Letters
Ethics Women's health
Volume 197 - Issue 10

Time to refocus the homebirth debate

Authors:  Lachlan J de Crespigny, Susan P Walker and Julian Savulescu

Med J Aust 2012; 197 (10): 551. || doi: 10.5694/mja12.11122
Published online: 19 November 2012
The risks to the future child of morbidity associated with birth outside a hospital setting - largely ignored to date - need to be better quantified and communicated.
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To the Editor: The New South Wales Coroner has recently determined that a woman’s decision to deliver at home without supervision (free birth) cost her baby her life.1 A South Australian coroner found that three fatal homebirths would not have occurred if the babies had been born in hospital.2 These avoidable tragedies are distressing, but fetuses have few ethical or legal rights; maternal autonomy includes the right to risk perinatal death.

However, blanket respect for maternal autonomy overlooks the risk to the health of any future child who might survive damaged. Clinicians and pregnant women have an ethical obligation to minimise risk of long-term harm to a 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 future harm to the child, such as advocating alcohol abstinence in pregnancy.

Peripartum events can result in death or long-term morbidity. The consequences of perinatal asphyxial injury and subsequent newborn encephalopathy range from death to intact survival. Outside of a hospital setting, acute intrapartum events, such as placental abruption, cord complications and shoulder dystocia are likely to delay delivery and access to advanced resuscitation, thus extending the duration of the insult, and the potential for long-term injury. These events may not only cause deaths but also present the risk of survival with disability. Indeed, in the Birthplace in England national prospective cohort study,3 the major contributors to adverse outcome were neonatal encephalopathy (46%) and meconium aspiration syndrome (13%), both of which are associated with potential long-term deficit. Nulliparous women with uncomplicated pregnancies who planned homebirths had a nearly threefold increase in adverse outcomes. Long-term follow-up is necessary to determine the sequelae so that risks to the future child associated with place of birth can be accurately quantified. Only then can these risks be weighed against potential benefits of reduced intervention rates.

The risks to the future child of morbidity associated with birth outside a hospital setting — largely ignored to date — need to be better quantified and communicated. Perinatal mortality is a tragic outcome, but may be the tip of the iceberg. More important ethically and legally is long-term harm to future children.4

Authors

  • Lachlan J de Crespigny1
  • Susan P Walker2
  • Julian Savulescu1
  • 1. Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK.
  • 2. University of Melbourne, Melbourne, VIC.

Correspondence: lachlandec@yahoo.com.au

Competing interests

No relevant disclosures.

References

View this article on Wiley Online Library

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