(An
Appeal to Fathers to Apply Wisdom)
By
Mike Brewer and Matthew Brewer, RN, PHRN
Abstract
For
a variety of reasons women are choosing to give birth at home even
though there may be competent labor and delivery facilities in their
communities. One of the results of the Reformation was to view all
aspects of life in light of the Scriptures in obedience to Christ.
Great advances were made in science, commerce and industry as
Christians applied a Biblical ethic to all enterprises. If the
presupposition that all Scripture is sufficient for living a godly
life is accepted, the trend toward home birth in the Christian
community should be examined to determine if there is a sound
theological basis for this health care choice. The Scriptures
declare that though man is prohibited from murdering or maliciously
injuring his neighbor, he also has a duty to act to avoid or minimize
the risk of death and injury from probable and knowable risk. Men
applying wisdom in medicine have developed equipment, procedures and
treatments to repair patient injury, reduce disease infection and
improve infant survivability. Several of the complications of
delivery which historically have taken the lives of many mothers and
infants are treatable with a high probability of survival when
interventions can be promptly administered such as are available in the
labor and delivery ward of a hospital. As some of these
complications result in large blood loss or oxygen deprivation,
successful intervention requires rapid recognition and treatment.
The speed of needed intervention is on the order of minutes, which can be a
challenge for a hospital and is an even more difficult, if not impossible, feat for a
location outside of a medical facility. As fathers are called to be
the providers and protectors of their families, it is incumbent on them to seek the Lord in His Word and to apply the wisdom of the
Scriptures to their particular circumstance in faith and reverence.
Given that an ethically operated hospital with proper infection
control, trained staff and maintained equipment is available in the
community, it would seem difficult to justify avoiding the use of
such a facility in favor of intentional delivery of a newborn in a
location without prompt access to life saving interventions.
(Key
words: Home birth, Reformed Theology, Infant Mortality, Homeschool,
Fatherhood, Pregnancy Complications, Natural Medicine )
Biblical Ethics
Biblical Ethics
Many
women are choosing to give birth to their children at their own home
instead of at a hospital for a variety of reasons. This trend seems
to be associated with displeasure with the institutional medical
infrastructure and with an affection for natural medical practices. The
home birth movement seems to have some following among homeschoolers
who have eschewed governmental, institutional education for a home
based, tutorial methodology. For those families that homeschool for
religious reasons, we suggest that the theological basis for the
discipleship of their children should also be applied to their
medical decisions in the care of their children. Our premise is that
the Christian should seek the wisdom of God’s Scriptures first as a
foundation toward exercising judgement in the various circumstances
of life. If a person rejects this Christian ethic as foundational,
our essay on this issue will seem as nonsense to their perspective.
Our
presupposition is that all Scripture is sufficient and that the moral
law of God endures. Obedience of the law generates no saving
righteousness for the soul, but all souls have a duty to obey God. A
soul is only made righteous by repentance of sin and faith in the
saving life, death, burial, and resurrection of Jesus Christ.
In
the realm of medical ethics the summary command is to love our
neighbor as ourselves (Leviticus 19:18, Mark 10:31). The particular
commands in the ten commandments are “Thou shalt not kill”
(Exodus 20:13) and “Thou shalt not steal” (Exodus 20:15). It is
inferred that if you harm another person you have stolen that
person’s health, time and/or ability to work. So all men are
commanded to not subject themselves or their families (a neighbor) to
procedures that have the intent to kill or maliciously harm. The
Scriptures record that God declared this moral law enduring and
incumbent upon all men, not just the Hebrews or Christians. “And
surely your blood of your lives will I require; at the hand of every
beast will I require it, and at the hand of man; and at the hand of
every man’s brother will I require the life of man. Whoso sheddeth
man’s blood, by man shall his blood be shed: for in the image of
God made he man” (Genesis 9:5,6). The Jew, the Christian, the
Atheist, the Marxist, the Muslim and the pagan are all commanded to
obey the moral law of God.
