On June 11, 2013, the first day of the Greek Home Birth Trials (against 79 parents, midwives and doctors), the attached letter appeared on the Greek OBGYN and Midwifery Society, as a warning against home birth.
Through the Greek branch of ENCA (European Network of Childbirth Associations), “ENCA –Hellas”, doctors, midwives and lawyers are making a public reply to this letter (also attached). We are defending the mother’s basic right to choose the conditions of her child’s birth, a legally protected right which is recently being threatened, especially in Greece. According to this year’s CEDAW, The U.N.’s Committee on the Elimination of All Forms of Discrimination Against Women, Greece has the highest percentage of cesarean section in the world. Most of these cesareans are performed under general anesthesia.
The Hellenic Action for Human Rights - "pleiades" (NGO), that has been active in birthrights in Greece, co-signs the following letter.
We are sharing our reply with you, as a “heads-up” on some major legal battles to come, regarding the rights of women in childbirth, in our country and in the European courts.
For more information, ways you can help, or if you would also like to sign our reply,
please contact:
please contact:
Dr. Roland Pavlou
E-mail: rpavlou63@gmail.com
OPEN LETTER
TO THE GREEK OBSTETRIC AND
GYNECOLOGICAL ASSOCIATION
Dear Sirs,
With respect to your recent circular (see footnote 1) entitled
“Home birth” (http://www.hsog.gr/gr_upload/htmlarea/toketos%20sto%20spiti.pdf)
we would like to underline the following:
“Home birth” (http://www.hsog.gr/gr_upload/htmlarea/toketos%20sto%20spiti.pdf)
we would like to underline the following:
1. Your claim that the rate of home births
presents a downward tendency has no scientific basis. In the USA
2. Your
statement that “the risks of perinatal death in home births is triple that in
hospital births” is not an “indisputable fact” as you claim. The
only study supporting it is that of Wax JR et al, 2010 [3]. We do not know why
you avoided listing it in your document references, while you referred to the
dialogue that followed. This study however was the object of intense criticism
by a large number of researchers because of its arithmetic and calculation
errors, because it selectively included only those studies that supported the desired
outcome, because it defined perinatal death according to criteria different to
those of the studies it relied on, because it excluded births with congenital
anomalies while the studies it relied on did not [4] [5] [6] etc. The criticism
was so intense that the editors of the American Journal of Obstetrics and Gynaecology,
which accommodated the debate, concluded in the end that “it is clear that we need more rigorous and better designed research on
this important safety issue of home birth, given the many confounding factors”
[7]. The fact that in spite of all the criticism the American College
We are obliged
to refer to a number of studies around the world which prove that home births have
similar or lower perinatal mortality, fewer complications, better APGAR scores,
fewer medical interventions (epidural, induction, episiotomy, forceps,
caesarian) and more infrequent need for subsequent neonatal intensive care
[9-24]. Some of these studies involve large numbers of cases, even 700.000
[19].
3. Your statement
that the selection of low-risk mothers as candidates for home birth can only be
accomplished by an obstetrician – gynecologist is in contrast to international
practice and attempts to exclude midwives from their vested professional duties
and rights. The role of midwives is not restricted to supporting obstetricians
and gynecologists. They have a vested right to practice their professional
duties independently and guide a pregnant mother without complicating or
high-risk factors to birth and refer according to their own professional
judgment only cases calling for medical intervention to an obstetrician or a
hospital. On the issue of inadequate training of the personnel involved in childbirth
(you apparently refer to midwives) and the “lack” of supportive infrastructure for
home births which you mention, we would expect that an association like yours would
(as far as you feel there is such lack) use its outlook to appeal to the state to
take all necessary measures to immediately upgrade and modernize training of
the involved personnel and improve and integrate the necessary infrastructure.
