AJOG ~ “Planned home birth: the professional responsibility response” ~ the latest anti-PHB in ACOG’s war

by faithgibson on January 5, 2013

in Contemporary Childbirth Politics

Planned home birth: the professional responsibility response

Presented at European Congress of Perinatal Medicine, Paris, France, June 13, 2012.

  • Frank A. Chervenak, MD, Laurence B. McCullough, PhD, Robert L. Brent, MD, PhD, DSc (Hon), Malcolm I. Levene, MD, FRCP, FRCPH, F Med Sc, Birgit Arabin, MD

 Full Text 


This article addresses the recrudescence of and new support for midwife-supervised planned home birth in the United States and the other developed countries in the context of professional responsibility. Advocates of planned home birth have emphasized patient safety, patient satisfaction, cost effectiveness, and respect for women’s rights. We provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth. We start with patient safety and show that planned home birth has unnecessary, preventable, irremediable increased risk of harm for pregnant, fetal, and neonatal patients. We document that the persistently high rates of emergency transport undermines patient safety and satisfaction, the raison d’etre of planned home birth, and that a comprehensive analysis undermines claims about the cost-effectiveness of planned home birth. We then argue that obstetricians and other concerned physicians should understand, identify, and correct the root causes of the recrudescence of planned home birth; respond to expressions of interest in planned home birth by women with evidence-based recommendations against it; refuse to participate in planned home birth; but still provide excellent and compassionate emergency obstetric care to women transported from planned home birth. We explain why obstetricians should not participate in or refer to randomized clinical trials of planned home vs planned hospital birth. We call on obstetricians, other concerned physicians, midwives and other obstetric providers, and their professional associations not to support planned home birth when there are safe and compassionate hospital-based alternatives and to advocate for a safe home-birth-like experience in the hospital.

There has been a recrudescence of and new support for planned home birth in the United States and other developed countries. The Centers for Disease Control report that from 2004 to 2009 home births in the United States rose by 29%, increasing from 0.56% to 0.72% of all births or 29,650 home births.1 There is also evidence that vaginal birth after cesarean delivery is increasing at home in the United States.2 Planned home birth for breech presentation has been defended as a legitimate option.3 Private midwives who provide home birth services have even become “status symbols.”4

Home birth rates in Europe and Australia vary over time and in different countries or provinces. In the Netherlands, home birth has been traditionally the first choice for so-called uncomplicated pregnancies, performed by midwifes or general practitioners. Moreover, women have to pay an extra amount (around €250) when deciding for a “nonindicated hospital birth” under the guidance of an obstetrician and even when they decide for a midwifery-guided delivery within the hospital. Nevertheless, the home birth rate in the Netherlands has decreased during the past 20 years from 38.2% (1989-91) to 23.4% (2008-10), mostly because of the increasing awareness of the media, patients, and obstetricians about the risks of home birth.5 In the United Kingdom 3% of total births occur at home, although less than half are planned.6 In Sweden, the estimated proportion of planned home births was 0.38 of 1000 of all term births.7

In Germany, more than 98% of all deliveries occur within hospitals, but the absolute number of deliveries in nonobstetric units is rising. Between 2000 and 2010, the absolute number of home births dropped from 4303 to 3587, but the number of deliveries in 138 certified freestanding midwifery unit settings rose from 4475 to 6775 per year as documented by the midwifery quality documentation system (abbreviated as QUAG).8 Seventy-four percent of these midwifery units perform less than 70 deliveries per year, and only 9% perform more than 155 per year. According to German law it is even accepted that the planned delivery of a singleton breech or twins can take place at home, if an obstetrician is present at delivery.

Professional organizations in most European countries favor hospital birth and their insurance systems pay for it. Nevertheless, planned deliveries within midwifery units or even at home are accepted and paid for, although the incidence of these deliveries is in general less than 2%.

In 2010, the European Court of Human Rights ruled on a case originating in Hungary in which it was argued that Hungarian law on home birth “dissuaded” health care professionals from assisting home birth in violation of the plaintiff’s “right to respect for her private life.” The Court found for her and stated that “the right of the decision to become a parent includes the right of choosing the circumstances of becoming a parent” and this encompasses professional assistance in home birth.9 The implications of this court ruling for clinical practice throughout Europe have not been fully assessed.

In 2011, the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives issued the following statement: “The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families.”10 Also in 2011, the American College of Obstetricians and Gynecologists (ACOG) stated that “it respects the right of a woman to make a medically informed decision about delivery.11

These recent statements by professional associations and by the European Court should not be allowed to stand unchallenged, because the positions taken about planned home birth, in our view, are not compatible with professional responsibility for patients. The advocates of planned home birth emphasize (1) patient safety, (2) patient satisfaction, (3) cost-effectiveness, and (4) respect for women’s rights. The purposes of this paper are to critically evaluate each of these claims and to identify professionally appropriate responses of obstetricians and other concerned physicians to each claim and therefore to planned home birth.

Sections on

Patient safety

Patient satisfaction


Respect for women’s rights

Professionally appropriate responses


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