Asignaturas Optativas del Segundo Ciclo

1. In many parts of the world, women have no choice but to deliver their children in their homes, with support only of the resources at hand. Against an often scantily provisioned background, a choice to plan for childbirth either in a hospital or comparably equipped birthing centre, or alternatively to deliver at home, appears an indulgence. When patients’ medical choices are available, they should be offered adequate information of the reasonably foreseeable risks, benefits, and implications of each option, from persons qualified to provide such information. The ethical goal of offering information is to serve women’s self-determination and human rights to respect. 2. In December 2010, a leading international human rights tribunal, the European Court of Human Rights, ruled that a law that interferes with physicians’ participation in women’s choice of planned home birth violates the women’s human rights. The tribunal found that pregnant women have a right to respect for their private and family life, which includes the right to choose to give birth at home. A law that deters physicians from providing professional assistance, by direct terms or ambiguity, obstructs women’s exercise of their right to choose their place of giving birth.

3. Arguments against the choice of home birth rely on a medical professional consensus that home birth is less safe than birth in a health care facility, and that a newborn child’s right to life and health includes safe birth. Records exist of home births attended by health professionals resulting in emergency hospital admissions, as well as of deaths or serious injuries to babies and/or mothers in home settings. 4. Counterclaims point to risks of hospital-borne infections, excessive, unwanted medical interventions, particularly unnecessary surgical deliveries, and the stress of being left alone due to limitations or prohibitions on the presence of partners and family members. Claims are made that it has not been proven that home births pose greater risks than births in hospitals. Further, it is asserted that decisions about risks to newborns and/or mothers are to be made by the mothers themselves, as aspects of their human right to self-

determination and their parental responsibility, rather than by legislatures, governmental regulators or medical professionals. 5. The European Court cited WHO recommendations in a 1996 report

of a technical working group created by the Department of Reproductive Health and Research. Entitled Care in Normal Birth: a practical guide, the report notes that place of birth is an issue only in developed areas of countries, since in many parts of the world women have no choice but to give birth at home. The report also distinguishes high risk births, which should be managed in well staffed and equipped facilities, where they are accessible, from low- risk, normal births in which women have a choice between health facility and home delivery.

6. The report observes that, despite selective cases, there are generally inconclusive data on the relative safety of health facility and managed home births, but notes that women’s satisfaction tends to be higher in the latter. It reports that many factors deter women from choice of the former, including “the cost of a hospital delivery, unfamiliar practices, inappropriate staff attitudes, restrictions with regard to the attendance of family members at the time of delivery and the frequent need to obtain permission from other (usually male) family members before seeking institutional care.”

7. Properly attended home birth requires some essential preparations, including clean water, careful hand washing, a warm room and warm cloths or towels to wrap around the baby. There must also be at least some form of clean delivery kit as recommended by WHO, to create a clean site and give adequate treatment to the umbilical cord. The WHO report notes that “transport facilities to a referral centre must be available if needed,” but also recognizes obstacles in “parts of the world where fewer than 20% of women have access to any type of formal birth facility.”

8. The report presents a contradiction in that, in less developed parts of the world, women may have no access to the facilities or trained personnel they want to provide birthing care, whereas “[i]n a number of developed countries dissatisfaction with hospital care led small groups of women and caregivers to the practice of home births in an alternative setting.” Statistical data of outcomes were scarce at the

time it was written, but the report includes information from an Australian study that, in planned home deliveries, “the number of transfers to hospital and the rate of obstetric interventions was (sic) low. Perinatal mortality and neonatal morbidity figures were also relatively low, but data about preventable factors were not provided.” 9. The WHO report concludes that “a woman should give birth in a place she feels safe, and at the most peripheral level at which appropriate care is feasible and safe… For a low-risk pregnant woman this can be at home, at a small maternity clinic or birth centre in town or perhaps at the maternity unit of a larger hospital. However, it must be a place where all the attention and care are focused on her needs and safety, as close to home and her own culture as possible. If birth does take place at home...contingency plans for access to a properly- staffed referral centre should form part of the antenatal preparations.”

Recommendations

1. Where women have a choice to give birth in a healthcare facility or at home, healthcare providers should respect their right to prefer home birth. As with the choice of any patient, the patient should be informed about its risks and alternatives, and their implications. For instance, patients should be made aware that those at high risk of birth complications may not feel ill or show signs of distress, so that planning home birth should be carefully assessed.

2. Preparation for home birth should be as comprehensive as the circumstances allow, with clear and adequate contingency plans for transportation where feasible to a referral centre where properly trained and equipped services are accessible. A clean delivery kit as recommended by WHO should be made available.

3. Where the services of qualified obstetrician-gynecologists are not regularly available or requested, practitioners should collaborate to prepare midwives, nurses and/or other female caregivers, to support women approaching and in labour with their trained skills, emotional support and physical comfort, to reduce women’s anxiety. This should extend to preparation for labour, labour itself and postpartum

care of the mother and newborn(s) (see recommendations on Task- Shifting in Obstetric Care).

4. Where laws prohibit or prevent practitioners from providing assistance to women who propose home birth, practitioners and their professional societies should urge and collaborate in law reform to advance women’s human rights of choice, and to assure women of the best professional advice and care in making their decisions.

London, March 2012

TASK-SHIFTING IN OBSTETRIC CARE