Are we misinforming our low-risk mothers regarding birthplace outcomes: is it time for formal consent?: AGAINST: Formal consent is not necessary for home births.

Abstract

Every woman with a planned pregnancy wants to have a good birth and a healthy baby. Low-risk expectant mothers, especially, are very likely nowadays to have the desired outcome. In Western countries births predominantly take place in hospital. In some countries, such as the Netherlands and the UK, home birth is still a viable option for low risk pregnant women. The debate about the safety of home birth is often heated and it is frequently suggested that women should wisely ‘choose to be on the safe side’ and opt for a hospital birth, since complications cannot always be predicted in advance. If it is true that the hospital is always the safest choice, the question may arise whether women who prefer to give birth at home should formally be advised of the risks and asked to give formal consent. We want to argue against formal consent in planned home birth situations, unless the system is such that formal consent is also being asked in case a low-risk woman chooses to have a hospital birth. Women should always be informed of the pros and cons of different places of birth and asked to consider carefully where they want to give birth. Placing the burden on home birth situations only, is misleading. In recent years a number of studies have looked at the safety of planned home births compared to planned hospital births in low risk pregnant women. The highest quality data and largest studies are from Dutch and UK studies (de Jonge A et al. BJOG 2015;122:720–728. BMJ 2011; 343:d7400 doi: 10.1136/bmj.d7400; BMJ 2013; 346:f3263 doi: 10.1136/bmj.f3263). Adverse perinatal outcomes were uncommon irrespective of birth setting. The largest study included 743 070 low-risk planned home and hospital births in the Netherlands. It showed no increase in adverse perinatal outcomes in home births (de Jonge A et al. BJOG 2015;122:720–728.). The UK Birthplace study showed an increase in adverse outcomes (not deaths) in home births, only in the subgroup of primiparous women (Open Access. BMJ 2011; 343:d7400 doi: 10.1136/bmj.d7400). A large Dutch study that looked at maternal outcomes, showed no increase in morbidity in planned home births (BMJ 2013; 346:f3263 doi: 10.1136/bmj.f3263). Low-risk women who have a planned birth in an obstetric unit are far more likely to receive medical interventions such as epidural anaesthesia, augmentation, instrumental delivery or caesarean section (Open Access. BMJ 2011; 343:d7400 doi: 10.1136/bmj.d7400). Those interventions carry risks for the mother and baby and in the case of caesarean sections also for the baby in a subsequent pregnancy (Kok N et al. BJOG 2014;121:216–223). In a system with good midwifery care, good transportation possibilities to hospital and good collaboration between midwives and obstetricians, such as in the Netherlands, the risks for the baby of a home birth are not larger than those of a hospital birth. The risks of interventions that can have major side effects, however, is far larger in a hospital than in a home setting. Pregnant women should receive ample information on the risks and benefits of place of delivery. Formal informed consent for home births only, denies low-risk pregnant women the opportunity to carefully consider the risks of a hospital delivery. Full disclosure of interests available to view online as supporting information. ■ Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.