Planned Home Birth: A Violation of the Best Interests of the Child Standard?

The American Academy of Pediatrics (AAP) has long and consistently championed the best interests of the child standard as the foundation of pediatric ethics.1 This standard obligates pediatricians to protect and promote the biopsychosocial interests of children who are patients, as these interests are determined in deliberative (evidence-based, rigorous, transparent, and accountable) clinical judgment and practice. The interests of parents do not play a direct role in the conceptualization of this standard, although the ability and willingness of parents to participate in the health care of their child can become ethically relevant considerations in some cases. It is worth noting that, in pediatric ethics, the best interests of the child standard generates the ethical obligation of parents to protect and promote the biopsychosocial interests of their children when their children are patients.The recent AAP statement, “Planned Home Birth,” endorses the ethical position of the American College of Obstetricians and Gynecologists in its statement on planned home birth2: “The American Academy of Pediatrics concurs with the recent statement of the American College of Obstetricians and Gynecologists affirming that hospitals and birthing centers are the safest settings for birth in the United States while respecting the right of women to make an informed decision about delivery.”3 The AAP statement also recommends that “there should be at least 1 person present at every delivery whose primary responsibility is the care of the newborn infant.”3 The AAP can take these positions only if they are consistent with the best interests of the child standard. The purpose of this article is to call into question whether the AAP statement is indeed consistent with this foundational standard of pediatric ethics.The resolution of this question depends directly on the preventable, increased perinatal risks of planned home birth. If planned home birth can prevent these risks if certain circumstances are met, then the best interests of the child standard is not violated. If, however, planned home birth cannot prevent these risks, even under improved circumstances, then the best interests of the child standard is violated.The AAP statement reviews current literature on the comparative outcomes of planned home birth. This literature shows that planned home birth “appears to be associated with a two- to threefold increase in neonatal mortality or an absolute risk of approximately 1 neonatal death per 1000 nonanomalous live births. Evidence also suggests that infants born at home in the United States have an increased incidence of low Apgar scores and neonatal seizures.”3 Given the importance of the best interests of the child standard, it is striking that no ethical analysis of these data appears in the AAP statement. This silence is inexplicable.The only reasonable interpretation is that the AAP Committee on Fetus and Newborn assumes that these increases in mortality and serious morbidity are consistent with the best interests of the child standard. This assumption is false. The increased perinatal risks of planned home birth are preventable in the hospital setting, where rapid response to maternal or fetal indications for cesarean delivery and where rapid neonatal intervention are both routinely available.2 The increased perinatal risks are therefore clinically avoidable and unnecessary. Neonatal morbidity and mortality are often directly related not just to inadequate neonatal care, but especially to adverse events during labor and delivery, none of which has been addressed by the AAP statement. From the perspective of the best interests of the child standard, planned home birth should be judged to have preventable, increased perinatal risk mostly because of unexpected intrapartum events and cannot be effectively managed by improved neonatal care. Planned home birth is therefore not consistent with the professional responsibilities of pediatricians. We have argued elsewhere that the professional responsibility model of obstetric ethics4 prohibits obstetricians from participating in planned home birth and obligates them to recommend against it in response to expressions of interest in it by pregnant women.5,6 Given the unavoidable limitations of technology and personnel and the delays from transportation, the best interests of the child standard requires that pediatricians not participate in planned home birth and not sanction planned home birth.We have recently completed an analysis of the US Centers for Disease Control’s National Center for Health Statistics Birth Certificate Data on the relative risk of home birth attended by midwives versus hospital birth attended by physicians for the period of 2007 to 2010. The study population included >13 million births, of which >67 000 were home births attended by midwives. We analyzed singleton term births (≥37 weeks’ gestation and ≥2500 g). The outcomes measured 5-minute Apgar scores of 0 and neonatal seizures or serious neurologic dysfunction.7We found that home birth attended by midwives, which we treated as a proxy for planned home birth, had a 10.55 relative risk (95% confidence interval 8.62–12.93) of Apgar score of 0 compared with hospital birth attended by physicians. Home birth attended by midwives had a 3.80 relative risk (95% confidence interval 2.80–5.16) of seizures or serious neurologic dysfunction compared with hospital birth attended by physicians.7 These newly reported outcomes are worse than those referenced in the AAP statement.The AAP statement provides a detailed account of the care of newborns at home. The statement details certain requirements for planned home birth. Some of these may make it relatively less risky to have a planned home birth, but overall they cannot be expected to sufficiently reduce the risk of planned home birth. For example, none of these recommendations addresses the well-reported increased risk of stillbirths in home birth or the known delays in transport times from home to hospital and admission to the NICU.2Some might argue that the AAP should not reconsider its position on planned home birth, because some pregnant women will choose planned home birth regardless of the statements from professional associations of physicians. Some might therefore go on to argue that the AAP is justified in calling for an additional attendant “whose primary responsibility is the care of the newborn infant”3 in planned home birth. We respond to this reasoning as follows. The AAP’s recommended “practice points” would be very difficult to effect routinely, unlike the hospital setting. This is because in the hospital setting, there are policies and procedures to ensure pediatric attendance. It is inconceivable that effective policies or procedures could be developed in the foreseeable future to ensure that the practice points are implemented. Attendance by pediatric clinicians at planned home birth implicitly endorses the belief that planned home birth’s perinatal risks are acceptable from the best interests of the child standard, when they are not. Moreover, only expert obstetric management in the hospital setting significantly modifies those risks; attendance by a pediatric clinician should not be expected to do so. Neonatal care should not be viewed in isolation but in the context of perinatal care. Pediatric clinicians should not participate in clinical management that violates the best interests of the child standard when that standard can be met routinely in the planned hospital birth setting.There are geographically remote areas in the United States where pregnant women live at considerable distance from the nearest hospital. Public policy should support transport of such pregnant women before the onset of labor. Only in circumstances in which this is not feasible would it be ethically permissible to consider implementing the AAP practice points.The AAP statement correctly states that hospital birth is the safest form of birth. However, the effect of this statement is to sanction, and unintentionally enable, planned home birth if certain circumstances are met. However, meeting these circumstances does not eliminate the preventable, increased perinatal risks of planned home birth. The AAP should consider withdrawing this sanction and replacing it with the professional responsibility of pediatricians to be strongly directive in recommending against planned home birth and recommending in favor of planned hospital birth. The AAP should also emphasize the professional responsibility of pediatricians not to participate in planned home birth, except in the very limited circumstances described in this article. Pediatricians should support creating settings that resemble home birth in the hospital and in birthing centers that are in or adjacent to hospitals.4,5