Jane McCredie: Birth choice risks

MELBOURNE woman Caroline Lovell collapsed and died in 2012 after giving birth to her second child at home.
    
The inquest into Ms Lovell’s death was held earlier this year and heard she had asked to be taken to hospital shortly after the birth, saying she was dying.

Sadly, that did not happen quickly enough to save her.

The inquest heard that one of the midwives involved in the case had previously written that women’s human rights were being violated “by a system that treats them as incubators … A system that uses ‘the best interest of the child’ as a weapon; that deems women incapable of making ‘good choices’ in order to police them”.

The often highly emotional debates around the practice of homebirth tend to focus on cases like this, pitting a potentially increased mortality risk for mother and infant against a woman’s right to choose how and where she wishes to give birth.

Balancing those kinds of conflicting imperatives is never easy, as two prominent Australian medical ethicists acknowledge in the Journal of Medical Ethics.

“There is a need to reconcile respect for a woman’s autonomy with the duty of care that practitioners have to the woman, but also and separately to the baby”,
Melbourne obstetrician Dr Lachlan de Crespigny and expatriate ethicist Professor Julian Savulescu write.

But they also argue that finding an adequate moral response to the potential risks of homebirth requires us to broaden the scope beyond mortality risk.

A disproportionate focus on maternal or infant mortality “overshadows the importance of harm to a future child created by avoidable, foreseeable disability”, they write.

Risk of disability might pose an even more fundamental moral objection to homebirth than the risk of death, they suggest.

“If one accepts that abortion is permissible because the fetus is not a person, one could consistently hold that maternal choices that increase the risk of perinatal mortality are morally equivalent to the choice to have an abortion or late abortion”, they write.

But a woman’s right to risk the life of her unborn child would not necessarily extend to risking disability for her “future child”, they suggest.

“Choices that do not cause the death of a fetus or newborn but raise the chances of severe long-term disability are different in kind because they involve harm to people who will exist”, they write.

“It is wrong to put a future child at an unnecessary risk of a life of disability. This is true whether one is prochoice or prolife.”

The authors have written on this issue previously. In 2012 after coroners’ hearings in NSW and South Australia into the deaths of four babies during homebirths, they wrote a letter to the MJA, calling for long-term follow-up of adverse birth outcomes “to determine the sequelae so that risks to the future child associated with place of birth can be accurately quantified”.

In their latest article, de Crespigny and Savulescu acknowledge the lack of clear data on risks of disability with homebirth and that there are “plenty of horror stories arising from both hospital and homebirth experiences”.

But, they argue, “what we do know about the risk of long-term disability suggests that competent hospital birth must be of lower risk to the future child than competent homebirth”.

These authors are not suggesting we should go so far as to ban homebirth, but they do believe health professionals should seek to dissuade couples from making that choice.

“Doctors and midwives often do not currently tell patients that there are predictable avoidable risks of future child disability with homebirth”, they write. “They should do so. Potential homebirth patients should be told that it is usually wrong to knowingly allow such a risk.”

That could lead to some interesting conversations.
 

Jane McCredie is a Sydney-based science and medicine writer.