Could a ban on homebirth be justified?

Agnes Gereb, a midwife in Hungary, has been imprisoned for performing home births http://www.guardian.co.uk/world/2010/oct/22/hungary-midwife-agnes-gereb-home-birth. She faces various charges, including negligent malpractice and manslaughter (relating to a homebirth in which the baby died after a difficult labour). While home birth is theoretically legal in Hungary, in practice independent Hungarian midwives are not certified as being able to ensure safe conditions for home birth.

Media commentary in this country has on the whole been very sympathetic towards Gereb (for example http://www.bbc.co.uk/programmes/b00vhfg2), implying that the rules which prevent women from giving birth at home are unwarranted restrictions on their freedom. Although in most developed countries home births are the exception rather than the rule, they are generally felt to be something women have a right to choose to have. A plausible reason for this is that birth is seen as a very important, as well as personal, experience which the mother should have control over. Is Hungary justified in challenging the existence of such a right?

There are good reasons for thinking that it is safer for a baby for it to be born at a hospital rather than at home. There are more doctors in the vicinity, as well as more equipment. In general, people’s approach to rights seems to be along the lines of ‘your right to swing your arm ends where my nose begins’. Those unable to defend their own noses from swinging arms are protected by the state through its legislature. Hungary’s stance on home births seems to be in line with this principle. If home births were entirely safe, they would be allowable, but as they are, a woman’s right to home birth is curtailed by a baby’s right to a safe delivery. In this case, there seems to be far more at stake for the baby (its life, or a disability free future) than for the mother. (See http://www.ajog.org/article/S0002-9378(10)00671-X/abstract, which indicates that there homebirth is associated with greater neonatal mortality.)

On the other hand, ‘how much is at stake’, in the sense used above, is not always what is at issue. For example, a parent might take their child by car to see a relative. Since more people die in car accidents than simply by sitting at home, this seems to be risking the child’s life for a benefit which is smaller than the value of a life. The reason that this is considered allowable is, arguably, the very low chance of an accident, as well as the fact that in general, using your car rather than staying at home confers a large benefit on both parent and child.

Therefore, what is of importance is not only how dangerous something is, but also how much benefit it produces. In this case, the mother who asked Gereb to deliver her baby at home claimed that her sister had had such a traumatic birth in hospital that she didn’t wish to have any more children. The benefit of having a homebirth was therefore judged to be considerable. However, while it seems plausible that the danger of homebirth is relatively inflexible, since it is not feasible to bring more doctors, or great amounts of equipment, into people’s homes, the benefit may be flexible. For example, in a paper on why women choose homebirths, some women site greater control and comfort as reasons for wanting a homebirth  – http://www.jmwh.com/article/S1526-9523(08)00338-3/abstract. They wanted their baby to be born in a peaceful and loving environment. While such an atmosphere may be easier to achieve at home than in a hospital, it may be easier to improve the comfort and peace of mothers in hospital than to improve their safety at home. If this could be done, that shows the inherent benefit of a homebirth over a hospital one to be decreased, while its danger is undiminished. (Midwifery-led units such as http://www.oxfordradcliffe.nhs.uk/forpatients/departments/womens/maternity%20services/spires.aspx might be thought of as such an endeavour.) Therefore Hungarian-style restrictions on home-birth may be justified when accompanied by endeavours to make hospital births as comfortable as possible, and to give mothers more control.

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17 Responses to Could a ban on homebirth be justified?

  • This is an interesting article. I agree with the need of the state (any state) to protect those who can’t “stop arms from swinging in their faces” themselves. What lacks here is the question of hospital practices in Hungarian maternity hospitals. Perinatal mortality rates do not show the whole picture, and there is more to a safe delivery than “simply not being dead”. And as it happens, Hungary’s ombudsman actually officially confirmed women’s rights to give birth at a location of their choice, including at home. It’s midwife-assisted births that are banned (it’s called practicing medicine without a license). You have to wonder what such a restriction does for the safety of mother’s delivering babies at home.

