AJOG anti-phb paper ~ section on Professionally Appropriate Responses
Professionally appropriate responses
What should obstetricians do to address the root cause of the recrudescence of planned home birth?
The first professional responsibility of obstetricians is to ensure that hospital delivery is safe, respectful, and compassionate.53, 54, 55, 56 Current, inappropriate practices may be fueling the recrudescence of planned home birth. Physician leaders need to closely scrutinize organizational policies and practices and should see to it that staffing is competent and adequate. Well-trained, compassionate in-house attending obstetric and anesthesia coverage should be required for all hospitals offering planned hospital delivery. Unnecessary obstetric interventions need to be assiduously prevented by adherence to evidence-based guidelines. 57, 58, 59
Teaching of noninvasive care and mode of delivery should become an essential part of training. Physician leaders must be especially watchful for trends of clinically unjustified increased intervention that results from inappropriate self-interest in reducing liability, convenience, or financial gain.44, 60
This focus on maternal and fetal safety should be complemented with an emphasis on compassionate care that respects pregnant women as persons by acknowledging and striving to meet their psychosocial needs. Home birth centers with immediate access to cesarean delivery, as well as collaborative practice models between obstetricians and nurse midwives should be encouraged.38, 39, 40, 41, 42, 43
The goal should be effective integration of clinically competent and empathetic obstetric care as presaged by the Scottish physician-ethicist John Gregory,61 more than 2 centuries ago, who called for physicians to be scientifically excellent and to exhibit “gentleness of manners, and a compassionate heart,” what Shakespeare calls “the milk of human kindness.”61
How should obstetricians respond when a woman raises the topic of planned home birth?
The increased risk of planned home birth is preventable by planned hospital delivery. Planned home birth should not be considered medically reasonable in professional clinical judgment. This clinical judgment should be respectfully communicated and the woman’s questions addressed in an evidence-based fashion.
Women should be informed of the high transport rate and the increased, preventable risks to herself, her fetus, and her infant, as well as the psychosocial harms of emergency transport. The obstetrician and other obstetric provider should recommend strongly against planned home birth and obtain informed consent for delivery in a safe and compassionate hospital environment or a birth center with immediate hospital access.
How should obstetricians respond to a woman’s request to participate in planned home birth?
For a woman who is nonetheless committed to planned home birth, the obstetrician should explain that professional responsibility prohibits participation in or facilitation of substandard clinical care.
The simple fact that a pregnant patient has made a request does not by itself create a professional responsibility to implement that request, especially when the request is for clinical management that is substandard.52
How should obstetricians respond when a patient is received on emergency transport from a planned home birth?
There is a strict professional obligation to provide excellent medical care in all obstetric emergencies. Without hesitation, therefore, the obstetrician should provide excellent, compassionate, emergency obstetric care to all pregnant women transported from planned home birth. Obstetricians have a compassion-based obligation to be aware to and address the psychosocial harms of such transport, in an attempt to ameliorate their long-term effects.
Should obstetricians participate in or refer patients to a randomized controlled clinical trial of planned home vs planned hospital birth?
Analysis of the safety data on home birth shows that there is an unacceptable risk to pregnant, fetal, and neonatal patients. Equipoise, an important ethical condition for initiating randomized controlled trials implies genuine uncertainty as to whether one treatment is better than another. For home birth, equipoise does not exist, because a controlled clinical trial with home birth as one arm would subject pregnant, fetal, and neonatal patients to preventable, unnecessary risk of mortality, morbidity, and disability when compared with hospital delivery. The fundamental ethical imperative in research with human subjects is to protect them from impermissible harm.62 This imperative would be violated by a randomized controlled clinical trial. This conclusion is made all the stronger when one realizes that fetal and neonatal patients are vulnerable subjects of research because they are incapable of consent and therefore cannot protect themselves. Randomized controlled clinical trials of planned home vs planned hospital birth violate research ethics. It is therefore impermissible for an obstetrician to participate in or refer patients to such trials.
How should professional associations of obstetricians respond to the recrudescence of planned home birth?
ACOG and RCOG should continue their important efforts to enhance patient safety and compassionate care for all hospital births and birth centers with immediate access to cesarean delivery. ACOG and RCOG should continue to support collaborative physician-midwife practices and strive for a home birth experience within the hospital.
Professional associations should also support policy changes and try to get an impact on health care politicians as demonstrated by the Steering Committee of Perinatal Care in the Netherlands. The Dutch minister of Health and Sports understood that 7 topics are essential to improve perinatal care in the Netherlands:
(1) to organize perinatal care with mother and child in the center,
(2) to introduce a proactive instead of a reactive care,
(3) to inform women about the importance of preconceptional heath,
(4) to promote collaborative practice, improve the quality of collaborative delivery, to make plans for the delivery if appropriate by a case-manager and increase visits at home after birth, reduce home delivery,
(5) to support national programs for prevention and care of women with poor psychosocial conditions,
(6) to not leave women alone from the first moment of delivery to the end, and
(7) that a woman can be reassured that at any time of the day or night any intervention that is necessary can be initiated within 15 minutes.”63
This last goal cannot now or in the foreseeable future ever be met by a home delivery.
Professional organizations should be willing to file amicus briefs in cases like the one decided by the European Court of Human Rights discussed earlier to ensure that courts take into account professional responsibility and integrity. Professional integrity and its implications for constraints on the rights of patients have played a major role in the reasoning of US state and federal courts about end-of-life decision making because the landmark decision In re Quinlan. Professional organizations should also reconsider their statements on planned home birth and bring them into line with professional responsibility, to prevent rights-based reductionism in obstetric ethics and practice.
Conclusion
Advocacy of planned home birth is a compelling example of what happens when ideology replaces professionally disciplined clinical judgment and policy. We urge obstetricians, other concerned physicians, midwives, and other obstetric providers, and their professional associations to eschew rights-based reductionism in the ethics of planned home birth and replace rights-based reductionism with an ethics based on professional responsibility.