However, as you very well know, the lack of support for home births by nearby
hospitals and clinics results not from lack of funds or training or
organization, but from the reluctance of your colleagues to work together with
health professionals handling home births. According to studies the correct selection
of “low-risk” mothers as candidates for home birth leads to fewer complications
and less need for emergency transfer to a hospital [25].
4. The mother, after the “detailed and documented information by the obstetrician” on the risk of complications you mention, does not “express an opinion”! She decides! This right (which includes her right to refuse medical interventions on her body) is an expression of the right of self-determination and is enshrined in the Greek Constitution, the European Convention of Human Rights, but also in the Greek Medical Code. In the case of Ternovszky vsHungary 14/2/2011 ) the European Court of Human
Rights (ECHR) is very explicit on the protection of the right of choice of the circumstances
of birth: “The notion of a freedom implies some measure of
choice as to its exercise. Therefore the right concerning the decision to
become a parent includes the right of choosing the circumstances of becoming a
parent” [26]. We consider it self-evident that the choice of childbirth
circumstances includes the choice of place, persons present and interventions
in the natural process of labour. We would also point out that maternity does
not limit the right to body self-determination. Additionally, the mother is by
nature the most appropriate spokesperson for the rights of her unborn child.
4. The mother, after the “detailed and documented information by the obstetrician” on the risk of complications you mention, does not “express an opinion”! She decides! This right (which includes her right to refuse medical interventions on her body) is an expression of the right of self-determination and is enshrined in the Greek Constitution, the European Convention of Human Rights, but also in the Greek Medical Code. In the case of Ternovszky vs
5. The
mother’s right to choose the circumstances of childbirth cannot be curtailed
through indirect, administrative legal measures concerning the issuance of
birth certificates etc, as implied in your document. Whichever administrative
procedures are chosen, they will have to serve the constitutional human rights
in childbirth to be legal.
6. The
conditions in Greek hospitals and clinics are not as great as you describe. It
is sufficient to mention the CEDAW report on Greece Greece Greece Greece Greece Greece
In conclusion,
we invite you to withdraw your document and contribute to a national campaign for
unbiased coordination of all health professionals involved in childbirth (including
obstetricians – gynecologists, midwives, neonatologists, emergency services
personnel, neonatal intensive care units personnel) to ensure the best possible
outcome for all childbirths, wherever the mothers decide to have them.
SIGNATURES:
Network for
Respect in Childbirth – ENCA Hellas
Konstantinos Anagnostopoulos, orthopedic
Maria Gosma, midwife
Eleanna Ioannidou, lawyer
Vassiliki – Anna Kakkava, gymnastics teacher, midwife
Paschalina Kambouridou, midwife – IBCLC
Electra Koutra, lawyer
Cassiani Mihopoulou, lawyer
Rolandos Pavlou, doctor
Helen Serpetini, midwife
Spyridon Christopoulos, pediatrician
Konstantinos Anagnostopoulos, orthopedic
Maria Gosma, midwife
Eleanna Ioannidou, lawyer
Vassiliki – Anna Kakkava, gymnastics teacher, midwife
Paschalina Kambouridou, midwife – IBCLC
Electra Koutra, lawyer
Cassiani Mihopoulou, lawyer
Rolandos Pavlou, doctor
Helen Serpetini, midwife
Spyridon Christopoulos, pediatrician
Hellenic Action for Human RIghts - "pleiades" (NGO)
REFERENCES:
1. MacDorman MF, Mathews
TJ, Declercq E. Home Births in the United
States 2000-2009. NCHS Data Brief 84;Jan 2012
2. MacDorman M, Declerq E, Menacker, Fay. Trends and characteristics of home births in
the United
States
3. Wax, J. R., F. L. Lucas, et al. (2010). “Maternal and
newborn outcomes in planned home birth vs planned hospital births: a
metaanalysis.” Am J Obstet Gynecol 203(3): 243 e241-24
4. Gyte G, Newburn M, Macfarlane A. Critique
of a meta-analysis by Wax and colleagues which has claimed that there is a
three-times greater risk of neonatal death among babies without congenital
anomalies planned to be born at home. NCT 2010 (cited 2011 March 1:1-8)
5. Keirse MJ. Home birth: Gone away, gone astray, and here
to stay. Birth 2010;37(4):341-46
6. Michal CA, Janssen PA,
Vedam S,, Hutton EK, Jonge A, Planned
Home vs Hospital Birth: A Meta-Analysis Gone Wrong. Medscape Ob/Gyn & Women's Health -
