Arguably, no discipline is more exposed to ethical dilemmas than obstetrics. Homebirth is one important example, but many of the ethical principles can be applied broadly.
Obstetricians make decisions: planned vaginal delivery or elective caesarean section? Induce or await spontaneous labour? Instrumental delivery or emergency caesarean section? All of these types of decisions are made many times each day by clinicians equipped with the necessary knowledge and skills. The fundamentals that allow such decisions to be made are instilled during training and later enhanced by clinical experience. Such is the College way. But do Fellows perform equally well when the decision is one of professional ethics?
In basic ethical terms, a decision to provide homebirth can be seen as a balance between beneficence (doing good) and maleficence (doing harm). If the balance favours harm, it should not be offered, given that the mere provision of a service by a ’respected‘ authority (in other words, a health practitioner or health service) is likely to be interpreted as imputing a level of risk acceptable to most women. For example, most of us could not even guess the risk of aircraft failure mid-flight. We make the assumption that the experts providing the service have determined the risk tolerance as acceptable to passengers. Can the same be said for homebirth?
The beneficence and maleficence of homebirth
Birthing in a familiar environment has obvious appeal. However, a greater beneficence in homebirth may derive from a desire for personal achievement. Summiting Everest comes at huge personal risk, with perhaps one in 20 not returning, but for some the enormity of the personal achievement justifies such a risk. Provide a challenge and someone will want to overcome it. I believe that homebirth has become a challenge.
Maleficence in homebirth derives from cases where there is an adverse outcome for mother or child that would have been avoided by hospital birth. The frequency of these events is described elsewhere, but a claim that these events do not occur in low-risk populations is untenable. They clearly do occur – and at a measurable frequency.
A further and less-defined maleficence comes from a potential impact of resource utilisation on other users of the health system. Difficulties experienced by the ambulance service are well publicised. Demands on emergency services at the receiving hospital are just as real and can impact on other patients. It is not a matter of whether this ever occurs, but how often. The frequency of emergency transfer from home to hospital remains considerable even after careful selection of patients. We train (and examine) our registrars in skillful management of labour ward to minimise the likelihood of simultaneous emergencies. The unexpected transfer from a homebirth bypasses that important safeguard.
Is it ethical to provide medical support for homebirth that is undertaken despite recommendations to the contrary? Here is the most obvious of dilemmas. In the event of unexpected complications of homebirth, the provision of emergency care is an obvious ethical obligation. However, provision of a ’back-up‘ service may lead to more women choosing homebirth than would otherwise do so. More homebirths would potentially result in an overall net increase in bad outcomes compared to the situation where back up is not provided.
The maleficence of a ’comprehensive back-up‘ service is maximised where it is mischievously portrayed as moving the risk profile to that of a hospital birth. The image is created of some sort of superior homebirth service that has made a Rolls-Royce out of a car with poor brakes, no seat belts and a zealot at the wheel. Mostly the latter will still reach their destination – but few would suggest it is wise to do so.
The only solution to this ethical dilemma is the provision of passive support. Mostly this is in terms of transfers from home to a public hospital. This is not easily portrayed as obstetricians supporting homebirth and represents a suitable ethical compromise.
Is it wise to polarise the community view of homebirth?
As indicated previously, a major incentive for homebirth enthusiasts is a simple human response to a challenge. Allowing that challenge to be politicised into homebirthers versus the rest creates a mindless frenzy resembling a collective of the least presentable football supporters. Add to this recipe, a substantive measure of perceived deliberate misinformation from the other side and the value of the personal satisfaction side of the decision equation rises to fever pitch.
Why do so many of our colleagues consistently exaggerate the risks of homebirth? The outcomes are quite bad enough, but it is a simple fact that the vast majority of women who attempt homebirth will accomplish that end without harm. Almost all women contemplating birth at home will know women who have had a successful homebirth experience. To directly or indirectly impute that a bad outcome is inevitable, or even likely, immediately destroys professional credibility. Further discussion becomes futile. Much wiser if the obstetrician advocates a risk-avoidance position aided by appropriate analogies. If you choose homebirth you are still likely to reach your destination, but was it a wise thing to do?
The fetus gains exponentially in status as pregnancy advances from its beginnings as a fertilised egg through to a term pregnancy, but even a term infant is not valued at the same level as an older child. This is true both in a legal sense (in other words, no legal protection to prevent the mother acting against the interests of the fetus; no coronial powers for investigation of late fetal death) and also from the commonly accepted risk tolerance in the course of normal obstetric practice (for example, attempting vaginal birth after a previous caesarean delivery).