    Olivia

  • Jonathan Herring says:

    The law in England has for a long time supported the principle that a competent patient has an absolute right to refuse treatment. That principle applies to pregnant women as much as anyone else. The proposal in this article suggesting we could force a woman against her wishes to reeive hospital care in labour would involve a major infringement of human rights. Of course the law might be wrong and maybe we should force all patients who make what “we” take to be foolish choices to have treatment whether they like it or not. But if we are going to do that it should apply generally and not just pick on pregnant women.

  • Michelle Hutchinson says:

    Thank you very much for your comments.
    I do not believe that the view I proposed above is accurately characterised as forcing women to receive treatment, and hence as breaching current views on human rights. Importantly, encouraging women to give birth in a hospital environment where there are doctors and equipment present does not mean forcing their labour to be intervened in. It is rather ensuring that should anything go wrong, and she decide she wants an intervention, that possibility is open to her.
    In addition, as is pointed out by Olivia, the restriction in place in Hungary is a ban on midwife-assisted births, rather than births at home. The criminalisation in Hungary is not of the mother, but of the midwife, who is deemed to be performing a service they are inadequately qualified for (a judgement which is of course very much disputed). This leads to the question of whether it is justifiable to have a policy which gives a person the right to do something, but denies others the right to help them. This is the case with suicide, for example, which is legal, though it is illegal to help the person. However, I fully agree with you Olivia that it is likely to put both the women and babies in danger if it leads women to give birth at home with no help at all. An analogy might be drawn here with the question of the legalisation of prostitutes working together – even those who oppose prostitution generally would be in favour of making those who practice it safer. They might therefore in favour of allowing prostitutes to work together, even if it would increase the occurrence of prostitution, because the alternative would be the few who engage in it being unsafe. So a person might be against homebirths in general, but believe that since they will occur regardless, it would be best for midwives to be allowed to help.

  • I’m not sure you can compare homebirth to prostitution. I do agree with the thoughts behind your comments however. It would be physically impossible (and therefore, arguably, ethically wrong) to legally forbid a woman from giving birth anywhere. Childbirth is a physical action that simply takes place, and can happen anywhere. Such a restriction would be just as pointless as forbidding people from having heart attacks, or even bowel movements. A ban on planned unassisted births would simply encourage those who are planning to give birth without the attendance of a medical professional to lie about their intentions. Despite the fact that unassisted childbirth is not, actually, illegal anywhere, women who give birth alone often still claim that it was an accident to avoid prosecution. Reading unassisted homebirth message board on the net will quickly inform you that a term was even invented for that very action: “Oops!” (As in, I am seeing an OB during my pregnancy, but I am planning to have an “Oops!” birth).

    It would be interesting to look at some of the states in the US where midwife-assisted homebirths are not legal. In those states (I can’t remember which ones they are), it is illegal for anyone to catch a baby outside of a hospital. In extreme cases, that could lead to the prosecution of those who provided help top a birthing woman in an emergency – a father catching his own baby after a precipitous birth, or a neighbor, or a friend. If a woman happens to catch her own baby, there has been no illegal act, but as soon as anyone provides assistance, that is a breech of the law. Personally, I think such laws are dangerous. Furthermore, I think it is unethical to have laws in place that prevent laypeople from attempting to provide medical assistance in emergencies.

    When discussing childbirth choices, I think there are really two relevant questions. The first is, where does the mother’s autonomy to make her own decisions end? And, who decides what is safe, and how?

  • And back to Hungary. You say that women giving birth in a hospital does not also equal forcing medical interventions upon them. I do not live in Hungary, but I do live in a neighboring Eastern European country. I can assure you a hospital birth without (yes, forced!) medical interventions is extremely rare. The concept of informed consent and refusal, which is an important right in many developed countries, does not exist yet. Suing medical staff is a theoretical option, but not an actual one. In my country of residence, that means that women who give birth in maternity hospitals (the vast majority) are subjected to interventions which range from simply pointless and perhaps a little humiliating to the medically dangerous. A few examples are shaving of pubic hair before childbirth, administering anemas, routine pitocin augmented labors even for women who are already in active labor, artificial rupture of membranes (breaking water) and routine episiotomies (vaginal cutting). Refusal leads to being treated badly, and then having the intervention performed anyway. This is hard to imagine for anybody in Britain, but it is the state of affairs. Such interventions seem to be a reflection of the patriarchal nature of these societies. Again, something that is difficult to imagine in Britain.