http://www.medscape.com/viewarticle/739987
7. Editors’ Comment. Amer J Obstet Gynecol 2011;e20
8. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 476: Planned home
birth. Obstet Gynecol 2011; 117:425
9. de Jonge A, van der
Goes BY, Ravelli AC, Amelink-Verburg MP, Mol BW, Nijhuis JG, Bennebroek
Gravenhorst J, Buitendijk SE Perinatal
mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home
and hospital births BJOG. 2009 Aug;116(9):1177-84
10. Olsen O, Jewell D, Home versus hospital birth, Cochrane
Database of Systematic Reviews September 12, 2012
11. Leslie Ms, Romano A.
Birth can safely take place at home and
in birthing centers. J Perinat Educ 2007;16(Suppl1):81S-88S.16
12. Olsen O. Meta-analysis of the safety of home birth.
Birth 1997 Mar;24(1):4-13;discussion 14-6
13. Janssen PA, Saxell
L, Page LA, Klein MC, Liston RM, Lee SK. Outcomes
of planned home births with registere midwife versus planned hospital birth
with midwife or physician. CMAJ 2009;181(6):377-83
14. Hutton E, Reitsma A,
Kaufman K. Outcomes associated with
planned home and planned hospital births in low-risk women attended by midwives
in Ontario, Canada, 2003-2006: A retrospective cohort study. Birth
2009;36(3):180-89
15. Janssen PA, Lee SK,
Ryan EM, Etches DJ, Farquharson DF, Peacock D, Klein MC. Outcomes of planned home births versus planned hospital births after regulation
of midwifery in British Columbia
16. Johnson K, Daviss BA. Outcomes of planned home birth with
certified professional midwives: large prospective study in North
America . BMJ 2005;330;1416
17. Schlenzka PF. Safety of alternative approaches to
childbirth. Palo Alto , CA Stanford University 19999
18. Birthplace in England England
19. Van er Kooy J, Peoran J,
de Graff JP, Birnie E, Denktas S, Steegers EAP, Gouke JB. Planned home compared with planned hospital births in the Netherlands
20. Kennare R, Keirse MJ,
Tucker GR, Chan AC. Planned home and
hospital births in South Australia 1991-2006: differences in outcomes. Med
J Aust 2009;192(2):76-80
21. Chamberlain G, Wraight A,
Crowley P. Home births: Report of the
1994 confidential enquiry of the National Birthday Trust Fund. Cranforth , UK
22. Ackermann-Liebrich U,
Voegeli T, Gunter-Witt K, Kunz I, Zullig M, Schindler C, Maurer M. Home versus hospital deliveries: follow up
study of matched pairs for procedures and outcome. Zurich
23. Wiegers TA, Keirse MJ, van
der Zee J, Berghs GA. Outcome of planned
home and planned hospital births in low risk pregnancies: prospective study in
midwifery practices in the Netherlands
24. de Jonge A, Mesman J, Manniën J, Zwart J,
van Dillen J, van Roosmalen J. Severe adverse
maternal outcomes among low risk women with planned home versus hospital births
in the Netherlands: nationwide cohort study.BMJ 2013;346:f3263
25. Amelink—Verburg MP, Verloove-Vanhorick SP, Hakkenberg RMA, Veldhuijzen
IME, Bennebroek Gravenhorst J, Buitendijk SE. Evaluation of 280 000 cases in Dutch midwifery practices: A descriptive
study. BJOG 2008;115:570-78
26. http://hudoc.echr.coe.int/webservices/content/pdf/003-3372071-3778873
27. CEDAW/C/GRC/7;
CEDAW/C/GRC/Q/7;Summary record of the 1112th meeting, 28 Feb 2013 ;par.6
28. CEDAW/C/GRC/7;
CEDAW/C/GRC/Q/7;Summary record of the 1112th meeting, 28 Feb 2013 ;par.12
29. CEDAW/C/GRC/7; CEDAW/C/GRC/Q/7;Summary
record of the 1112th meeting, 28 Feb 2013 ;par.19
30. CEDAW/C/GRC/7; CEDAW/C/GRC/Q/7;Consideration of reports submitted by States
parties under article 18 of the Convention on the Elimination of All Forms of
Discrimination against Women, 14 Mar 2013; article 12; par 258
