Reply: To PMID 23151491

Letters to the Editors www.AJOG .org Redefining ethics in home birth TO THE EDITORS: In a recent opinion piece, “Planned home birth: the professional responsibility response,” Chervenak et al1 argue against the ethics of home birthing stating that advocates of planned home birth have emphasized 4 points: patient safety, patient satisfaction, costeffectiveness, 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.” Regarding patient safety, the authors say, “Maternal and fetal necessity for transport during labor is often impossible to predict.” Home birth women by definition are selected based on their health. They labor as nature intended without interventions. In experienced hands, transport is rarely “impossible” to predict. The authors state the most common reasons for transport are pain relief and prolonged labor, neither being unsafe. The argument against home birth in the United States continues by presenting safety data from South Australia, a system that has no resemblance here. The authors state, “It is antithetical to professional responsibility to intentionally assign any damaged or dead pregnant, fetal, or neonatal patient to this category, even if the number is small.” Yet ample evidence exists that similar cohorts of normal women delivered out of hospital vs a hospital have cesarean section rates of 6% and 24%,2 respectively. By that standard the increased morbidity of the hospital model if held to the same standard would be professionally irresponsible. Regarding patient satisfaction, the authors assume the high rates of transport undercut the raison d’être of planned home birth. A Dutch study from 2008 showing persistent levels of frustration for up to 3 years in 17% of transported women is cited.3 That implies an 83% satisfaction rate. A fairer comparison would be the satisfaction rate of US women with successful home vs hospital births. I disagree with the solution of supporting “homebirth-like” environments in the hospital setting. Minimal savings in cost comparison data from Britain are cited, vs US cost comparisons. The cost of a typical home birth in the United States is about 35% of that in hospitals. Savings over a cesarean birth approach 80%.4 When cesarean section rates approaching 35%5 are factored in, the savings is even more significant. Regarding women’s rights, the authors avoid using the beneficence-based model of ethics which, as with vaginal birth after cesarean, supports a woman’s reasonable choice.6 Instead it is stated, “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.” But home birth advocates do not support unconstrained rights or rights-based reductionism.- Stuart James Fischbein, MD Sanctuary Birth and Family Wellness Center 11965 Venice Blvd., Suite 307 Los Angeles, CA 90066 angelfi[email protected] The author reports no conflict of interest. REFERENCES 1. Chervenak FA, McCullough LB, Brent RL, Levene MI, Arabin B. Planned home birth: the professional responsibility response. Am J Obstet Gynecol 2013;208:31-8. 2. Stapleton SR, Osborne C, Illuzzi J. Outcomes of care in birth centers: demonstration of a durable model. J Midwifery Women Health 2013;58: 3-14. 3. Rijnders M, Baston H, Schonbeck Y, et al. Perinatal factors related to negative or positive recall of birth experience in women 3 years postpartum in the Netherlands. Birth 2008;35:107-16. 4. Childbirth Connection. Transforming maternity care. Average charges for giving birth: state charts. Available at: http://transform.childbirthconnection. org/resources/datacenter/chargeschart/statecharges/. Accessed April 22, 2013. 5. Martin JA, Hamilton BE, Ventura SJ, et al. Births: final data for 2010. Natl Vital Stat Rep 2012;61:4-5. 6. Charles S. The ethics of vaginal birth after cesarean. Hastings Cent Rep 2012;42:24-7. ª 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 2013.04.025 REPLY Dr Fischbein claims that our criticism of planned home birth from the perspective of the professional responsibility of obstetricians does not succeed. Ethical analysis of planned home birth, like ethical analysis of all topics in obstetric and medical ethics, should be both evidence-based and argumentbased.1 On the topic of patient safety, Dr Fischbein states that the need for transport can be predicted in “experienced hands” but provides no documentation for this claim. The Birthplace in England study reported on transport rates as high as 45%.2 Dr Fischbein bears the burden of proof to identify evidence-based criteria for the reliable prediction of the need for transport and fails altogether to meet this professional obligation. He then states that “pain relief and prolonged labor” do not indicate unsafe clinical conditions, again without supporting documentation. The claim that the experience in another country does not apply in the United States requires Dr Fischbein to demonstrate the disanalogy, which he does not do. Dr Fischbein states that a cesarean delivery rate in the hospital setting