Besides examining the evidence, the reviewers also address the interplay of autonomy and concern for fetal rights. Having recently participated in similar discussions at the Human Rights in Childbirth Conference, I was excited to see the following commentary:
This review shows that there is no strong evidence to favour either planned hospital or planned home birth for selected, low risk pregnant women. From an autonomy-based ethical perspective the only justification for practices that restrict a woman’s autonomy and her freedom of choice, would be clear evidence that these restrictive practices do more good than harm (Enkin 1995), as we stated in the previous version of this review (Olsen 1998). A decade later, the European Court of Human Rights in Strasbourg handed down a judgment stating that “the right to respect for private life includes the right to choose the circumstances of birth”. Thus, no matter what the level of evidence is, European governments are not allowed to impose, e.g. “fines on midwives assisting at home births” as it “constitutes an interference in the exercise of the rights ... of pregnant mothers” (Registrar 2010). On the other hand, the ethical concept of the fetus as a patient (Chervenak 1992) may lead some to state that “Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it” (Chervenak 2011) and that “In clinical practice it involves recommending … aggressive management (interventions such as fetal surveillance, tocolysis, Caesarean delivery)” (Chervenak 1992). In this ethical perspective recommendations about interventions are acceptable even when they are not supported by randomised controlled trial (RCT) data. The lack of strong evidence from RCTs and an autonomy-based ethical perspective lead to the conclusion that all countries should consider establishing home birth services with collaborative medical back up and offer low-risk pregnant women information about the available evidence and the possible choices.One of the limitations of a Cochrane Review of home birth is the very small number of RCTs on home birth. I highly recommend reading the chapter on home birth in Amy Romano and Henci Goer's new book Optimal Care in Childbirth. They examine a large number of high-quality studies that the Cochrane Review does not include. (My review of this book is forthcoming.)
The updated Cochrane Review is significant for those working to reform American maternity care policies. Notice the language supporting autonomy, accurate information, integrated home birth services, and professional collaboration from last year's Home Birth Consensus Summit. The new Cochrane recommendations should make it easier to translate these consensus statements into action:
- We uphold the autonomy of all childbearing women....Shared decision making includes mutual sharing of information about benefits and harms of the range of care options, respect for the woman’s autonomy to make decisions in accordance with her values and preferences, and freedom from coercion or punishment for her choices. (Statement 1)
- We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes. All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits. (Statement 2)
- Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings. (from Statement 6)
For more information on the Cochrane Review on home birth:
"Amy Romano and Henci Goer's new book Optimal Care in Childbirth. They examine a large number of high-quality studies that the Cochrane Review does not include."
ReplyDeleteCochrane reviews have very clear criteria to define a high quality study acceptable for inclusion. If Romano and Goer include studies not included in the Cochrane review, they are of lower quality than acceptable for a systematic review. That doesn't mean they are not useful, but I'd be careful about labeling them high-quality in a context where definitions are sharp (and consistently applied across topics).
Allisen, I don't think that non-RCTs are necessarily of lower quality. There are some things that can't always be studied well with RCTs (like home birth, as the Cochrane authors discuss) and that's where other types of studies are quite important.
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