Home birth is unsafe: FOR: The safety of planned homebirths: a clinical fiction.

Abstract

Patient safety measures and a culture of safety improve obstetric outcomes (Grunebaum A. et al. Am J Obstet Gynecol 2011; 204: 97–105). The tools of obstetric patient safety include teamwork, team training, emergency drills, audits, best-practice protocols, safety checklists, outside review of performance, caesarean delivery, and access to specialised care. It takes a clinical village to improve safety in childbirth—that clinical village is absent in homebirths. Birth at home without advanced equipment or breadth of well trained personnel and essential clinical services leads to inadequate patient safety and unacceptable preventable adverse outcomes such as increased neonatal and delivery related perinatal deaths, and low Apgar scores (Grunebaum et al. Am J Obstet Gynecol 2014; 211: e1–7; Evers et al. BMJ 2010;341;c5639; Grunebaum et al. Am J Obstet Gynecol. 2013;209:323; e1–6). Consider the striking range of clinically significant conditions that cannot be adequately addressed in homebirths. In emergencies such as cord prolapse, cord compression, abruptio placentae, ruptured uterus, and fetal heart decelerations, transport from home to a medical facility to manage such emergencies is delayed. Timely caesarean delivery within the standard of care, an intervention maligned by some homebirth advocates, saves women and newborns daily in hospitals worldwide and is unavailable at homebirths. Pre-eclampsia can occur without warning and requires immediate treatment to prevent adverse outcomes. Magnesium sulphate, the main agent to treat pre-eclampsia and prevent eclampsia, requires intensive monitoring of the pregnant and fetal patient and cannot be appropriately administered at homebirths. Shoulder dystocia occurs often without apparent risks and requires an experienced team to perform the right manoeuvres and to resuscitate the newborn. This team is unavailable in homebirths. Homebirth midwives in the USA sometimes attempt breech presentations, twin deliveries, and trial of labour after caesarean. These and other conditions with potentially adverse outcomes require teamwork, extensive expertise, neonatal and anaesthesia support, and equipment such as ultrasonography. None of these is available in homebirths. Postdate pregnancies constitute about 25% of homebirths in the USA and often require electronic intrapartum fetal monitoring unavailable in homebirths. Neonatal complications, breathing issues, meconium aspiration, and previously undiagnosed fetal anomalies can occur unexpectedly and may require immediate resuscitation, intubation and mechanical ventilation usually by paediatricians or neonatologists, who are unavailable in homebirths. Maternal complications, extensive cervical lacerations, sidewall lacerations, retained placenta, and excessive postpartum haemorrhage may require equipment, positioning, adequate anaesthesia and personnel as well as access to blood products that are unavailable at homebirths. Despite an increase in unacceptable preventable adverse outcomes, homebirth proponents nevertheless claim that planned homebirth is safe because of the supposed selection of low-risk pregnancies. This claim of safe homebirths requires the adoption of clinical fiction—the existence of no-risk pregnancies. Such clinical fiction has no place in professionally responsible obstetric care (Chervenak FA et al. Am J Obstet Gynecol 2013;208:31-8).