The
case law in the Scriptures expands on the moral principle to not harm
another soul so as to include a burden to protect others from potential
harm that has a known probable risk. Consider the laws regarding a
goring ox in Exodus 21:28-29: “If an ox gore a man or a woman,
that they die: then the ox shall be surely stoned and his flesh shall
not be eaten; but the owner of the ox shall be quit (i.e. acquitted).
But if the ox were wont to push with his horn in time past, and it
hath been testified to his owner, and he hath not kept him in, but
that he hath killed a man or a woman; the ox shall be stoned, and
his owner also shall be put to death.” There are more nuances to
this case law but the clear moral principle is revealed that if there
is knowledge of a credible risk of injury to others and no prudent
action is taken, there is more culpability for the harm than if the
risk was unknown or unsuspected.
The
case law also discloses that the prenatal infant is due the protection of
the law (Exodus 21:22-25). The plain reading of Exodus 21:23, “And
if any mischief follow [to a fetus born prematurely due to an injury
to the mother], then thou shalt give life for life,” suggests that the
infant is due the same legal status of an adult that was murdered.
The phrase “life for life” would seem to refer to capital
punishment for the death of the infant. Regarding pregnancy and
childbirth, it can be inferred that the same standard of care due an adult
to protect him/her from credible risk would be due to an infant as well. In
addition, due to God’s teaching on His special anger for evil done
to the helpless and voiceless, since infants are not able to give
consent or defend themselves, the caregiver should afford a level of
care even more cautious than that due an adult.
Furthermore, the authority of the parent is not absolute in adjudicating what is life-saving care of an infant or child. If we read Psalms 82 as a rebuke against civil authorities (the judges of Israel), we see that God holds the judges culpable for not defending the case of the powerless. Being that the gestating infant is an extremely defenseless person, it is reasonable to infer that the state has a duty to protect the infant from the evil harm intended by an infant’s parents. Psalms 82:4 says to “... deliver the poor and needy: rid them out of the hand of the wicked.” Also we have the noble example of the Hebrew midwives who protected the Hebrew infants from the malice of Pharaoh (Exodus 1:15-22). In verse 17 we read, “But the midwives feared God, and did not as the king of Egypt commanded them, but saved the men children alive.”
So, in summary, it seems the Scriptures declare that there is a standard of care for infants that is at least equal to adults and that there may actually be an even higher standard of care in taking measures to avoid doing harm to infants. Those in responsibility such as fathers and civil authorities have some level of accountability for what happens in their jurisdictions. In the instance of life threatening circumstances, there is some overlap and both authorities have a duty to God to protect life even if it means to disobey the evil intent of another governing authority.
So why are professing Christians declining the use of competent medical facilities in regards to the birth of their children? Perhaps it is from a misconception of the risks and benefits of the medical facility. We are called to be diligent to understand consequences. “A prudent man foreseeth the evil, and hideth himself: but the simple pass on, and are punished. By humility and the fear of the Lord are riches, and honor, and life” (Proverbs 22:3,4). We are called to be humble and learn. We are called to be perceptive and take action. Regarding the birth of children at home, we are making the case to be wise. If a family is living where the hospital is filled with infection, incompetence and malice, it would be wise to give birth at home. Additionally, a family may live in a location where the distance to travel to a competent facility would be more hazardous than delivering the child at home. It would seem wise to not travel and provide the best care available in that remote location.
Medical Perceptions
Furthermore, the authority of the parent is not absolute in adjudicating what is life-saving care of an infant or child. If we read Psalms 82 as a rebuke against civil authorities (the judges of Israel), we see that God holds the judges culpable for not defending the case of the powerless. Being that the gestating infant is an extremely defenseless person, it is reasonable to infer that the state has a duty to protect the infant from the evil harm intended by an infant’s parents. Psalms 82:4 says to “... deliver the poor and needy: rid them out of the hand of the wicked.” Also we have the noble example of the Hebrew midwives who protected the Hebrew infants from the malice of Pharaoh (Exodus 1:15-22). In verse 17 we read, “But the midwives feared God, and did not as the king of Egypt commanded them, but saved the men children alive.”
