Redefining Ethics.
Truth or Tyranny?
In a recent opinion piece published earlier this year in the
AJOG, “Planned Home Birth: The Professional Responsibility Response”,
Chervenak, et al(1) argue against the ethics of home birthing stating that advocates
of planned home birth have emphasized 4 selling points: patient safety, patient satisfaction, cost effectiveness, and respect for
women’s rights. “{The Authors} provide a critical evaluation of each of
these claims and identify professionally appropriate responses of obstetricians
and other concerned physicians to planned home birth.” Most of what followed in the rest of his article was neither
inductively or reductively logical.
As to point 1,
patient safety, he says, “Maternal and fetal necessity for transport during
labor is often impossible to predict.” Home birth women by
definition are cherry picked for their health. They are allowed to labor as
nature intended without interventions. In experienced hands, transport is rarely
“impossible” to predict. He states the most common reasons for transport are
pain relief and prolonged labor, neither being unsafe. He continues his
argument against home birth in America by presenting safety data from South
Australia, a system that has no resemblance here.
He summarizes his
anti-safety position this way: “It is antithetical to professional responsibility
to intentionally assign any damaged or dead pregnant, fetal, or neonatal
patient to this category, even if the number is small.” Yet ample evidence
exists that similar cohorts of normal women delivered out of hospital vs.
hospital have c/section rates of 6% and 24% respectively (2). By the author’s very
own words then, the increased morbidity of the hospital model if held to the
same standard would be professionally irresponsible.
As to point 2, patient satisfaction, he assumes the high rates of transport
undercut the raison d’etre of planned home birth. He cites a Dutch study from
2008 showing persistent levels of frustration for up to 3 years in 17% of
transported women. Conversely, that would seem to imply an 83% satisfaction
rate. A fairer comparison would be the satisfaction rate of American women with
successful home birth vs. hospital birth, but none was made. His solution of
supporting “homebirth-like” environments in the hospital setting, sadly, shows
a complete lack of understanding of mammalian birth.
As to point 3, cost effectiveness, he cites minimal savings in cost comparison
data from Britain. Again, the author is using foreign data from a country with single-payer, socialized medicine when a simple Google
search easily produces reliable American cost comparison data. This tactic is most concerning in its dishonesty.
The cost of a typical home birth here is about a third of that in hospitals.
Savings over a cesarean birth approach 85% (3). When c/section rates
approaching 35% in the hospital setting are factored in the cost savings is
significant.
Finally, as to point 4, respect for women’s rights, Dr. Chervenak makes the classic straw man
argument. He avoids altogether using the beneficence based model of
ethics which, as with VBAC, supports a woman’s reasonable choice (4). Instead he states, “From the perspective of
the professional responsibility model, insistence on implementing the unconstrained
rights of pregnant women to control the
birth location is an ethical error and therefore has no place in professional
perinatal medicine.” But home birth advocates don’t support unconstrained
rights or rights based reductionism. Dr. Chervenak has created a whole new
theory of ethics, “professional responsibility ethics”, which in his opinion
trumps beneficence based ethics and respect for patient autonomy.
Skewed evidence, selection bias, straw men and anecdotes do
not equal data but that is what is presented by the authors as an ethical argument
against home birthing. This group of well credential authors has written an
article that is more propaganda than evidence based opinion. They might as well
have said, ACOG thinks home birth is very, very bad and asked us to make up an
argument on their behalf.
1. Chervenak,
FA, et al. Planned Home Birth: the professional responsibility response. Am J Obstet Gynecol. 2013 Jan;208(1):31-8
4. The Hastings Center Report:
“The Ethics of Vaginal Birth After Cesarean”, Sonya Charles http://www.medscape.com/viewarticle/767504_3
Stuart J. Fischbein, MD FACOG
Medical Director, Sanctuary Birth & Family Wellness
Center
Los Angeles, CA
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