10:14am Wednesday 23 August 2017

The continuing tragedies of home birth and the rights of the future child

Julian

by Julian Savulescu

Windsor Coroner’s Court has heard that a mother died within hours of giving birth at home after a private midwife committed a horrifying catalogue of errors.

According to reports, the woman had previously delivered twins by emergency caesarean section, one of which later died. Her husband said his wife was ‘brainwashed’ into having a home birth by the midwife, who insisted it was safe.

The Royal College of Obstetricians and Gynaecologists advise delivery in hospital after caesarean section so that an emergency caesarean delivery can be carried out if necessary. The midwife denied trying to persuade the couple to have a home birth. However she has greater responsibilities than this; as professionals we should try to persuade women to deliver in hospital if this is a safer option.

But the midwife seems to have prioritised homebirth over life itself when she reportedly stated: “Claire had a great pregnancy, she had a really lovely spontaneous birth at home and I hope Simon in time will remember that.”

The midwife is also accused of multiple errors in management including failing to realise around a third of the placenta was retained in the uterus and missing a vaginal tear which would normally be stitched immediately in hospital under anaesthetic.

The midwife is said to have performed CPR on the bed, where it was less effective, instead of on a firm area such as the floor. She said she attended refresher emergency medicine courses each year and had never been told to move someone on to a floor to perform CPR.

‘My whole practice has always been extremely kind and gentle and thoughtful and caring,’ she added. ‘I did the best I could under the circumstances,’ she is quoted as saying in the Daily Mail.

The woman was taken to hospital by ambulance but died later that day.

Homebirth perinatal deaths of infants who would have survived if they had been born in hospital are reported more commonly than maternal deaths. All such potentially avoidable tragedies are distressing. But the fetus has few ethical or legal rights; maternal autonomy includes the right to risk perinatal death as well as her own death. Ultimately women have autonomy regarding whether to take such risks.

Professionals and pregnant women have an ethical obligation to minimise risk of long term harm to the future child; harm to people who will exist is a clear and uncontroversial morally relevant harm. Consistent with this, antenatal care focuses on minimising the risk of harm to the future child, whether by advocating for alcohol abstinence in pregnancy, folic acid supplementation to reduce the chance of neural tube defect, or minimising teratogenic risks of medications in pregnancy.

Maternal and perinatal mortality are truly tragic outcomes. Professionals must encourage women to deliver in a safe environment and also practice safe and competent obstetrics. The professional bodies and the law must do all they can to ensure this happens.

Currently the homebirth debate focuses on such disaster. It is a terrible tragedy that Claire died foreseeably and avoidably in this manner. But the silent tragedies are not the deaths, but the long term disability that results from homebirth. And it is this risk that weighs most heavily against homebirth.

What disability? When a baby is obstructed in labour at home, or born with hypoxic brain injury, the delay in transferring to a tertiary hospital may result in permanent severe disability that will persist for the rest of that person’s life. In some cases, that disability was avoidable if the delivery had occurred in hospital. To take an extreme example, a person might be avoidably quadriplegic.

Now what risk should a parent take to have “a really lovely spontaneous birth at home” that justifies quadriplegia? One in 1000? One in 1000 000? Anything?

We contend that the choice to have “a really lovely spontaneous birth at home” is only justified if exposes the future child to zero risk of avoidable disability. And this is just never the case.

Why else would modern obstetrics have been developed?

Professor Julian Savulescu is a distinguished visiting professor in the Faculty of Arts at Monash University and a professor of practical ethics at Oxford University.

This article originally appeared in The Sunday Age.


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