There is a sense in the United States that a woman has a right to give birth in the hospital. In fact, most people can’t imagine giving birth anywhere else. Fewer than 2% of births in the U.S. occur outside of a hospital. Hospitals are required to accept birthing women–even undocumented immigrant women receive emergency Medicaid to cover the cost of a hospital birth. Insurance policies often do not cover homebirth but they are required to cover hospital birth. While some state Medicaid programs cover homebirth (e.g. Washington), most do not. But does a woman have the same right to birth at home that she does to birth at a hospital?
Working through ACOG and its journal, Obstetrics and Gynecology (aka The Green Journal), obstetricians vociferously push their view that homebirth is dangerous. While there certainly may be dangers in birthing at home, recent studies have relied on birth certificate data to indicate dangers. Marian McDorman, a senior statistician with the National Center for Vital Statistics, has said repeatedly (most recently in the Daily Beast) that vital records data are not appropriate for research: “There are quite a few limitations in using that data for that kind of analysis.” Vital Statistics reports are descriptive in nature for this reason.
In a recent workshop I attended on linking Vital Statistics data with Medicaid claims, the statistician leading the workshop pointed out flaws in a recent study of Apgar scores and neonatal seizures in home, hospital, and birth center births. Among the flaws: hospital birth certificates are generally filled out within 24 hours (while for home births, they are generally filled out later), thus truncating the time during which a seizure could be reported for a hospital birth. A senior statistician for the state of Washington also pointed out that homebirth midwives reliably fill out every field in the birth certificate while most hospitals rarely do.
It is hard to tell whether hospital birth is really safer than homebirth (or vice versa) for low risk births. Politics take over the debate, and women are left with rhetoric rather than information. For high risk births, however, there is some agreement from both sides that the intrapartum and neonatal death rates* are higher when a woman births at home.
High risk births include breech presentation, vaginal birth after cesarean (VBAC), maternal complications such as preeclampsia or gestational diabetes, and multiple gestations (e.g. twins). While women in these circumstances are more likely to be subjected to interventions in the hospital that may be unnecessary, they and their babies have a lower risk of dying in the hospital. These high risk conditions sometimes result in complications that simply cannot be handled adequately at home and may not present in such a way that a hospital transfer can occur in time.
Death is the ultimate negative outcome in medicine. Long term disability for the infant or woman is also a poor outcome. While medicine acknowledges short term morbidities such as maternal hemorrhage or neonatal respiratory distress, these are generally not taken particularly seriously as long as everyone appears to be all right in the long run.
The question is then, should women who are well informed of the risks and benefits of home vs. hospital birth be allowed to choose where to birth?
At the Institute of Medicine Birth Settings Workshop, I chatted with a number of Certified Professional Midwives (CPMs), the kind of midwives who generally attend births only outside of a hospital. I asked if they were willing to attend high risk home births, such as breech births. They replied that the choice of birth setting was entirely up to the woman. They explain the risks thoroughly, and if the woman still chooses to birth at home, they will attend her.
ACOG’s official position is remarkably similar: a woman may make choices that entail risk, even if the doctor does not agree, and should not be prosecuted or persecuted for her choices (though that doesn’t mean the doctor should provide the care). Among their recommendations in their Committee Opinion, “Maternal Decision Making, Ethics, and Law,” is
Pregnant women’s autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman’s broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman’s autonomy.
ACOG’s Committee opinion, “Planned Home Birth” even reluctantly acknowledges a woman’s right to birth at home: “Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery.” (Though they do not support physicians’ attending home births.)
In an ironic twist, ACOG supports physicians who actively act in ways they believe are not in the best interests of a woman’s health as long as they explain the risks to the woman and she still wants the procedure. While they are not obligated to perform the procedure, ACOG’s Committee Opinion, “Elective Surgery and Patient Choice,” says it is ethical for the physician to perform operations such as ovary removal or cesarean section on patient request.
In addition, as Marian McDorman has pointed out, even in high risk situations, the absolute risk of a bad outcome from homebirth is very small. I would point out that in contrast, the absolute risk of unnecessary clinical intervention in hospitals (and associated morbidities), including administration of high alert medications such as Pitocin and unnecessary cesarean surgery, is very, very high. In the case of a woman wishing to have a VBAC, the chance of of cesarean in a given hospital may be 100%, even if the woman meets ACOG criteria for safe VBAC.
Personally, I would choose to birth at the hospital if my pregnancy indicated that my birth would be high risk. But that is my choice. I would not want someone to force me to birth at home because that person thought that the relative risk of morbidity at the hospital was higher than that of death at home, or because hospital birth in the U.S. is outrageously (and unnecessarily) expensive, or because some hospitals cannot be trusted to act in the woman’s best interests as a matter of policy, or because U.S. hospital births have among the worst maternal and infant outcomes in the developed world.
A practitioner does not have to attend a high-risk homebirth (or any homebirth), just as a practitioner is not obligated to perform a maternal request cesarean. But if it is not wrong to put a woman and infant at risk from unnecessary surgery because the woman believes that is the best decision for herself, then why is it wrong to support a woman in homebirth if she believes that is the right decision?
We need to separate ethics, which are often personal, from the law, which is universal. As long as a woman’s body is her own, she has the right to determine where it should be, when she is giving birth, and always.
*The intrapartum rate refers to deaths during labor and delivery; the neonatal rate technically refers to the first 28 days, but it is often truncated to refer to the first 24 or 48 hours. A study should explain which definition it is using.