In a world of low risk obstetrics, is home birth unethical

It is reported that women who give birth at home with an independent midwife are nearly three times more likely to have a stillbirth than those who give birth in hospital; many other outcomes were “significantly better”. 

 

Perinatal deaths following home birth were associated with an underestimation of the dangers of high risk pregnancies such as preterm birth, twins, vaginal breech births and fetal distress (Bastian H et al.  BMJ. 1998; 317: 384–388). Even some IVF pregnancies were managed at home.

 

Midwives are trained in carrying out normal deliveries, not complex high risk manipulative deliveries such as breech deliveries; these should not be performed by unskilled operators. In addition, caesarean section is advocated for most women with a breech presentation or twins. 

 

Home birth in high risk patients is inadvisable and experimental (Bastian) and is opposed by professional colleges and here and here. Women with an increased risk of complications should be delivered in hospital where obstetricians can spot those complications. Women should be told this – in the recent study there is no suggestion that UK midwives told them. 

 

There is some dispute about the risk of home birth for low risk women. Two UK studies have suggested outcomes comparable to hospital delivery in terms of mortality and morbidity (Campbell R et al. BMJ 1984;289:721-4); however others suggest there is an increased risk of perinatal death (Bastian, Mori R et al. BJOG 2008;115:554-9, Pesce A. ANZJOG 2009; 49: 340-340). 

 

There are benefits to home birth. For example, women are more likely to avoid perineal trauma and to breast feed successfully. Cited reasons for choosing an independent midwife include the desire for continuity of care and carer and for a genuine partnership (Frohlich J. MIDIRS Midwifery Digest 2007; 17:313-8) plus the wish to keep birth free from medical interventions (Anderson T. MIDIRS Midwifery Digest 2002;12:405-7).

 

The RCOG supports the provision of home birth services for women at low risk of complications. American and Australian colleges disagree, the former believes home birth puts the woman and her baby's health and life at unnecessary risk – it places the process of giving birth over the goal of having a healthy baby. 

 

In labour there are potentially sudden serious complications for the woman and/or baby. Minimizing perinatal and maternal morbidity and mortality necessitates access to fetal monitoring, immediate anaesthesia and caesarean section, plus paediatric care. Perinatal death is a crude indicator of safety of labour – there is also presumably an increased risk of perinatal morbidity. This is more important since a newborn may be left with impairments. 

 

Home birth by an independent midwife, particularly of high risk pregnancies, could be immoral in face of likely increased risk of neonatal morbidity if it is not of great importance to the fetus (by removing health risks) or to the woman. If there is a risk it must be justified by a benefit to the fetus or woman. The relative risks will vary with whether the pregnancy is high or low risk and the available staff and facilities. 

 

But is it is not at all clear that it is reasonable for professionals to support a woman choosing it because there are benefits to her. Why should fetuses be exposed to harms, or possible harms, merely so that the woman can derive some significant (but not enormous) benefit? In many other settings we would think it unethical for a woman to risk harms to her fetus merely in order to derive some significant (but not enormous) benefit. For example, we might find it unethical for a woman to drink alcohol or take recreational drugs, even though the woman may consider that the benefits to her are significant. We may think that she should avoid extreme sports, or holidaying somewhere with no/poor medical services late in pregnancy. Fetal harms are different to prenatal testing and selective termination because then no child will exist, so harm cannot arise. But with home birth a child will likely exist but potentially harmed by labour and delivery.

 

Perhaps a more defensible position for home births would be one holding that the risks to the fetus of labour and delivery are sufficiently high in high risk pregnancies, or sufficiently uncertain in low risk pregnancies, that home births should only be performed where they convey significant benefits to the baby. There are benefits to the baby with home delivery. But the potential risks of home birth include far more profound deficits, including life long neurological deficit, which far outweigh benefits to the baby. 
    
Home births should not be prohibited; after all, we don’t prohibit smoking during pregnancy, we merely discourage it. Funding for home delivery should be only for low risk women managed by credentialed midwives who participate in an audit process in regions with appropriate support and back up. It is ethical for pregnant women to choose to have home births only in such controlled situations, although it seems doubtful that home birth conveys a net benefit to the child even in low risk pregnancies.  

 

Benefits of home birth may primarily be for the benefit of the woman and this imposes risk to the baby. Either this risk should not be imposed or a justification must be made for a woman exposing her baby to morbidity for a delivery environment that is in her interests but not those of her baby.

There is legal justification for a mentally competent woman to choose an option that seems irrational or wrong to clinicians, even if the consequences are potentially fatal (Re MB (an adult: medical treatment) [1997] 2 FLR 426 (per Butler-Sloss LJ). But they should be advised of the risks. It is often unethical for women to elect for home birth; professionals should therefore not encourage it (though they should not prohibit it either). 

Acknowledgement: thanks to Tom Douglas for his input