- Should risk factors and HB be regulated
- What are the ethical considerations when a MW takes a client with risk factors?
- Do we consider risk to be on a spectrum? Or would we like to see some hard lines about what is considered risk and what is not?
- What role (if any) does choice regarding testing impact risk?
- Do you think that a woman choosing HB in the presence of risk factors is primarily driven by the mother or by MWs? What are the ethical implications of this difference?
- What about consent? Are mothers who choose HB with risk factors given adequate information about HB and risk factors? What would/does this look like?
- What do you think about the term "variation of normal"?
- How do your own experiences with HB impact your opinion this issue?
I think the discussion of anemia and home birth hits all of these topics listed above.
Should risk factors and HB be regulated?
Many places, a maternal hemoglobin lower than 10g/dl is considered a contraindication to OOH birth. Is this appropriate? Or is this a risk factor that can be brushed aside as a 'variation of normal'?
What are the ethical considerations when a MW takes a client with risk factors?
There are so many ethical considerations when a MW knowingly takes on a client with risk factors. Does the client understand the risks? Is the MW trained and skilled and staffed to handle any complications that may arise from this increased risk? Is the midwife influencing the client with her own comfort level with certain risk factors? What are the ethical implications when a MW openly states that she takes on clients with risk factors. Or if the MW decides that a hemoglobin of < 10g/dl is not a contraindication to OOH birth? What if the MW believes that a lower hemoglobin is actually *better* for the mother? Is this ethical?
What role (if any) does choice regarding testing impact risk?
Well, if we don't perform screening or diagnostic tests during pregnancy, we can't really know which risk factors are present. Is it ethical to practice blindly - say, not knowing blood type, CBC, maternal antibodies, etc? A client has a right to refuse any and all tests - yet what is the responsibility of the MW to gather this data and base decisions on known information. If as a MW I allow my clients to refuse to have their hemoglobin checked, and the client suffers a morbid blood loss at a planned OOH birth related to undiagnosed anemia, am I not responsible as the MW for omitting this crucial assessment? Or is this solely the client's responsibility? The client refuses a standard of care, the MW agrees to this deviation of care, the client suffers, and it is the client's responsibility? No, I don't agree to this at all. At some point, refusing testing is a valid rationale to risk a client from the MW's care.
Choice regarding testing impacts risk quite a bit. Though too often, an 'unknown status' is treated like "WNL"
Do you think that a woman choosing HB in the presence of risk factors is primarily driven by the mother or by MWs? What are the ethical implications of this difference?
What about consent? Are mothers who choose HB with risk factors given adequate information about HB and risk factors? What would/does this look like?
I used to believe that the choice to have an OOH birth in the presence of risk factors was primarily driven by the mother. After my experience with OOH births and MWs, I believe it is more driven by the MW's 'comfort' in higher-risk situations. It is very rare that a home birth client has the medical background to understand the risks of OOH birth, and the types of critical situations that could arise, and the near impossibility of OOH providers to handle certain complications without serious repercussions in the OOH setting. There are a few clients like this - but they are very few. I find that most parents/clients trust the MW's comfort level - and when a MW expresses comfort with a certain situation, they are led to believe it is safe.
What are the ethical implications of this? Well, it goes against the ethical principle of veracity - the duty to tell the truth. This is tricky because verbally, the MW may recite the all the risks, but non-verbally, the MW may be expressing comfort, and the biggest non-verbal cue would be the MW's willingness to continue to plan an OOH birth. WOW. What confusion for the client!
Consent in this situation.... needs to be clear, with no ambiguity. "This poses an increased risk to your health, your life, your baby's health, your baby's quality of life." Sorry if this sounds like fear-mongering. But too often, we want to bet our money on everything turning out 'just fine' because they probably will. This is a disservice to clients who are misled into believing their risk factors are inconsequential. Informed consent has to be pretty powerful - and let's not forget that true informed consent involves presenting alternatives. <---- that's plural. It's my responsibility to share with the client ALL the alternatives in a given situation (if there is sufficient time). Not "Well, you can go to the evil hospital and have an induction and a c-section" but "Dr A works in hospital B and can take on your care." "Dr B works in hospital C, and the OB nurses are very mother-baby friendly," or "CNM D has a great collaborative relationship with DR E, they practice about an hour away, but they also have very holistic care."
Informed consent from the MW would, in my ideal world, include the following: "I am not trained or skilled in handling this situation, and in my professional judgment, you are safer in a hospital setting with access to skilled staff and emergency equipment."
I actually do believe in informed consent. But in certain situations, I would want the client to know that a decision to birth at home is NOT a safer one. But a riskier one. That would need to be VERY clear. No pretending that: 1) the risk factors are not meaningful, 2) the birth is appropriate for OOH, 3) the MW is equipped to handle these complications.
What do you think about the term "variation of normal"?
Largely a matter of opinion. I've heard it used often to describe situations that are NOT normal. Not even close to normal. It's used to reassure clients that they do not need to transfer their care to a physician. Or it's just wishful thinking by the MW. Maybe a combination of these two things.
I *do* believe there are some variations of normal.... not a fan of the Friedman curve... but have seen deviations from the Friedman curve that I would consider truly 'variations of normal' and others that clearly were not. A matter of opinion.
If we're talking about hemoglobin. I'm not one that would take risks with an anemic mother at home. This seems to be asking for trouble. A heavy blood loss can make the most beautiful, glorious natural birth a very difficult and traumatic experience. My role as a provider is to assure the gentlest passage possible - having an anemic post-partum mother with delayed lactogenesis is not a gentle birth experience! It is a very difficult experience.
How do your own experiences with HB impact your opinion this issue?
Personal opinions and experiences play HUGE roles in normalizing certain conditions in OOH birth. How many stories are out there about women with ***significant*** risk factors having *successful* homebirths?
I've had OOH births with risk factors, but I do not broadcast these risk factors to the world because I know they were risk factors. Telling others that my births ended up 'just fine' is misleading, and because of my professional status, I also believe it is unethical. Some of the risks I was "comfortable with" at home - others I think should have been handled in the hospital. I can't go back and change that. And I was in no mindset during labor to critically and objectively evaluate my situation. Yes, I consider myself educated and intelligent - but labor is mind-altering. Only in retrospect can I think clearly about the decisions that were made (not by me, but on my behalf!) during my OOH labors.
I know enough to know that my personal experiences and opinions are not sufficient reasons to reassure others that risk factors can be ignored or minimized.
Even with significant increased risk, most births will turn out 'just fine'. This creates a very distorted picture of risk.
Should I tie this back to hemoglobin levels? If I decide that 10g/dl or less is an acceptable level for mothers planning OOH birth, how many women who meet this criteria will suffer under my care? How many will have difficult postpartum recoveries? How many will have uneccessary breastfeeding challenges and delayed milk production? How many will require fluid resuscitation or blood transfusions? How will their risk of postpartum transport increase - I would expect a higher percentage of anemic mothers to have to transport for PP complications than the non-anemic mothers. Is this acceptable practice?
HUGE topic, here. Hard to keep it short. Thank you for letting me express myself here.