To argue on the grounds of potential death to the child will be hugely influential for some women, but much less of a priority for others.3 For the latter group, the child itself may have little in the way of its own ethical rights. A much stronger influence may come from the prospect of caring for a disabled child – seeing it not from the child’s perspective but from the impact on their own lifestyle. But, do we as a profession acknowledge this outcome as a possible consequence of risk-prone obstetric practice?
Is it wise to deny pregnancy care at term as a potential cause of long-term disability? Legal determinations and clinical experience would suggest that for many parents, a potential for long-term disability of their child is a very influential factor in decision-making around birth choices. Yet many of our profession engage in an enduring campaign of misinformation with respect to late pregnancy management and the causation of life-long disability. Some actually believe there is no causation. The much quoted Blair and Stanley paper attributed approximately ten per cent of cerebral palsy to intrapartum events.4 A parallel literature suggests severe intellectual and/or motor disability in approximately 50 per cent of survivors of hypoxic ischaemic encephalopathy (HIE) at term5, which in turn can be expected in 1000–2000 term births.6 As evidenced by these figures, long-term disability is fortunately an uncommon outcome with modern pregnancy management. However, to think or indicate that pregnancy care at term is not a potential causal factor in long-term disability is both erroneous and dangerous.
Is it wise to have a restricted view of evidence?
The next mistake that indirectly advocates for homebirth is an unhealthy obsession with the randomised controlled trial (RCT). There is a common failure to appreciate that RCTs are the least appropriate evidence to use in situations where the outcome is rare, but of high clinical importance. The broader medical profession is widely complicit in this most obvious of errors, but fortunately there are researchers advocating a broader view evidence.7-9 If a more sensible approach to evidence is taken, patient care will only benefit and give obstetric practice greater credibility in areas where serious adverse outcomes are rare but calamitous. For example, where an epidemiological overview observes an unusually high number of deaths in association with homebirth, that evidence requires serious consideration. This is all the more so where there is an underlying premise that the patients who are selected for homebirth have a lower risk profile.
The cost of obstetric mishaps and their causation
If the community assesses the cost of an adverse outcome to be high, there is a strong financial incentive to be risk averse with respect to that activity. A powerful tool in the promotion of homebirth would be a decision to subsidise professional indemnity premiums for homebirth midwives. However, such a subsidy perverts market forces that would assign a true cost to risk-prone professional activities. Yet most obstetricians benefit from various indemnity subsidies and those that practice in a more risk-averse manner go largely unrewarded in terms of lower premiums.
In the public sector, there are even greater distortions. A CEO is financially rewarded for overbooking obstetric numbers, reducing medical staffing and other risk-prone activities. The true cost of bad decisions is hidden by public hospital insurers that poorly relate hospital premiums to the cost of adverse outcomes, therein promoting bad administration. This fallacious management also applies to public hospital-supported homebirth, in that the community pays for the adverse outcomes while the health administrator reaps the financial reward resulting from freeing up a hospital bed.
No-fault compensation is a very worthy goal. Those with genetic, postinfective or traumatic disability are deserving of much improved support. However, should parallel legislation simultaneously reduce recourse to legal action in the event of risk prone professional behaviours, an inhibitor of these practices is subdued.
Unwise or unethical?
To conclude that the beneficence of homebirth outweighs the maleficence is mostly to be blinkered by a professional fervour that has clouded good clinical judgement. How could it ever be that a quanta of great homebirth experiences could compensate for a single parent denied the immeasurable and repeated joys of raising a healthy child? But to fault the parents is unfair. Almost without exception, they are guided by health professionals in whom they trust – as it happens, unwisely.
So is the health administrator unethical when he/she advocates for homebirth, knowing that there may be praise and even reward from factions within the health department? Is the health professional unethical when he/she declares a patient to be low risk and not
in need of modern obstetric care? Is it even more unethical if the motivation (consciously or subconsciously) is to gain personal advantage as the primary provider of maternity care, protecting the patient from unnecessary medical intervention?
In my view, these are not examples of unethical behaviours. They are the product of distorted thinking that advantage their own position – rationalisation. When these thoughts are further ratified by colleagues of similar disposition, the delusion is reinforced. They are unwise. Practitioners ascribing to such ideologies have not dared to closely scrutinise their rationalisation and show it to be false. The obstetric profession must lead the homebirth debate with a wisdom it is yet to show.