Planned home birth: The professional responsibility response

Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY.
American journal of obstetrics and gynecology (Impact Factor: 4.7). 11/2012; 209(3). DOI: 10.1016/j.ajog.2012.10.002
Source: PubMed


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.

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Available from: Laurence B Mccullough,
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    • "It affects millions of women, neonates and families every year. It is a field in which debates around the risks and benefits of risk-aversion for the well-being of mothers and their babies are especially heated, persistent, and polarised (Cahill, 2001; Chervenak et al., 2013). It was the first health care area to systematically use the classic EBM technique of systematic reviews of randomised controlled trials to create a standardised evidence base for care, and, as such, it was the foundation for the creation of the Cochrane Collaboration. "
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    ABSTRACT: The linear focus of 'normal science' is unable toadequately take account of the complex interactions that direct health care systems. There is a turn towards complexity theory as a more appropriate framework for understanding system behaviour. However, a comprehensive taxonomy for complexity theory in the context of health care is lacking. This paper aims to build a taxonomy based on the key complexity theory components that have been used in publications on complexity theory and health care, and to explore their explanatory power for health care system behaviour, specifically for maternity care. A search strategy was devised in PubMed and 31 papers were identified as relevant for the taxonomy. The final taxonomy for complexity theory included and defined 11components. The use of waterbirth and the impact of the Term Breech trial showed that each of the components of our taxonomy has utility in helping to understand how these techniques became widely adopted. It is not just the components themselves that characterise a complex system but also the dynamics between them. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Midwifery 06/2015; 31(9). DOI:10.1016/j.midw.2015.05.009 · 1.57 Impact Factor
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    • "He describes the operation of self-regulation and the power to remove practitioners, as means of ensuring professional orthodoxy in the control of birth by professionals. That orthodoxy is made explicit in the USA, for example by Chervenak et al. (2013) who actively espouse professional dominance in the management of birth, including overriding the home birth requests of pregnant woman. Chervenak et al. are explicit in their call to enforce professional dominance in birth as a norm and propose that any professionals or policy makers who condone home birth should themselves be sanctioned. "
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    ABSTRACT: Purpose ‐ The purpose of this paper is to describe what it is like to be a midwife in the professionally isolated and marginalised arena of home birth in Ireland and to explore whether the organisation of home birth services and professional discourse might be undermining the autonomy of home birth midwives. Design/methodology/approach ‐ This paper is drawn from auto-ethnographic field work, with 18 of the 21 self-employed community midwives (SECMs) offering home birth support to women in Ireland from 2006 to 2009. The data presented are derived from field notes of participant observations and from interviews digitally recorded in the field. Findings ‐ Home birth midwives must navigate isolated professional practice and negotiate when and how to interface with mainstream hospital services. The midwives talk of the dilemma of competing discourses about birth. Decisions to transfer to hospital in labour is fraught with concerns about the woman's and the midwife's autonomy. Hospital transfers crystallise midwives' sense of professional vulnerability. Practical implications ‐ Maternity services organisation in Ireland commits virtually no resources to community midwifery. Home birth is almost entirely dependent upon a small number of SECMs. Although there is a "national home birth service", it is not universally and equitably available, even to those deemed eligible. Furthermore, restrictions to the professional indemnification of home birth midwives, effectively criminalises midwives who would attend certain women. Home birth, already a marginal practice, is at real risk of becoming regulated out of existence. Originality/value ‐ This paper brings new insight into the experiences of midwives practicing at the contested boundaries of contemporary maternity services. It reveals the inappropriateness of a narrowly professional paradigm for midwifery. Disciplinary control of individuals by professions may countermand claimed "service" ideologies.
    08/2014; 3(2). DOI:10.1108/JOE-03-2013-0005
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    • "Since many women with a planned home birth are transferred during labour, these negative experiences might overshadow the positive experiences of women giving birth at home, resulting in an overall reduced sense of control for women planning a home birth. This was also suggested recently, in a clinical opinion report [11]. However, there was no evidence until so far to support this. "
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    ABSTRACT: In the Netherlands, low risk women receive midwife-led care and can choose to give birth at home or in hospital. There is concern that transfer of care during labour from midwife-led care to an obstetrician-led unit leads to negative birth experiences, in particular among those with planned home birth. In this study we compared sense of control, which is a major attribute of the child-birth experience, for women planning home compared to women planning hospital birth under midwife-led care. In particular, we studied sense of control among women who were transferred to obstetric-led care during labour according to planned place of birth: home versus hospital. We used data from the prospective multicentre DELIVER (Data EersteLIjns VERloskunde) cohort-study, conducted in 2009 and 2010 in the Netherlands. Sense of control during labour was assessed 6 weeks after birth, using the short version of the Labour Agentry Scale (LAS-11). A higher LAS-11 score indicates a higher feeling of control. We considered a difference of a minimum of 5.5 points as clinically relevant. Nulliparous- and parous women who planned a home birth had a 2.6 (95% CI 1.0, 4.3) and a 3.0 (1.6, 4.4) higher LAS score during first stage of labour respectively and during second stage a higher score of 2.8 (0.9, 4.7) and 2.3 (0.6, 4.0), compared with women who planned a hospital birth. Overall, women who were transferred experienced a lower sense of control than women who were not transferred. Parous women who planned a home birth and who were transferred had a 4.3 (0.2, 8.4) higher LAS score in 2nd stage, compared to those who planned a hospital birth and who were transferred. We found no clinically relevant differences in feelings of control among women who planned a home or hospital birth. Transfer of care during labour lowered feelings of control, but feelings of control were similar for transferred women who planned a home or hospital birth.As far as their expected sense of control is concerned, low-risk women should be encouraged to give birth at the location of their preference.
    BMC Pregnancy and Childbirth 01/2014; 14(1):27. DOI:10.1186/1471-2393-14-27 · 2.19 Impact Factor
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