Mrs. R is a 39-year old woman who is three months pregnant with her first child (her age makes her “high-risk”). She would like to deliver the baby at her home with a midwife present. Mrs. R does not have any other significant risk factors for an unhealthy delivery. She lives 25 miles away from the nearest neonatal intensive care unit (NICU).
What kind of ethical issues are involved in this case? Should a midwife agree to attend Mrs. R’s home birth? What should a physician advise? Mrs. R believes she has a right to decide where and how to give birth. Does the baby have rights? Is legislation appropriate?
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Mrs. R has the right to deliver where she chooses because retaining her psycological well being and comfort would reduce stress during delivery improving the probable outcome of the birth. Investigating the experience of the midwife with higher-risk patients would be useful in determining her ability to protect the mother and new-born. If the hospital nearby has the capacity to receive the delivery under an emergent condition that the midwife cannot handle and transportation is available, then the only ethical dilemma involves the risk that a negative outcome could occur before the proper care can be provided. Given precedents of the right for a woman to choose her pregnancy status privately I do not believe that legally she could be mandated to deliver her baby in a venue that is comfortable to her.
ReplyDeleteThe personal experience of delivering at home for the mother may far outweigh the possible risk of harm to the mother or newborn.
I guess we are assuming that she has been made aware of the risks of having a home birth and has chosen to disregard them, right? If so, then there is very little we can do to stop her. Legally, she cannot be coerced into having the baby in hospital. However, she will have to find a midwife willing to be present and assume the liability of this potentially high risk situation. What we could legislate, though, is restricting the rights of midwives to assist her with this. Midwives could be prohibited by law from assisting in high risk births based on specific criteria defining high risk. If we had that kind of legislation, Mrs. R could have her baby where ever she wants but the fact that it is unsafe to do so at home might become more obvious to her. Having midwives who will agree to assist in these cases legitimizes the desire to have a home birth even when it is potentially dangerous to the baby.
ReplyDeleteI believe that in this case the mother's autonomy and the justice involved in allowing her to make her own decision greatly outweighs the issue of non-malfeasance with regards to both the infant and the mother.
ReplyDeleteThe justice and autonomy involved in allowing the mother to make her own decision with regards to the birth support the application of deontological (because respecting the mother's autonomy is something that all people can understand and endorse), relativist (because in our culture the mother's autonomy is supported), and principle-based ethical theories (sorry, I'm a first year!).
I'm not sure if midwives abide by the same standards as doctors, but if they didn't, there wouldn't even be an issue for them to attend to the home delivery. If they did need to abide by the same code, I believe he/she could still ethically perform the delivery because, again, the patient's autonomy and justice with respect to her decision outweigh any issue of non-malfeasance.
Mrs. R is high risk for some serious complications during her delivery, including placenta previa resulting in the need for a C-section. According to the Mayo Clinic, women over age 35 are at higher risk for labor problems in general. For Mrs. R to choose to ignore her high-risk status and deliver somewhat far from advanced care, she is taking away her newborn’s right to emergent care that is available to him/her.
ReplyDeleteWe have laws in this country that require emergency rooms to treat anyone who shows up at their doors with a medical emergency. That’s because our society believes that everyone has a right to life-saving care at a minimum (basic health care is a whole other discussion). Mrs. R is taking that chance, and arguably that right, away from her baby.
At a certain point in a pregnancy, we consider the fetus to be a whole person (I don’t know what that point is). This is demonstrated by laws that consider the homicide of a woman in her third trimester to be a double homicide. If a toddler were injured to the point of needing life-saving care, nobody would condone the child’s mother delaying the child’s arrival at the emergency room because the mother had something else she wanted to do for herself. If a mother knew that her child was life-threateningly allergic to bees, we would prosecute her for abuse if she sent her child to kill the nest of bees on the front porch. That is, at a certain point, we expect mothers to drop their own wants and desires for themselves in order to protect the life of their children.
I do not believe that we should legislate scenarios when it is or is not appropriate for high-risk mothers to deliver at home. Perhaps it would be appropriate to legislate what types of high-risk deliveries midwives are allowed to attend. I believe that in this high-risk situation, protecting the baby’s rights to emergent health care should trump the mother’s autonomy to make bad decisions for herself.
