Takeaway
During the pandemic, many women are forced to consider alternatives to hospital births. It's vital for obstetric providers to be open to facilitating safe births regardless of the setting.
Lifelong Learning in Clinical Excellence | May 5, 2020 | 3 min read
By Frances Wang, grad student at Johns Hopkins Bloomberg School of Public Health, George Zhang, grad student at Johns Hopkins Bloomberg School of Public Health, Marielle Gross, MD, Johns Hopkins Berman Institute of Bioethics, Sarah Frey, grad student at Johns Hopkins Medicine, Vivian Nguyen, Johns Hopkins medical student 2020
During the COVID-19 pandemic, the importance of avoiding hospitalization whenever care can be delivered to patients at home is an ethical imperative. Childbirth is the most common indication for U.S. hospital admission. Home birth may offer an intriguing, but controversial alternative.
Current recommendations
The U.S. standard of care is delivery in a hospital or birth center, and there is disapproval of planned home birth due to concern that potentially life-saving interventions aren’t immediately available. The American College of Obstetricians and Gynecologists (ACOG) recommends against home birth given U.S. data showing increased neonatal morbidity and mortality compared to hospital birth. Notably, malpresentation, multiples, and prior cesareans are considered absolute contraindications due to further neonatal risks.
At baseline, some women seek to avoid hospital birth due to iatrogenic harms, excess costs, cultural dissonance, and potential emotional or physical trauma. The medical benefits of home delivery include decreased operative vaginal or cesarean delivery rates and fewer severe perineal lacerations. However, most U.S. women view labor and delivery without full benefits of hospital resources as unacceptably risky. Thus, over 98% of births occur in hospitals and only 1% deliver at home.
The changing paradigm
However, given the increased danger due to hospitalization during COVID-19, this balance of risks and benefits may have shifted. Increasing restrictions on hospital visitors and potential separation of mother and baby for infection control practices are amplifying concerns about hospital birth. Pregnant women suddenly find themselves caught between stay at home orders, advice to avoid hospitals unless absolutely necessary, and expectations of hospital birth plans. The demand for home births has skyrocketed. Where disease burden is the greatest, some are choosing to selectively travel to hospitals with less COVID-19 burden to give birth. This increases the risk of viral spread.
Data talks . . . or does it?
Clinicians need to revisit this issue. The most important benchmark of patient safety during home birth is the presence of qualified birth attendants with appropriate support and access to timely hospital transfer. However, the U.S. observational data supporting our current recommendations are limited and notably confounded, as they don’t control for these protective factors. Additionally, selection bias and low absolute numbers of adverse events contribute to difficulty applying the limited data available to individual patients seeking guidance. Meanwhile, data from other high income countries, where home birth is well-integrated into the health system, describe no increased neonatal morbidity or mortality compared to hospital birth. Likewise, ACOG endorses birth centers, which similarly guarantees appropriate support and have outcomes equal or better than hospitals.
How to change with the changing times
We also must admit that, as obstetricians, our aversion to home birth is colored by traumatic experiences of negative outcomes, including tragically botched failed home births, fueled by a hostile medicolegal environment. It doesn’t help that outside of COVID-19, much of the discourse has been dominated by tension between obstetricians, for whom erring on the side of caution means intervening, and those who rebuke medicalization of pregnancy and birth. Patients and providers may be at an impasse between too little, too late and too much, too soon.
The question becomes: can we deliver the safety of birth centers to women at home during the pandemic? And how do we optimize outcomes for women who are not ideal home birth candidates, but nevertheless choose it?
We’re currently exploring the appropriate steps to increase safety of home birth during COVID-19 and potentially beyond. We advise the following steps to be implemented immediately to reduce harm to maternal and neonatal morbidity and mortality due to the pandemic.
1. Non-judgmentally screen all patients’ birth plans.
2. Educate yourself on risks, benefits, and safe alternatives to hospital birth.
3. Give individual recommendations and shared decision-making that addresses each woman’s unique circumstances, including access to appropriate home birth support.
4. Facilitate linkage to integrated care for those who choose home birth.
5. Consider efforts to expand or redeploy obstetrical providers to non-hospital settings.