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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.
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As a follow-up, readers might be interested in this report of a maternal death at home:
http://www.theage.com.au/victoria/coroner-says-caroline-lovell-died-after-midwife-gaye-demanuele-let-her-bleed-out-in-birthing-pool-20160324-gnq3u1.html
You might note the midwife’s name.
Hi, David. It’s worthwhile putting energy into refuting misinformation, in my view, so that others can also have the data at their fingertips. Anonymous ”Sojourner” has misrepresented the UK Birthplace Study results – particularly the mortality, but also the complications. This is in a study that had tighter risk-outs than the Aus publicly funded HB system. Mortality in the data presented in the main paper was about double for first-timers, compared with low-risk hospital births. However, the analysis excluded 18,269 low risk women who were planning homebirth at the start of the study, despite the fact that they went on to have a homebirth within the NHS service.That group is buried in the supplementary material of the paper, and showed that, in this other group, (excluded from the studies because of previous complications), the mortality was also fully double the higher-risk group in hospital). These studies don’t report the disability resulting from hypoxia, but one cannot dismiss the disability caused from the greater incidence of fractures, meconium aspiration or brachial plexus injury. How many of us would trade those effects on our babies for the family experience of birthing at home?
Sue, don’t waste your energies. ” Against stupidities the gods contend in vain” Freidrich Schiller.
Re: The Birthplace Study referred to by Dr Ieraci:
The NICE recommendations follow on from the research evidence in the 2011 Birthplace Cohort Study of over 64,000 fit and healthy women in the UK, birthing at home or in obstetric units. For first babies there was a slightly higher risk when born at home 9.3/1,000 compared to 5.3/1,000. These figures represent 91 adverse outcomes out of 15,000 births, but the figures only reached statistical significance because they combined mortality with specific morbidities – a fractured humerus or clavical, meconium aspiration syndrome and brachial plexus injury. These are not necessarily life threatening events and if one looked only at mortality there was little difference in the comparison between home and hospital, and those differences did not reach statistical significance. In other words, the very small numbers of mortalities could have occurred by chance.
That research also shows that women birthing in obstetric units have greater risks of caesarean sections, episiotomies, forceps or ventouse, and less successful breastfeeding.
Anonymous ”Sojourner” appears to read selectively. Both the UK Birthplace Study and the review of the publicly-funded Aus homebirth systems showed a clear excess in mortality – and didn’t even report disability – in comparison to equivalent-risk hospital birth. In the UK Birthplace study -BMJ 2011,despite tight risk-out criteria and a 40% transfer rate to hospital, there was a 3X excess mortality in the neonates born to first-time mothers. Hypoxic injury is not reported. The Australian evaluation was in MJA 2013 – Publicly funded homebirth in Australia: a review of maternal and neonatal outcomes over 6 years. Again, approx 3X mortality compared with similar-risk hospital births, and, again, disability was not reported.
The studies tend to include epidural pain relief as an ”intervention”. For many women, access to effective pain relief is a priority, not an unwelcome ”intervention”.
Neonatal death affects entire families, multi-generationally, whether the death is a ”viable foetus”, ”unborn child” or ”future child”. In considering choices, families should be aware that the chance of the foetus/baby/child dying at a home birth, is measurably and reproducibly greater than in hospital. They should also be made aware that midwife-provided, low intervention births are the default in public hospitals, with escalation to other providers, procedures and intervention according to need.
It is interesting that MJA InSight is content to publish an article that contains not even one primary reference to any scholary study. Of couse, it is a commentary piece.
The article is followed by comments that reference a letter co-authored by an opinion based blog writer that references a study with an abstract that does not concur with its own study’s statistical findings. http://blogs.crikey.com.au/croakey/2010/01/20/more-critique-of-the-homeb… http://www.crikey.com.au/2010/01/20/don’t-believe-the-home-birth-horro…. Melissa Sweet writes: “When the dominant politics is determined for homebirth to be eradicated there is little chance for science to project an informed and balanced voice into the debate.”
Also notable is the shift in language from “foetus” to “unborn child” to now, in the langauge of de Crespigny and Savulescu, the “future child”. The foetal personhood debate is shifting gear.
A multi-study Cochrane review did examine neonatal morbidity as criteria: http://onlinelibrary.wiley.com/store/10.1002/14651858.CD000352.pub2/asse… The reviewers state: “Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications.”
The real issue is: Who has the right to make the decisions in every aspect of a woman’s reproductive life?
Unequivocally, only the woman herself.
Thanks for raising this very important topic, Jane. Modern, hospital-based midwifery and obstetrics has created a sort of ”spectrum bias” that fools people into thinking that labour and birth are safe processes in the absense of intervention. Of course, most babies and mothers don’t die, just like the vast majority of people driving without seatbelts don’t die. But the significant risks are relatively easily mitigated.
The evaluation of the Australian publicly funded Home Birth trial showed a three-fold mortality for home birth compared with similar-risk births in hospital (See Ieraci and Tuteur letter to MJA 2013 – https://www.mja.com.au/journal/2013/199/11/publicly-funded-homebirth-australia-review-maternal-and-neonatal-outcomes-over-6). This study didn’t even consider the incidence of hypoxic-ischaemic encephalopathy, resulting from prolonged hypoxia – a cause of long-term disability.
I concur with de Crespigny and Savulescu – information for people considering birth choices should include the risk of significant disability for the child – quite apart from mortality. These disasters can destroy families.