This is a continuation of yesterday’s post.
If you haven’t read part 1, drop to the bottom of this web page and use the “back to previous post” link.
Review of: “Planned home birth: the professional responsibility response”
Frank A. Chervenak, MD, et al
Presented at European Congress of Perinatal Medicine, Paris, France, June 13, 2012
“An editorial in Lancet succinctly summarized this point: “Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.”
My Comments:
These authors assert that definitive scientific facts have proven PHB to be so dangerous that it represents a totally irresponsible and unethical choice by the childbearing woman, by midwives and by any obstetrician or other physician who voluntarily cooperates with the mother-to-be or the midwife or any group that advocates for OOH midwifery that does not provide for immediate access to Cesarean surgery.
They use a number of studies designed and conducted by obstetricians, including the fruit of the poison tree — the Pang et al (Planned Home Births in Washington State, 2002 ), which later became the lynch pin of the Wax Meta-analysis which used it to conclude that neonatal mortality risk for PHB was 2 to 4-fold increased. It is interesting to note that the extremely long and important benefits to mothers report in the Wax paper are never considered to be worth of mention.
But based on their certitude of unmitigated risks to neonates as an irrefutable fact, the authors make the case that PHB it is a professionally irresponsible the practice of midwifery which is likewise irresponsible any individual or group to advocates for PHB.
For obstetricians who supporter or advocate for PHB, or provide any medical services, the authors recommend that such doctors be subject to professional censure by peer review, and “justifiably incur professional liability and sanction form state Medical board”.
They also believe that government policy makers who support PHB as a lawful activity parents and birth attendants should be exposed as threats to professional responsibility.
These conclusions are based on a complicated ethical premise that challenges that generally accepted right of women to make decisions about make decisions and control what happens to her own body, including decision relative to pregnancy and the choice of a planned home birth under the management of a midwives.
In currently accepted model, the physician is required, after fully-informed consent, to abide by the mother’s decision, even it the doctor him or herself does not see this as the best optioThis typical view of the obstetrician’s responsibility is identified as acknowledging and implementing “the patient’s preferences, without constraint”. They however dismisses this as a “purely contractual model of the physician-patient relationship in which the woman protects herself by the exercise of her autonomy-based rights”.
This is identified as “rights-based reductionism” and described as a false choice and subsequently rejected as an inferior basis for making childbirth-related decisions. According to these authors, the contemporary social perspective that currently respects the pregnant woman’s rights to make decisions about place-of-birth. While the paper argues that PHB is relatively risky, the woman’s unwelcome decision is specifically faulted because it “systematically overriding the professional care provider’s responsibility”.
They describe the childbearing woman as having subordinated physician’s obligation to protect her and her baby by making a decision that an obstetrically-trained physician believes to be is a bad decision. “The physician’s role is to identify and present medically reasonable alternatives for the management of pregnancy, ie, clinical management for which there is an evidence base of net clinical benefit.” This is seen as violating the “independent obligation, as a matter of professional integrity, to protect pregnant, fetal, and neonatal patients”.
They conclude that: “In a professional relationship, the physician’s integrity justifiably limits the woman’s rights by limiting the scope of clinically reasonable alternatives.” Beneficence-based and autonomy-based obligations combine to create the professional responsibility to empower the pregnant woman to make informed decisions.
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Here are the otherstatement on the idea that ethics for the obstetrical profession as a hierarchal circumstances in which obstetricians, as acknowledged ‘experts’ in childbirth, know what is better what is good for childbearing women than do those women themselves. What follows are only statement not already quoted in my commentary.
______________________________________________________
We fully support and endorse professionally responsible midwifery, but reject professionally irresponsible home-birth midwifery and advocacy of it.
Obstetricians who nonetheless do so should be subject to peer review and justifiably incur professional liability and sanction from state medical boards. Policy makers who do so should be exposed as threats to professional responsibility.
In summary, selective cost-effectiveness analysis is not consistent with professional responsibility and may seriously mislead public officials in policy deliberations about permitting and funding planned home birth.
Respect for women’s rights
There are 2 ways in which respect for women’s rights can be understood.
The first starts with the right of the woman to make decisions and control what happens to her body. The physician is bound to acknowledge and implement the patient’s preferences, without constraint. This is a purely contractual model of the physician-patient relationship in which the woman protects herself by the exercise of her autonomy-based rights.
“In a democratic society, a woman has the right to choose where she might undergo one of the most important experiences of her life, and where she will begin to bond with a child she will raise lovingly.”48
This is rights-based reductionism, in which the patient’s rights systematically override professional responsibility. In the resulting contractual relationship the physician’s obligation to protect the pregnant woman, much less the fetal and neonatal patient is completely subordinated to the woman’s rights.29
In a professional relationship the physician and other obstetric providers do have an independent obligation, as a matter of professional integrity, to protect pregnant, fetal, and neonatal patients.29, 49 T
These beneficence-based obligations must in all cases be balanced against autonomy-based obligations to the pregnant patient.
Beneficence-based and autonomy-based obligations combine to create the professional responsibility to empower the pregnant woman to make informed decisions about the management of her pregnancy and care of her newborn child.29, 50
The physician’s role is to identify and present medically reasonable alternatives for the management of pregnancy, ie, clinical management for which there is an evidence base of net clinical benefit.
In a professional relationship, the physician’s integrity justifiably limits the woman’s rights by limiting the scope of clinically reasonable alternatives.
This limitation does not exist in the rights-based reductionist model of women’s rights.
In the professional responsibility model of decision making, the patient has the right to select from among the medically reasonable alternatives.
If she rejects them all and also remains a patient, then her refusal is not a simple exercise of a negative right to noninterference.
Her refusal is more complex, because it is coupled with a positive right to the services of clinicians and the resources of health care organizations and society.51
In all ethical theories positive rights come with limits.
In the clinical setting ethically justified limits originate in professional integrity, because professional integrity prohibits provision of clinical management that is not safe.52
In summary, 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.
An editorial in Lancet succinctly summarized this point: “Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.”
Professionally appropriate responses
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
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.
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.
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.
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
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 [i.e. current ideas of patient autonomy and a woman’s right to be fully informed and subsequently make reproductive healthcare decisions] in the ethics of planned home birth and replace rights-based reductionism with an ethics based on professional responsibility.
An editorial in Lancet succinctly summarized this point: “Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.”
