Are home births 'unethical' and 'dangerous'?
“Home births could be as dangerous as ‘driving without putting your child's seatbelt on’,” The Independent reports.
The headline is based on a recently published narrative review that looked at home births and future risk to the child following birth, such as going on to have a disability later in life.
The researchers argue that home birth does carry a very small, but avoidable, risk of causing long-term disability to the baby, due to lack of access of hospital services in cases of emergency.
They make the case that this is akin to driving your child without fitting their seatbelt. While the chances of an accident during any given car journey are small, you are still exposing your child to an unnecessary and unavoidable risk. And a similar unavoidable risk is associated with home births. So a case could be made, in their opinion, that such an action is unethical.
They say that to properly assess the risk of home births, more research is required about long-term outcomes, not just immediate outcomes that occur shortly after birth.
They recommend couples should be better informed of the long-term risks and say doctors should attempt to dissuade couples when they elect a place of birth that puts the health and well-being of the future of the child at potential risk.
It is important to note that this research is not a systematic review, so it is unclear if all the relevant literature on this topic has been captured by the review. There is always the risk with this sort of narrative review of “cherry-picking” – evidence supporting the authors’ viewpoint is cited, while evidence contrary to their views is ignored.
A systematic review would have been a more effective, if time-consuming, method of assessing the pros and cons of home birthing.
The review does raise some interesting points but it is important not to lose sight of the many reported benefits of home birthing, such as decreased psychological trauma and reduced risk of a forceps delivery being required.
Read more about your options about where to give birth.
How common is home birth in the UK?
In the UK, expectant mothers can chose to give birth at home, in a unit run by midwives (a midwifery unit or birth centre), or in hospital. In England, around one in every 50 babies is born at home.
What type of paper is this?
This was a narrative review that looked at home birthing and future risk to the child such as the child going on to have a disability.
A narrative review is a discussion of what is known on a particular topic. They can usually be considered an informed overview, written by experts in the field to provide an overview of the topic. In contrast to systematic reviews, narrative reviews often do not report the methods used to identify and select the studies discussed. This means that they are not considered as reliable as systematic reviews.
It is probably useful to consider narrative reviews as opinion pieces, similar to an editorial in a newspaper, rather than as fresh evidence.
Who produced this review?
The review was carried out by an Australian obstetrician and gynaecologist and an Oxford University ethics professor. It was published in the peer-reviewed Journal of Medical Ethics and the authors report they received no funding.
What evidence does the paper look at?
The researchers looked at what types of disability may be associated with home birth and the risk of disability. They give examples of where new-borns may require interventions not readily available in the home environment, such as when a labour is ‘obstructed’ or a baby is born with hypoxic brain injury (caused by not enough oxygen to the brain). They say immediate treatment is crucial to the outcome of the baby and that delay in transferring to an appropriate hospital may result in permanent severe disability for the child.
The researchers report there is limited data available on the risk of long-term disability after homebirth. This is, in part because documenting disability requires difficult, expensive and very large long-term follow up studies. They say another reason is that reliable data is hard to come by because many home births where complications are experienced transfer to hospital and are recorded as hospital births.
In what the researchers describe as a ‘brief review’ of the literature, they describe particular studies on homebirth that have mixed findings. One UK study was reported as finding women on their second or more birth with a planned home birth experienced fewer ‘interventions’ than those planning birth in an obstetric unit, with no impact on outcomes for the baby around the time of the birth. A reported limitation of this study was that it may have been underpowered to detect major disease.
They also describe a study that showed significantly worse outcomes for the baby in home births – pooled findings (a meta-analysis) from 12 studies and 500,000 planned homebirths showed newborn death tripled.
What points and theories does the paper look at?
The researchers also look at the ethical and moral obligations of mothers and professionals around birthing. They make the point that death of the mother or child during childbirth (which is rare), must be recorded, but that if the baby is injured during childbirth, the full extent of the harm is often not obvious until years later.
They say that choices by mothers and professionals that raise the chances of long-term disability for the child involves harm to people that will exist and that this is morally relevant harm.
They make the case that the benefits to the mother who chooses to home birth are outweighed by the potential risk of long-term disability to the child. And placing your own needs over the long-term safety of your child could be, in their opinion, an example of unethical behaviour.
Laws around home birthing are also described in the review.
Conclusion
This narrative review has looked at the risks of homebirth and future risk to the child.
The review has been written by two experts in the field and may not represent the opinions of other experts.
This research was not a systematic review and as the methods used by the researchers for gathering studies that looked at homebirths are not reported, it is unclear if the researchers have captured all of the relevant literature on this topic. Also, they may have selectively chosen to showcase studies that supported their argument. So, the studies presented may provide a biased view of the topic.
That said, and despite the researchers arguing that homebirth should not be recommended by professionals, they do recognise that most women will deliver at home with good outcomes for both the mother and child. Current estimates suggest that in the UK, having a first baby at home slightly increases the risk of a poor outcome for the baby, including death and complications that may result in long-term health problems (from five poor outcomes in 1,000 for a hospital birth to nine in 1,000 – almost 1% – for a home birth). For low risk women having a second of subsequent baby home birth does not increase the risk (3 poor outcomes per 1000 births for hospital births and 2 per 1000 births for home births).
Read more about the options of where to give birth and the benefits of making a birth plan.
A case could be made that rather than discouraging home births, we should instead be improving the levels of support to women who choose to home birth and so reduce the risk of complications. However, in cash-strapped times there are always going to be competing priorities.
