The recent outbreak of measles in California has resulted in at least 156 cases across eight states and continues to fuel the debate around vaccinations. Home births, another hotly contested topic, are also on the rise. Both of these controversies have the potential to put a patient and a physician at odds, leading to a debate in the exam room.
In the United States, approximately 25,000 (0.6 percent) births occur outside of the hospital each year, the majority of which are planned. Women may choose to deliver at home because they want to avoid what they see as unnecessary medical interventions, to be in a more comfortable environment, or because of negative experiences in a hospital. As an obstetrician and a maternal fetal medicine specialist, I have witnessed an escalation in home births in my five years of practice. While there are data to suggest that an unplanned birth outside a hospital setting is associated with poor outcomes, the data surrounding planned and attended home birth are less clear. Indeed, there are no well-designed randomized trials that definitively settle the debate.
I am not in favor of home birth. I believe the safest place for a laboring woman is in a hospital or birthing center. Labor and the associated complications are not predictable. When potentially life-saving interventions are delayed because a woman is laboring outside a hospital setting, the consequences can be catastrophic. So when Anna, a patient of mine, said she wanted to deliver at home, I was initially frustrated. I offered information and provided my recommendation. It was clear she understood the message I was relaying and my concerns surrounding her choice, yet she was unwavering in her decision.
The professional societies that guide obstetric and neonatal practice patterns have a fairly clear stance advocating for birth in a hospital setting. That said, The American Congress of Obstetricians and Gynecologists states, "Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery." The latter part of that statement recently caught my attention and altered how I approached the issue with Anna.
While vaccinations have implications for the collective, as we have seen from the rapid spread of measles, home births have little to no direct impact on the community as a whole. Anna's choice to deliver outside a hospital is not a nuisance to society and does not fundamentally impinge on the rights of other individuals. While it could be argued that opting to deliver at home may lead to extreme morbidity for Anna or her baby, ultimately utilizing unnecessary resources when care is sought, there are no data to suggest that might be the case.
I believe that as a physician it is my duty to offer a recommendation to my patients based on my years of training and experience. While discord can be uncomfortable with patients with whom I disagree, I owe it to the women I care for to enter a dialog surrounding their medical choices and to engage in thoughtful discussion and respectful debate. What I quickly found in speaking with Anna was that she, like many of my patients, was smart, well-informed, and had the best interest of her family in mind. As I listened to her, our dialogue extended beyond an attempt to convince her to deliver in a hospital and allowed me to understand why she was making her decision.
Further, the truth is, Anna was not asking me to provide services outside an accepted practice or beyond what would be deemed standard of care. In fact, she was merely omitting herself from that care -- a personal decision. When a decision about a medical intervention has little to no impact on society at large and when there are no clear, well presented data to guide a decision, I have learned to respect a woman's right to make her own choices. Of course, even those who support and advocate for home birth would agree that the option is not viable for a complicated pregnancy or when a delivery has a significant potential to require escalation in care. After I gave my recommendation to Anna, and she continued to voice her preference for a home birth, my job was to help her plan for the safest birth possible.
In an era where patients are seeking information beyond the advice of a medical provider and are vying for control of their medical care, medical professionals need to learn how to enter conversations where their recommendations may not be followed. Attempting to dissuade a convinced patient can be alienating, pushing the patient further away, and driving a chasm between the patient and provider ultimately benefiting no one. It is still the job of the medical community to offer information and voice a recommendation. Sometimes coming along side patients in shared decision-making, even when it goes against medical advice, may offer a chance for the best possible outcome.
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