I think that all four bio-ethical principles support a woman's choice to deliver at home in the presence of a midwife. The psychological, emotional, and some may even argue physical health, will benefit from a woman delivering in the environment and with the practitioner that she feels most comfortable with. By allowing, and even supporting, a woman’s choice to deliver at home the physician is respecting the patient’s autonomy and acting on principles of beneficence. In terms of non-maleficence, the risks associated with home birth are debatable. While the AMA and ACOG do not support home birth, the WHO does support a woman’s choice to deliver at home, in the case of low-risk pregnancies. Justice is an interesting principle, because it depends upon which wider community that is being considered. If physicians and legislative bodies deny women the freedom to choose where they deliver there is a risk of alienating women, and families, from clinical care completely. This potentially fosters a negative experience and opinion of clinical care and may discourage prenatal, postnatal, and infant care.
ReplyDeleteI believe that physicians should support a woman’s decision to deliver at home and offer additional back-up support in the case of an emergency. It would also benefit their patients if physicians were knowledgeable enough to counsel women considering home birth as well as refer patients to midwives or other childbirth resources centers.
There are some legal considerations for physicians to consider, however. In about eleven states direct-entry midwives are legally prohibited from practicing. Most certified nurse-midwives practice in a clinical or hospital setting; therefore direct-entry midwives are the professionals that attend the majority of home births. While direct-entry midwives do complete standardized training they are currently not recognized by some states as professionals. Physicians practicing in all states, by supporting home births or proving back-up care, are rejecting the AMA and ACOG positions on home birth and in some states they are acting illegally. I would like to see the AMA, ACOG, and those states that do not recognize direct-entry midwives to re-consider home birth and re-define their positions.
Aleciafields-
ReplyDeleteThat is really interesting. I had no idea it was illegal for physicians to assist with home births in some states. Wow. I wonder if that has more to do with lawsuits and less to do with ensuring a good standard of care?
OB/GYNs are currently the most-sued specialty (with pediatricians coming in as least). From a risk-management perspective, if I were an OB/GYN, there is absolutely no way I would ever encourage a patient to have a home birth because if something did go wrong there would be very little I could do about it and I'd risk getting sued. To make matters worse, in this scenario the patient lives 25 miles away from the nearest NICU so if something did go wrong, it might be too late once she arrived at the hospital.
I'd like to see the AMA, ACOG, etc. reexamine their guidelines on home births, but I don't think we will see much support from OB/GYNs on this issue until there is real legal reform on how malpractice suits are handled (including caps on payouts).
The physician that Mrs. R is seeing for her prenatal care needs to have an honest discussion with her about the potential complications that could arise given her age. When I say "honest", I mean no sugar-coating what so ever. If Mrs. R still insists on having a home birth, the treating physician should document that this discussion took place in Mrs. R's medical record. Ultimately, it is up to Mrs. R. Her autonomy as a patient needs to be respected, even it may seem that she is not making the right decision.
ReplyDeleteArgyl-
ReplyDeleteI also have some speculations about why the laws are in place and I am saddened to think that the standard of care is being jeopardized due to malpractice threats (but not surprised). I do think that OB/GYNs are put in a difficult position and even if they wanted to support a woman's decision to deliver at home they can't afford be involved, so long as the legislation exists and the AMA/ACOG do not endorse such practices.
I mentioned this prompt to a former colleague of mine that is currently a lactation consultant and the mother of two, both of which were delivered at home (and in a state where direct-entry midwives are technically illegal). Her response was "women are going to do it anyway and we want them to have access to quality care. And, we make home birth safer by licensing midwives and having some accountability." I thought it was another interesting argument to consider.
For thousands of years, women have been delivering babies in their homes, often attended by midwives. Perhaps a good solution would simply be to ensure that high risk mothers receive solid pre-natal care and appropriate pre-natal ultrasonography and standard tests, and then let them deliver at home with a licensed midwife.
ReplyDeleteBy ensuring that midwives are highly trained, rather than restricted, it will ensure that women can continue to have children in the comfort of their own homes without being forced to deliver in an institution.
Rain Drop,
ReplyDeleteMuch is made of prenatal care, but it will not usually prevent catastrophic events-- it can really only alert you to the possibility that something is wrong. Often it isn't even reliable at doing that. If the baby needs emergency care immediately after birth and is born at home, it really won't matter how many ultrasounds the mother had or how knowledgeable the midwife is. Babies in distress need the help of really expensive machines that are only available in fully-equipped NICU centers. No midwife can compete with that.