instance, 20 minutes is the standard used in the assessment of perinatal centers.

None of these standards of care can be consistently met when pregnant patients have started the labor process at home and then are transported to obstetric units, and the inherent problems with transport are largely irremediable even with significant investments of capital. Moreover, even if rates of emergency transport were low, there still should be considerable concern given the severity and frequency of the reasons for transfer.

Ethics, our response

The RCOG-RCM statement emphasizes the psychosocial importance of planned home birth and says that the focus should not be exclusively on the physical safety of planned home birth.

Other supporters of home birth, including some experts in the United States, focus on the absolute risk of planned home birth rather than the relative risk. According to these experts, in the broader context, the numbers of adverse outcomes are so small that it is ethically acceptable to support a patient’s desire for home birth. The ACOG, meanwhile, says that pregnant women should be informed of the risks of planned home birth, as summarized in the 2010 review.

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.

[email protected]

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).

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).

A population-based study from South Australia on all births and perinatal deaths between 1991 and 2006 – one of the studies included in the review – reported that the overall perinatal mortality rate of nonhospital deliveries was similar to that for planned hospital births. However, there was a 7-fold higher risk of intrapartum death and a 27-fold higher risk of death from intrapartum asphyxia (Med. J. Austr. 2010:192;76-80).

A key complicating factor in planned home birth is the frequent need for transport to the hospital. Maternal and fetal reasons for transport during labor include failure for labor to progress, unbearable labor pain, fetal malpresentation, abrupt deterioration of fetal heart rate, uterine rupture, acute bleeding, placental abruption, acute sepsis, and cord prolapse.

Neonatal reasons for transport include signs of respiratory distress, unexpected very low or very high birth weight, and acute sepsis. Indeed, in the 2010 meta-analysis, respiratory distress and failed resuscitation contributed disproportionately to neonatal deaths among planned home births.

The 2010 review concluded that more data are necessary before drawing any conclusions regarding maternal mortality in planned home vs. planned hospital delivery. Although rare, preventable maternal death may nevertheless sometimes occur. Just recently, an Australian midwife and home-birth advocate died from postpartum hemorrhage after attempting to deliver her second child at home.

These complications and high-risk conditions are often impossible to predict, even with the best possible prenatal screenings, risk assessments, and fetal surveillance during labor. Women need immediate access to in-hospital care and emergency cesarean delivery.

Even studies that generally support home birth have reported high rates of transport. For example, the recent Birthplace in England prospective cohort study reported transport rates from nonobstetric units to the hospital of 36%-45% for nulliparous women and 9%-13% for multiparous women (BMJ 2011:343;d7400).

Adverse outcomes were similarly much higher in this study in women having their first baby at home. For women "without any complicating factor at the start of care in labour," the adjusted odds ratio of a primary outcome event for births planned at home, compared with planned obstetric unit births, was 1.59. The primary outcome in this study was defined as a composite measure of perinatal mortality and intrapartum-related neonatal morbidities (which include early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, and brachial plexus injury).

This adjusted odds ratio of an adverse event increased to 1.75 in a subgroup analysis of nulliparous women, and to 2.8 when the sample was restricted to nulliparous women with no complications at the start of labor. Although the authors did not elucidate on the issue of transport, the 59%-75% increase in a poor primary outcome may largely be attributed to the delay in access to hospital care from transport time.

In the Netherlands, where there is a long tradition of organized home birth with well-trained midwives, 49% of primiparous and 17% of multiparous women are transported during labor (BJOG 2008:115:570-8). Research done in the Netherlands also shows that women who are transferred to a hospital have a significantly higher rate of operative vaginal and secondary cesarean delivery.

In the United States, women tend to envision that any complications can be easily mitigated by a rapid and seamless transport and transition to the hospital, but in reality, even the best of transport systems experience unavoidable delays that can result in increased mortality and morbidity.

The standard of care in the United States is that "decision to incision" should take no more than 30 minutes, and ACOG has said in a recent practice bulletin that once a decision for operative delivery has been made in the context of a Category III EFM tracing, it should be accomplished as expeditiously as possible. The standards outside the United States are much the same, if not stricter. In Germany, for instance, 20 minutes is the standard used in the assessment of perinatal centers.

None of these standards of care can be consistently met when pregnant patients have started the labor process at home and then are transported to obstetric units, and the inherent problems with transport are largely irremediable even with significant investments of capital. Moreover, even if rates of emergency transport were low, there still should be considerable concern given the severity and frequency of the reasons for transfer.

Ethics, our response

The RCOG-RCM statement emphasizes the psychosocial importance of planned home birth and says that the focus should not be exclusively on the physical safety of planned home birth.