  • G Lewis says:

    The problem with the research you have published to back up a suggestion that home birth is unsafe, if that it is an international study and the world is just not homogenised enough for me to consider it valid.

    Consider British research, for example: Chamberlain, G, Wraight A, Crowley P. Home Births The report of the 1994 confidential enquiry. National Birthday Trust Fund. Parthenon Publishing which showed research over the last couple of decades has found that planned home birth is at least as safe as hospital birth for healthy women with normal pregnancies. In addition, home birthers are half as likely to have a caesarean section, half as likely to have an assisted delivery and have a lower risk of haemorrhage. Babies born at home are less likely to have birth injuries and less likely to need resuscitation.

    Has midwifery standards declined so greatly in just over a decade that this research is no longer valid in a British setting?

    I gave birth at home in London, within a couple of miles of four or five hospitals with a (fantastic in my opinion) British trained midwife. I was the only woman in my antenatal class to have a homebirth and the only woman to have a spontaneous normal birth. A coincidence indeed?

    The problem with the nanny state, is that it presumes woman are untrustworthy, faulty beings that are far too silly to be trusted to make the right decision when it comes to birthing the nation’s future. If you sue the woman’s assistant, you might as well sue the woman, you are still forcing our hand.

  • One wonders if charges would have been laid had she given birth at home with a doctor and experienced the same tragedy.

    As a neonatologist who trained in Australia in the 1980’s I have gone through a phase of being vehemently opposed to home birth, having seen a number of disasters after planned home births ( they tend to land in NICU ).

    On closer inspection though, most of these came from high – risk women who would not have met normal criteria for home birth, but who had rejected hospital birth, often because of their own or their friends’ experiences, sometimes for ideological / philosophical reasons. They were conducted out of the system and without any of the supports normally available.

    Having spent >30 years as a fly on the wall of Obstetrics I can see why many reject the hospital option. We are still not very good at explaining and engaging, consent processes are commonly laughable and one still sees things such as vaginal or rectal examination by total strangers without consent or introduction. This occurs at one of the most fundamentally important and vulnerable times in a woman’s life (especially when one thinks of the retraumatising effects of all this for the >10% of women who have experienced sexual abuse of some kind)..

    As soon as one goes into hospital intervention rates rise ( induction, epidural , caesarian section etc ) All of these are associated with complications for the mother and baby so careful balancing of risks is essential, some also being life-saving. This may not occur – things become ‘routinised’.

    As indicated in the cited article ( and a number of others ) it is difficult to prove that Home Birth is more dangerous for the mother if the mother is low risk. The evidence does favour some increase in risk for the baby and one does have to consider the very rare catastrophe ( e.g. torrential haemorrhage ) which may produce maternal death.

    Given the lack of strong evidence either way, the strength and polarity of the positions taken and the vehemence with which they are expressed is curious, at least if one believes that the community debate is a debate about medical evidence and the ethics of how it should be applied.

    We in medicine have often been remarkably reluctant to look at ourselves and ask why some women reject medically based care around childbirth ( which is in itself something of an aberration – care by women being the historical norm ).

    Those who have looked more closely have often directed their efforts into the development of hospital based “Family Birth Centre ” type care, which is midwifery led but on a context in which all of the resuscitation facilities of a tertiary centre are available if needed. As indicated by other correspondents, these are a good compromise for many ( but still not all ) families, but even then can have a rough ride.

    I vividly recall a group of us being lectured in the late 80’s by a senior obstetrician about the new midwifery led model in our family birth centre . The new centre was apparently ” a lesbian communist plot to undermine the medical profession and destroy society as we know it “. What was truly terrifying was that he believed every word of this and that a substantial percentage of the audience were lapping it up. There are still some in Obstetrics who are not all that far from this position.

