The home birth debate: Why scientists need to pay attention to values

This presentation is part of the The Role(s) of Values in Science track. A growing number of scientific studies show that, among low-risk women, there is no increased maternal or neonatal risk for planned home births compared to planned hospital births (Janssen et al, 2002; Fullerton et al, 2007; de Jonge et al. 2009). Nonetheless, the American Medical Association (AMA) and the American College of Obstetricians and Gyneocologists (ACOG) have both recently adopted resolutions strongly opposing home births for any woman because they believe that the safest setting for labor and delivery is in the hospital or a birthing center within a hospital complex (ACOG 2008; AMA 2008). In fact, the AMA is currently supporting legislation that would make it illegal to give birth or assist a birth out of a hospital setting (AMA 2008). Interestingly, the ACOG and AMA resolutions provide no references supporting their claim that a hospital setting is the place for labor delivery. The ACOG statement does claim, however that the studies comparing the safety and outcomes of hospital and home births are “limited and have not been scientifically rigorous.” At the same time, organizations such as the American College of Nurse-Midwives, the American Public Health Association, the Midwives of North America, and proponents of home birth have argued that the ACOG is simply disregarding the scientific evidence on the relative safety of planned homebirths and that it is applying to out-of-hospital birth scientific evidence a standard that other ACOG obstetric recommendations do not meet (Cohain 2008; Young 2008; Lowe 2009). It is true that there are several obstacles to conducting empirical studies on the relative safety of home births for low-risk women. First, because in some countries like the US a very small umber of women have planned homebirths, it is often difficult to conduct a study with a sufficiently large sample size. Second, because pregnant women cannot be assigned a place of birth regardless of their preferences, ethical and practical reasons make it impossible to conduct randomized clinical trials. Third, there are limitations related to a variety of confounding variables such as how to determine the skill of the birth attendant, when birthing location counts as planned or unplanned, and how to determine when women are low-risk. Given this state of affairs, one might be tempted to conclude that the conflict between opponents and proponents of home birth is solely the result of empirical or methodological disagreements about how to conduct home birth safety studies. Hence, where the opponents of out-of-hospital births are skeptical about the possibility of performing well-designed research studies of sufficient size, the proponents simply point to the existence of such studies. The purpose of this presentation is to argue that the dispute between opponents and proponents of the safety of home birth is not solely a product of empirical or methodological disagreements. Rather, disagreement about the evidence for the safety of homebirths is grounded on disagreements over particular epistemological and ethical values that are often implicit, as well as over the weight that those values should be given. Specifically, we show that disputes about the relative safety of home births depend on value judgments about 1) what counts as good evidence in medical science (including what sort of data should be collected, how outcomes should be measured, and whether the precautionary principle should be employed), 2) what counts as maternal and neonatal risks, 3) how risks ought to be weighed, and 4) which background assumptions are most appropriate in interpreting data. If our claims are correct, continuing this debate by focusing exclusively on methodological issues is unlikely to solve the impasse between those who reject the safety of out-of-hospital births and those who support the availability of home birth as a safe option for low risk women. What is needed, in order to move the debate about home birth forward, is to ensure that the value judgments underlying the choice of particular methodologies, the interpretation of evidence, and the design of clinical trials are made explicit and are critically evaluated by a diverse group of stakeholders. We take this case to be illustrative of a larger problem. Regardless of a growing body of literature, scientists still work under the assumption that they need not (and should not) endorse any particular social or ethical values. There is fear that doing so is likely to lead to bias. This case shows that failures to be attentive to the values at stake in research can cause scientists to talk past each other and may lead to public policy that is not really supported by the best evidence available. Good science requires careful attention to the evidence, adequate research methodologies, and suitable questions. But as necessary as all these factors are, they are not always sufficient. For some type of research at least, attention to the value judgments that underlie such research is also essential