FOOTNOTE 1.-
1.GREEK OBSTETRIC AND GYNAECOLOGICAL ASSOCIATION
Member of FIGO & EBCOG
ALKAEOU 10 · ATHENS
HOME BIRTH
chairman
V. TARLATZIS Professor, Thessaloniki University
Deputy Chairman
I. E. MESSINIS
Professor,Thessalia University
Professor,
Gen. Secretary
A. LOUFOPOULOS Professor,Thessaloniki University
Spec. SecretaryD. CASSANOS
Professor,Athens University
Professor,
Treasurer
N. VRACHNIS
MembersG. Galazios
Professor
Thrace University
G. Gribizis
TH. STEFOS
Professor,Ioannina University
G. FARMAKIDES
NHS Manager
Former Assoc. Prof.
Crete University
Former Assoc. Prof.
Home birth has in recent years been an option for a small number of women in some countries. England Netherlands
It is an undisputable fact that resent studies have shown that mortality rates in home births are triple those in hospital births [1], leading to a dramatic revision of this practice. There are now particularly strict guidelines for characterizing pregnancies as “low risk”, limited to multiparous and excluding nulliparous pregnancies [2-3].
Furthermore, it is common knowledge that a pregnancy free of any risk factors and a normally progressing labor can at any moment present serious and sometimes even lethal complications, such as maternal heavy hemorrhage, fetal shoulder dystocia or fetal cardiopulmonary resuscitation. It is imperative that such complications should be treated in an organized location with strict specifications, by multi-person and well-trained groups, capable of addressing any rapidly aggravating incident.
The choice of cases characterized as “low risk” is also of critical importance. This cannot be accomplished with a superficial approach. It can only be achieved through an integrated assessment by a suitably trained Obstetrician – Gynaecologist.
The need for immediate transfer [to a nearby medical centre] is emphasized in all countries with experience in home births [4]. A functioning national health system would ensure a fast and safe transfer to an organized hospital. The question is therefore how feasible is the immediate transfer (in a short time) to an organized unit under the present conditions of the country.
We believe that in respect to home birth we are at a very early stage in Greece
parent and child identification in home births. The state should work on extended legal framework concerning the protection of women and accountability.
Every woman is indeed entitled to express her opinion on the method and place of birth, after a detailed and evidence-based information by the attending obstetrician on the risks and possible complications based on international resources and practice, in a decision on which two lives depend: her own and that of her fetus. In conclusion, we feel the need to refer to the extremely high quality of services provided by Greek birth centers (public and private), with the lowest complication rates in Europe, which has often been highlighted by international press, describing Greece as the safest country for births.
1. Kirby, R.S. and J. Frost, Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol, 2011. 204(4): p. e16; author reply e18-20, discussion e20.
2. Brocklehurst, P., et al., Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England
3. Buekens, P. and M.J. Keirse, In the literature: home birth: safe enough, but not for the first baby. Birth, 2012. 39(2): p. 165-7.
4. Rowe, R.E., et al., Transfers of women planning birth in midwifery units: data from the birthplace prospective cohort study. BJOG, 2012. 119(9): p. 1081-90.
