The AAP responds to obstetrician criticism of its homebirth position


You may recall that last fall the American Journal of Obstetrics and Gynecology published a position paper opposing homebirth and I savaged it (You heard it here first: new paper opposing homebirth is poorly researched, relies on bad studies and is woefully paternalistic).

The paper in question is The paper is Planned home birth: the professional responsibility response by Chervenak et al.

Chervenak is presenting a personal, religious philosophy on maternal autonomy and fetal beneficence and it would have been appropriate for him and his colleagues to acknowledge that their views are not supported by the mainstream medical ethics community. Simply put, in light of American law, and non-religious moral ethics, Chervenak et al. are wrong about the extent of women’s autonomy and women’s ethical obligations toward their unborn children.


Women’s well established right to medical autonomy is not “rights-based reductionism”; it is a foundation of medical ethics. Professional responsibility never involves forcing patients into doing what you recommend or harranging them for failing to follow your recommendations. Professional responsibility requires informed consent, nothing less and most certainly, nothing more.

Chervenak et al. have now taken their incorrect and misguided argument to the journal Pediatrics. In a paper entitled Planned Home Birth: A Violation of the Best Interests of the Child Standard?, Chervenak actually has the temerity to accuses the AAP of violating ethical standards in their position statement on homebirth, published earlier this year.

The AAP statement correctly states that hospital birth is the safest form of birth. However, the effect of this statement is to sanction, and unintentionally enable, planned home birth if certain circumstances are met. However, meeting these circumstances does not eliminate the preventable, increased perinatal risks of planned home birth. The AAP should consider withdrawing
this sanction and replacing it with the professional responsibility of pediatricians to be strongly directive in recommending against planned home birth and recommending in favor of planned hospital birth. The AAP should also emphasize the professional responsibility of pediatricians not to participate in planned home birth, except in the very limited circumstances described in this article. Pediatricians should support creating settings that resemble home birth in the hospital and in birthing centers that are in or adjacent to hospitals.

Once again, Chervenak et al. are spectacularly wrong are wrong about the extent of women’s autonomy and women’s ethical obligations toward their unborn children.

Not surprisingly, the American Academy of Pediatrics (AAP) has responded sharply to the accusation, Policy Statement on Planned Home Birth: Upholding the Best Interests of Children and Families written by Kristi Watterberg on behalf of the Committee on Fetus and Newborn.

The arguments made by Chervenak et al regarding the “best interests of the child” have several notable flaws. First, before delivery, the fetus is not an independent being (child), but a fetus, and the authors inexplicably ignore both the ethical principle of autonomy for the expectant mother and the difficult balance of maternal and fetal benefits and harms. Previous commentary by these authors advocates overriding both maternal and fetal rights, arguing instead for the “professional responsibility model of obstetric ethics … In other words, it appears that physician beneficence is the dominant ethical principle, and that when a pregnant woman becomes an obstetric patient she gives up her autonomy and her decision-making capability to the physician…

Watterberg concludes:

…[W]e firmly believe that the policy statement on planned home birth follows the AAP mandate to promote the best interests of children and their families, by acknowledging maternal and family autonomy and the complexity of their decision-making, by setting rigorous standards for care of infants born in any setting, and by promoting increased professional collaboration and communication.

Watterberg is correct.

Chervenak et. al, in addition to being wrong about the ethical principles that govern a woman’s right to choose homebirth,  appear to believe that they speak for most obstetricians when the reality is the opposite. Most obstetricians recognize that both medical ethics and the law requires that a woman’s decision to choose homebirth must be respected.

Chervenak and colleagues are certainly entitled to their personal opinions, but that’s all they are, merely their personal opinions. It is deeply unfortunate that they have chosen to mistake their personal beliefs for the ethical principles that govern contemporary medical practice.