    A consequence of this is that such centres can still function in isolation from the general system, being like lifeboats bobbing along with fins circling in the water around them. One sits in Morbidity – Mortality reviews and hears “another family birth centre disaster” when cases come up, while medically led cases go through without much comment. This produces a defensiveness and hardening of attitudes on both sides of the boundary, with unfortunate behaviour on both sides and the attendant clinical risks.

    This is not universal – I have worked in systems in which midwife led teams are accepted as just another way of having babies and all goes on perfectly sensibly, but one still sees bad examples.

    Because of this background I question whether the charges laid had much to do with the facts of the case and whether they had more to do with the infantile turf war which still rages in many places between midwifery and obstetrics. It is hard not to see much of this war as a war for control of women’s bodies and the power and money which can be harvested therefrom.

    It is hard as a neonatologist to fully support a choice which probably does increase the risk for babies, but we do as a society accept all sorts of ways in which parents increase risks for their children in ways which fly in the face of the evidence ( e.g. non immunisation).

    If we take the view that the parent is generally the best advocate the child is going to get we have to take the rough with the smooth – empowerment and education of parents, while providing a range of alternative choices is far more likely to advantage children than coercive measures based around inter-professional jealousies and insecurities.

    How hard can it be to listen to women and find some way to meet their needs as expressed, whether at home or in hospital?

  • Andrew, the Hungarian “midwife” Agnes Gereb is actually an obstetrician.

    Thank you for your very interesting views on childbirth and reproductive choices – it’s quite enlightening to hear such an honest and balanced view from someone who works in the field.

  • Andrew Watkins says:

    Oops.

    Initial post described her as “midwife”, so this perhaps needs to be corrected

    Best Wishes

  • Michelle Hutchinson says:

    Thank you for your extensive and interesting comments, Andrew. There are various reasons for which I have referred to Agnes Gereb as a midwife. Firstly, most other sources refer to her in that way (for example the Guardian article first cited), so it might be thought misleading not to. In addition, ‘midwife’ in at least in part defined in terms of practice – she was delivering babies outside of a hospital environment with minimal interventions, a practice generally referred to as midwifery, even if she was also qualified to provide other services. Lastly, her licence to practice medicine has been previously revoked, which makes it doubtful whether it would still be accurate to call her a doctor. I agree, however, that it is an interesting question whether it is more justifiable for someone qualified as an obstretrician to deliver a child in the home than for someone qualified specifically as a midwife, or whether that is not the case, yet the media perception would (unwarrantedly) be different.

  • Homebirth itself is not unethical and therefore should not be banned. A woman has the right to an informed refusal medical treatment of any kind. The real problem is that it is almost impossible for homebirth advocates to be informed about the risks of homebirth because professional homebirth advocates are dishonest about those risks. There is not a book or website by professional homebirth advocates that is honest about the fact that homebirth triples the rate of perinatal mortality in low risk women. This has been confirmed repeatedly by numerous scientific papers and by national statistics from the US and Australia among other countries.

    Homebirth and midwifery advocates point with pride to a recent study that showed that homebirth with a midwife in the Netherlands is as safe as hospital birth with a midwife (Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births). They tout this study as evidence that homebirth is as safe as hospital. A new study, just published today in the British Medical Journal, suggests an entirely different explanation: Dutch midwives have unacceptably high rates of perinatal mortality both at home and in the hospital. Indeed, the perinatal mortality rate for LOW risk women cared for by Dutch midwives is HIGHER than the perinatal mortality rate for HIGH risk women cared for by Dutch obstetricians in the hospital!

    In the UK, homebirth has been promoted by the government (to save money) despite the fact that there is not a single study that shows it to be as safe as hospital birth. Indeed, the FIRST such study is currently being conducted by the National Perinatal Epidemiology Unit (NPEU). Absent reliable information on homebirth deaths, how can anyone British woman make an informed choice for homebirth?