Other supporters of home birth, including some experts in the United States, focus on the absolute risk of planned home birth rather than the relative risk. According to these experts, in the broader context, the numbers of adverse outcomes are so small that it is ethically acceptable to support a patient’s desire for home birth. The ACOG, meanwhile, says that pregnant women should be informed of the risks of planned home birth, as summarized in the 2010 review.

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.

[email protected]

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).

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).

A population-based study from South Australia on all births and perinatal deaths between 1991 and 2006 – one of the studies included in the review – reported that the overall perinatal mortality rate of nonhospital deliveries was similar to that for planned hospital births. However, there was a 7-fold higher risk of intrapartum death and a 27-fold higher risk of death from intrapartum asphyxia (Med. J. Austr. 2010:192;76-80).

A key complicating factor in planned home birth is the frequent need for transport to the hospital. Maternal and fetal reasons for transport during labor include failure for labor to progress, unbearable labor pain, fetal malpresentation, abrupt deterioration of fetal heart rate, uterine rupture, acute bleeding, placental abruption, acute sepsis, and cord prolapse.

Neonatal reasons for transport include signs of respiratory distress, unexpected very low or very high birth weight, and acute sepsis. Indeed, in the 2010 meta-analysis, respiratory distress and failed resuscitation contributed disproportionately to neonatal deaths among planned home births.

The 2010 review concluded that more data are necessary before drawing any conclusions regarding maternal mortality in planned home vs. planned hospital delivery. Although rare, preventable maternal death may nevertheless sometimes occur. Just recently, an Australian midwife and home-birth advocate died from postpartum hemorrhage after attempting to deliver her second child at home.

These complications and high-risk conditions are often impossible to predict, even with the best possible prenatal screenings, risk assessments, and fetal surveillance during labor. Women need immediate access to in-hospital care and emergency cesarean delivery.

Even studies that generally support home birth have reported high rates of transport. For example, the recent Birthplace in England prospective cohort study reported transport rates from nonobstetric units to the hospital of 36%-45% for nulliparous women and 9%-13% for multiparous women (BMJ 2011:343;d7400).

Adverse outcomes were similarly much higher in this study in women having their first baby at home. For women "without any complicating factor at the start of care in labour," the adjusted odds ratio of a primary outcome event for births planned at home, compared with planned obstetric unit births, was 1.59. The primary outcome in this study was defined as a composite measure of perinatal mortality and intrapartum-related neonatal morbidities (which include early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, and brachial plexus injury).

This adjusted odds ratio of an adverse event increased to 1.75 in a subgroup analysis of nulliparous women, and to 2.8 when the sample was restricted to nulliparous women with no complications at the start of labor. Although the authors did not elucidate on the issue of transport, the 59%-75% increase in a poor primary outcome may largely be attributed to the delay in access to hospital care from transport time.

In the Netherlands, where there is a long tradition of organized home birth with well-trained midwives, 49% of primiparous and 17% of multiparous women are transported during labor (BJOG 2008:115:570-8). Research done in the Netherlands also shows that women who are transferred to a hospital have a significantly higher rate of operative vaginal and secondary cesarean delivery.

In the United States, women tend to envision that any complications can be easily mitigated by a rapid and seamless transport and transition to the hospital, but in reality, even the best of transport systems experience unavoidable delays that can result in increased mortality and morbidity.

The standard of care in the United States is that "decision to incision" should take no more than 30 minutes, and ACOG has said in a recent practice bulletin that once a decision for operative delivery has been made in the context of a Category III EFM tracing, it should be accomplished as expeditiously as possible. The standards outside the United States are much the same, if not stricter. In Germany, for instance, 20 minutes is the standard used in the assessment of perinatal centers.

None of these standards of care can be consistently met when pregnant patients have started the labor process at home and then are transported to obstetric units, and the inherent problems with transport are largely irremediable even with significant investments of capital. Moreover, even if rates of emergency transport were low, there still should be considerable concern given the severity and frequency of the reasons for transfer.

Ethics, our response

The RCOG-RCM statement emphasizes the psychosocial importance of planned home birth and says that the focus should not be exclusively on the physical safety of planned home birth.

Other supporters of home birth, including some experts in the United States, focus on the absolute risk of planned home birth rather than the relative risk. According to these experts, in the broader context, the numbers of adverse outcomes are so small that it is ethically acceptable to support a patient’s desire for home birth. The ACOG, meanwhile, says that pregnant women should be informed of the risks of planned home birth, as summarized in the 2010 review.

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.

[email protected]