Women 'must be warned of home birth risks' on ethical grounds
Couples should be warned of the risks of home birth, including the “silent tragedy” of long-term disability for their babies, experts have said in a journal.
While studies have shown an increased risk of a baby dying during a home birth, little has been said about the chance of disability – which can occur due to factors such as oxygen starvation, they argued.
The authors said deprivation of oxygen – known as hypoxic ischemic encephalopathy (HIE) – can lead to cerebral palsy, and motor and cognitive problems that can be detected at school-age.
While campaigners in favour of home births focus on the fact women may need less intervention, such as forceps, there has been little focus on the risk of disability.
The authors said “part of the enthusiasm for home birth is related to cost-cutting”, adding: “Couples should be warned of avoidable and foreseeable risks of future child disability.”
Professor Julian Savulescu, from the faculty of philosophy at Oxford University, and obstetrician and gynaecologist Associate Professor Lachlan de Crespigny, of the University of Melbourne, said that when problems occur at home there can be a delay in transferring women to hospital for specialist help.
“Delay in transferring to a tertiary hospital may result in permanent severe disability that will persist for the rest of that person’s life,” they write in the Journal of Medical Ethics.
“Vital delays are inevitable in some cases,” they added. “These can lead to disability, which was avoidable if the delivery had occurred in hospital.”
The authors argue that when labour is obstructed or the baby starts to suffer from lack of oxygen, the “immediate treatment” of the baby is crucial for its immediate and longer term health.
To take an extreme example, the lack of equipment to deal quickly when such events occur at home might result in avoidable quadriplegia, they added.
A 2011 Oxford University study found babies born to first-time mothers who choose a home birth are almost three times more likely to die or suffer a medical complication.
The Birthplace in England study found these babies were 2.8 times more likely to suffer serious problems compared with those born in hospital obstetric units.
Problems included stillbirth after the start of labour, the baby dying within the first week of birth, brain injury, fractures to the upper arm or shoulder during birth, and faeces in the lung.
There was no increased risk for babies whose birth was planned at units led by midwives, either ones that stand alone in the community or which are attached to a hospital.
There was also no increased risk for second or subsequent babies whose mothers planned a home birth, the study found. The overall risks were low.
The researchers pointed to a further study which found that while women experienced lower rates of Caesarean section during home births, the risk of the baby suffering seizures or having a low wellbeing score (known as Apgar score) at birth was higher.
They also pointed to an analysis of 12 studies of 500,000 planned home births in low-risk women that showed death rates among babies tripled.
In another study, women who started off labour with a midwife and were than transferred to consultant care had a 2.5 times higher risk of their babies being admitted to intensive care than those women who stated off labour under a consultant.
The researchers said they acknowledged that hospital births are not without their own risks, and that home birth is often seen as a more natural and less interventionist alternative.
“However, labour and delivery is a time of high risk, and home birth may expose the future child to unreasonable risk of potentially life-changing disability for benefits that may be comparatively small,” they said.
“Home birth appears to be a risk factor for the future child, or at least so uncertain, that it should be discouraged, pending further research.
“Doctors and midwives often do not currently tell patients that there are predictable avoidable risks of future child disability with home birth. They should do so.”
The authors said women’s choices should be respected but they and their partners may be poorly informed of all the risks they could be taking by choosing a home birth.
“Birth is an inherently risky time for mother and baby”, they said, adding: “Modern obstetrics has been one of the great advances of modern medicine. Yet today, some people wish to return to the past.
“When a baby is injured during childbirth, the full extent of the harm is often not obvious until years later.”
They added: “One silent tragedy is the long-term disability that can result from home birth. And it is this risk that we… argue weighs heavily against home birth.”
Elizabeth Duff, senior policy adviser at the National Childbirth Trust (NCT), said: “Home birth should be considered a mainstream option for women in the UK alongside birth centres and hospital maternity units, provided women have a straightforward pregnancy.
“There are many potential benefits to having a home birth, especially for low risk women and second time mothers, including better outcomes associated with continuity of care. For higher risk mothers or those having their first baby, giving birth in a hospital may be the preferred choice.
“It is crucial that prospective parents are offered the highest quality information about the risks and benefits of all birth settings. The immediate safety of the
baby and mother and their long-term well-being are the key factors in decision-making.”
Maternity minister Dr Dan Poulter said: “Safety of mother and baby always remains paramount. In the UK, clinicians discuss the various birth options available for mothers and any associated risks in order to help them make an informed choice.
“If a home birth is not deemed clinically appropriate then this is made clear very early on in the pregnancy,” he added
Louise Silverton, director of midwifery at the Royal College of Midwives (RCM), said: “We agree that decisions about where to give birth should be based on the best possible evidence.
“The Birthplace Study of 2011 showed that planned out-of-hospital births were, generally, as safe for the baby as those in hospital for low-risk women having their second or subsequent baby.
“This major study took into account early indicators of the potential risks of future disabilities to the baby.”
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