of 24% results in an unacceptable increased morbidity when compared to the out-of-hospital cesarean delivery rate of 6%. As applied to planned home birth, the claim is absurd, inasmuch as cesarean deliveries are not performed SEPTEMBER 2013 American Journal of Obstetrics & Gynecology 279 Letters to the Editors in the home setting. Even if the comparison were not absurd, simply reporting the rates of a procedure in the absence of outcomes data does not count as evidence-based reasoning. Worse, the paper that Dr Fischbein cites provides outcomes data on care in birth centers.3 Planned birth at home, the focus of our paper, is not planned birth at a birth center. The outcomes in the latter cannot be represented as the outcomes of the former. The disanalogy is obviouseand egregious. Regarding patient satisfaction, our point in citing the Dutch experience waseand remainsethat in one of the most highly developed home birth systems in the world there are significant rates of failure to achieve patient satisfaction. A dissatisfaction rate of 17% is high per se and therefore intrinsically clinically significant. Asserting the obvious corollary of 83% satisfaction should be read for what it is: an attempt to distract the reader from a substantial, documented problem with planned home birth. Dr Fischbein then states that he disagrees with national efforts to improve the homelike setting of hospital delivery without any supporting reasons. Asserting conclusions in the absence of supporting reasons is what Platoelong agoehad Socrates in the Dialogues characterize as “mere opinion,” which never counts as argument-based reasoning. As to cost-effectiveness, we emphasized that analyzing the cost of home birth by comparing charges for home birth to charges for hospital birth is incomplete and therefore potentially misleading. Dr Fischbein’s invocation of relative costs of vaginal vs cesarean delivery does not address relative overall cost. His claims about comparative cost are therefore incomplete and misleading. As to women’s rights, Dr Fischbein invokes the ethical analysis of vaginal birth after cesarean delivery by Charles,4 who argues that the autonomy of pregnant women is justifiably constrained by the professional judgment of obstetricians about what is medically reasonable.4 Dr Fischbein neglects to inform his reader that Charles4 bases her argument explicitly on our approach to obstetric ethics. Having rejected our approach (albeit without any supporting argument), Dr Fischbein invokes a paper based on it. Dr Fischbein succeeds in both deceiving his reader and violating the principle of noncontradiction. This principle forbids simultaneously holding a proposition and its denial to be true and is therefore a disabling mistake in both evidence-based and argument-based reasoning. www.AJOG.org Planned home birth is a serious topic in obstetric ethics. Judgments about its ethical acceptability must therefore be deliberativeeexplicitly appealing to the results of evidencebased and argument-based reasoning.5 Dr Fischbein’s letter does neither and therefore makes no serious contribution to how obstetricians should understand their professional responsibility concerning planned home birth. Frank A. Chervenak, MD Weill Medical College of Cornell University 525 East 68th St. New York, NY 10065 [email protected] Laurence B. McCullough, PhD Baylor College of Medicine Robert L. Brent, MD, PhD Thomas Jefferson University Malcolm I. Levene, MD Leeds University Amos Grünebaum, MD Weill Medical College of Cornell University Birgit Arabin, MD Philipps University The authors report no conflict of interest. REFERENCES 1. McCullough LB, Coverdale JH, Chervenak FA. Argument-based ethics: a formal tool for critically appraising the normative medical ethics literature. Am J Obstet Gynecol 2004;191:1097-102. 2. Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400. 3. Stapleton SR, Osborne C, Illuzi J. Outcomes of care in birth centers: demonstration of a durable model. J Midwifery Womens Health 2013;58: 3-14. 4. Charles S. The ethics of vaginal birth after cesarean. Hastings Cent Rep 2012;42:24-7. 5. Chervenak FA, McCullough LB, Brent RL, Levene MI, Arabin B. Planned home birth: the professional responsibility response. Am J Obstet Gynecol 2013;208:31-8. ª 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 2013.04.026 Planned home birth: the professional responsibility responseea midwifery response TO THE EDITORS: The clinical opinion related to planned home birth by Chervenak et al1 requires a midwifery response. Home birth is a complex choice that includes the rights of women over their bodies; these rights do not go away because 280 American Journal of Obstetrics & Gynecology SEPTEMBER 2013 health professionals or governments ban them. The authors suggest that women’s rights should be superseded by the clinician’s obligation to protect the pregnant woman and the “fetal, neonatal patient.” This paternalistic discourse privileges