Paul Burcher

Homebirth Transfers in the United States: Narratives of Risk, Fear, and Mutual Accommodation

The purpose of this study was to explore the contested space of home-to-hospital transfers that occur during labor or in the immediate postpartum period, as a means of identifying the mechanisms that maintain philosophical and practice divides between homebirth midwives and hospital-based clinicians in the United States. Using data collected from open-ended, semistructured interviews, participant observation, and reciprocal ethnography, we identified six key themes—three from each provider type. Collectively, providers’ narratives illuminate the central stressors that characterize home-to-hospital transfers, and from these, we identify three larger sociopolitical mechanisms that we argue are functioning to maintain fractured articulations at the time of transfer. These mechanisms impede efficient and mutually respectful interactions and can result in costly delays. However, they also contain the seeds of possible solutions, and thus are important starting points for developing an integrated maternity system premised on mutual accommodation and seamless articulations across all delivery locations.

A Crusade Against Home Birth

A recent study by Grunebaum et al examined the relationship between place of birth and adverse neonatal outcomes (Apgar of 0 at 5 minutes, and neonatal seizures or serious neurologic dysfunction—hereafter referred to as neonatal seizures) as reported in birth certificate data from 2007 to 2010 for term newborns (n = 13,891,274) (1). Outcomes were analyzed by four practitioner types: hospital physician, hospital midwife, freestanding birth center midwife, and home birth midwife. The authors claim that babies born at home and in freestanding birth centers were at a significantly higher risk of having a 5-minute Apgar score of 0 (RR = 10.55 and 3.56, respectively) and neonatal seizures or serious neurologic dysfunction (RR = 3.80 and 1.88). However, these findings must be interpreted with caution for several reasons. Limitations of birth certificate data for epidemiologic analysis have been widely discussed in the literature, and include concerns about the completeness and accuracy of reporting of specific items on birth certificates, and the inability of birth certificates to provide longitudinal information (such as for planned home births that transfer to the hospital) or information on clinical intentions (2–4). The neonatal seizure variable, for example, is one of several medical variables unreliably reported on birth certificates (4–6). Two detailed studies comparing birth certificate data to medical records in New Jersey and Tennessee yielded sensitivity rates for neonatal seizures of 0.226 and 0.182, respectively (5,6). This means that approximately 80 percent of cases of neonatal seizures identified on medical records are not reported on birth certificates. Data of this poor quality should not be used as the main outcome measure in any study. Although reporting of data on 5-minute Apgar scores in broad categories (such as <7 or ≥7) is a bit better (7), no studies have examined the validity of reporting of 5-minute Apgar score = 0. However, there is substantial evidence that the reporting of this item on birth certificates is very problematic. Watterberg found that although large differences existed between home, birthing center, and hospital settings for reported Apgar scores of 0 and 10, these differences were greatly reduced for Apgar <4, and virtually eliminated for the combined category of Apgar 9 or 10 (8). There appear to be real differences between how physicians and home and birth center midwives perceive and report Apgar scores at the edges of the Apgar spectrum. Physicians are more likely to report fine gradations of either very low or very high Apgar scores, whereas home and birth center midwives are more likely to report Apgar scores of 0 or 10 more absolutely. Apgar score <4 is the more commonly used measure of early neonatal compromise, and has the added advantage of providing greater numbers of cases for analysis. The reported odds ratios for 5-minute Apgar score of 0 and neonatal seizures in the Grunebaum et al study are based on very small numbers of cases, and thus have limited generalizability or clinical relevance. It is also well-established that Apgar scores are poor predictors of neonatal outcomes (9), so even if these data could be improved, they

The Ulysses contract in obstetrics: a woman's choices before and during labour

Women recognise that labour represents a mind-altering event that may affect their ability to make and communicate decisions and choices. For this reason, birth plans and other pre-labour directives can represent a form of Ulysses contract: an attempt to make binding choices before the sometimes overwhelming circumstances of labour. These choices need to be respected during labour, but despite the reduced decisional and communicative capacity of a labouring woman, her choices, when clear, should supersede decisions made before labour.

The case against cesarean delivery on maternal request in labor.

The ethical obligations of an obstetrician to a patient who requests a cesarean delivery without maternal or fetal indication differ depending on whether the request is made before or during labor. Informed consent is an essential dimension of respecting patient autonomy, and the process of informed consent should be extensive for a cesarean delivery in the absence of maternal or fetal indications during active labor. For this reason, physicians should rarely grant a request for cesarean delivery made during active labor. Although physicians may think that declining a request for cesarean delivery is a violation of patient autonomy, they should also be concerned about the violation of patient autonomy that results if they are unable to adequately complete the process of informed consent during labor.

Reproductive Ethics: New Challenges and Conversations Introduction

When we first envisioned organizing a conference solely on issues in reproductive ethics we were met by some skepticism by friends and colleagues. Were there really enough compelling topics and scholarship in this area to sustain interest for a 2-day conference? Our view, and the perspective confirmed by this book, is that reproductive ethics is a field that has many questions, which we have only started to explore to the extent that they deserve. There are two reasons this is true. One is that some “hot button” issues have received all the attention—abortion, in particular, comes to mind here. The other is that unlike many well-litigated areas of bioethics, such as end-of-life care, emerging technologies in reproductive ethics are changing the ethical playing field faster than the bioethics literature can keep pace. As for whether reproductive ethics can sustain interest we can only note that it is hard to imagine a subject that humans spend more time and energy upon than sex and reproduction. It is the only area of bioethics that can be called sexy without invoking an implausible metaphor.

The Periviable Cesarean Section: Can a Case Be Made for Expanding Beneficence in Decision-Making?

The objectives of patient care during a periviable preterm delivery are to support patient autonomy, while balancing risks and benefits, and provide evidence-based obstetric care. In most cases of periviability, delivery by a cesarean section is not consistent with these patient care goals, given its lack of maternal or fetal medical benefit, and is therefore considered medically inappropriate. However, by expanding the definition of benefit to include potential maternal psychological and spiritual goals, there are cases in which a cesarean may be ethically justified. In this chapter we explore this concept and suggest that in the context of realistic maternal goals and adequate informed consent, a cesarean section at 22 weeks gestation may be ethically justified through an expanded definition of maternal beneficence.