    There’s no need to ban homebirth. However, there is an urgent need to make sure that women have access to accurate information about the risks of homebirth. If they knew the truth, most women wouldn’t dream of risking their babies lives.

  • Michelle Hutchinson says:

    I entirely agree with you Amy, that the lack of reliable information is a very big problem, which we should concentrate on solving. However, given that you seem to believe that homebirth greatly increases the risk of death to the baby, it appears strange to declare unequivocally that it is not unethical. On a view which sought to maximise happiness, or one which required its advocates to minimise harm to others, or one which encouraged treating others as they wanted to be treated, to name but a few examples, having a homebirth could be unethical if it increased the chance of death for the baby.

  • “However, given that you seem to believe that homebirth greatly increases the risk of death to the baby, it appears strange to declare unequivocally that it is not unethical.”

    I’m speaking about existing law, which has a firm basis in medical ethics, not what I wish people would do. A woman has the right to abort a baby. No one can force her to carry a pregnancy to term, let alone force her to undergo a particular procedure in order to have a healthy baby. Homebirth and even refusing medical care during pregnancy cannot be prohibited.

    Our system is a rights based system, not a utilitarian system. For better or worse, you cannot violate an individual’s right to autonomy in order to maximize happiness or minimize harm.

    You could not legally ban homebirth in the UK or the US for these reasons. Moreover, from a practical point of view, I suspect that a ban is unnecessary. If we made sure that women had accurate information about the risks, far fewer women would choose homebirth.

  • A lack of reliable information about the risks of homebirth or hospital birth is indeed a big problem – on both sides of the debate. I agree that research into childbirth safety is a priority. The new study released in the Netherlands is indeed somewhat shocking, and I am certain that many conclusions will be drawn from it. Making reliable information available enables families to make more educated choices. However, it is individual families who should be weighing the risks and benefits of any birth choice carefully, to come to a personal decision. Not everybody’s circumstances are the same. Quality midwives are available in some places, and not in others. Quality hospitals are available in some places, not in others. There are many factors to consider in the decision-making process, and the family itself is the only “body” able to make that choice. It is restricting birth choices that I would consider to be unethical.

  • Arguably, a ban on home births is not merely justified, but urgently morally required. What distinguishes decisions by a competent woman during pregnancy and delivery is that her choices can seriously harm the interests of the future individual which the fetus will become. I have argued elswhwere (Savulescu J. (2007) ‘Future People, Involuntary Medical Treatment in Pregnancy and the Duty of Easy Rescue’ Utilitas, Volume 19, Issue 01, March, pp 1-20 doi: 10.1017/S0953820806002317, Published online by Cambridge University Press 06 Mar 2007) that the interests of future people ground ethically the involuntary treatment of women in pregnancy, where the harm to pregnant woman is small. Jonathan Herring is right that the law allows competent pregnant women to refuse treatments with the result of harm to their fetus’ future interests. But the law in this regard is wrong. No one has the right to unjustifiably harm other people, including pregnant women. If home births are less safe than hospital births, publicly funded health care systems they should not offer them. We should not offer care or treatment in public system which will foreseeably and avoidably harm future people. It has taken a couple of hundred years to lower the horrendous infant mortality and injury rates of pregnancy and child birth. It is unethical now to cast these aside and avoidably and foreseeably cause harm to future generations.

  • Julian – that is, of course, assuming that homebirths are actually less safe. Judging by your name, you come from Romania? I’d love to hear your opinions about the conditions of maternity hospitals in Romania. At the very least, I am sure that you would have to agree that the system should be greatly improved? Since the vast majority of women in Eastern European countries gives birth hospitals, should that not be the priority instead? Informed consent is also greatly lacking in these countries.

  • Lesley Page says:

    The basic premis is wrong because the research on home births has been selected in a biased way. The majority of high quality research on home birth suggests that birth at home is no less safe than birth in hospital for the baby when the pregnancy was healthy. Intervention rates were lower for those women who planned to give birth at home. Satisfaction levels were much higher.

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