So, in summary, it seems the Scriptures declare that there is a standard of care for infants that is at least equal to adults and that there may actually be an even higher standard of care in taking measures to avoid doing harm to infants. Those in responsibility such as fathers and civil authorities have some level of accountability for what happens in their jurisdictions. In the instance of life threatening circumstances, there is some overlap and both authorities have a duty to God to protect life even if it means to disobey the evil intent of another governing authority.
So why are professing Christians declining the use of competent medical facilities in regards to the birth of their children? Perhaps it is from a misconception of the risks and benefits of the medical facility. We are called to be diligent to understand consequences. “A prudent man foreseeth the evil, and hideth himself: but the simple pass on, and are punished. By humility and the fear of the Lord are riches, and honor, and life” (Proverbs 22:3,4). We are called to be humble and learn. We are called to be perceptive and take action. Regarding the birth of children at home, we are making the case to be wise. If a family is living where the hospital is filled with infection, incompetence and malice, it would be wise to give birth at home. Additionally, a family may live in a location where the distance to travel to a competent facility would be more hazardous than delivering the child at home. It would seem wise to not travel and provide the best care available in that remote location.
Medical Perceptions
If
some of the motivation for declining medical care is due to a lack of
medical information, this paper is to help highlight some of those
risks. The paper will also attempt to provide a rebuttal to some of
the proponents of intentionally having a child born at home. One of
the benefits of competent medical care is the ability to promptly
address delivery complications. Note, we are only mentioning some
unforeseen complications. Many other complications such as placenta
previa or structural abnormalities would be identified with standard
United States prenatal care and may be accounted for in perinatal
care planning.
Common
Complications:
Abruptio
Placentae is a sudden partial or complete separation of a normally
implanted placenta before the infant is born. Vaginal bleeding may
be present in marginal abruptions, but concealed abruptions do not
have external bleeding; thus the clot continues to grow further
separating the placenta from the uterine wall. 0.5% to 1% of
pregnancies have placental abruption, and it accounts for 10-15% of
perinatal (closely associated with child birth) deaths. Multigravida
status (multiple pregnancies), abdominal trauma, falls or maternal
age are known associated factors. Besides bleeding or known trauma,
tenderness, uterine irritability (mild contractions), drops in blood
pressure and poor fetal heart rate can indicate the possibility of
abruptio placentae. Diagnosis is by emergent ultrasonography. If it
is clearly mild, bed rest, steroids and tocolytics to prevent labor
would be given. Signs of fetal compromise can develop rapidly and
“intensive monitoring” of mother and baby is essential. Large
bore intravenous treatments (IV’s) are recommended for
administration of fluids and blood products should that become
necessary. If there are signs of fetal or maternal compromise,
immediate delivery via cesarean section is necessary.
Pre-Eclampsia
/ Eclampsia: Pre-eclampsia is a high blood pressure condition >139
Systolic Blood Pressure (SBP) or > 89 Diastolic Blood Pressure
(DBP) after 20 weeks of pregnancy accompanied by protein in the
urine. Pre-eclampsia often occurs in 1st pregnancies, and is also
associated with women over 35 years old, obesity, and chronic high
blood pressure. Pre-eclampsia is a generalized vasospasm (blood
vessel constricting) affecting 5-10% of all pregnancies. Maternal
and fetal morbidity can be decreased with early detection and
management while it remains mild pre-eclampsia. Severe pre-eclampsia
is when the high blood pressure is to a point that it is causing
significant reduction in the amount of blood flowing to the baby.
Anti seizure medicines and blood pressure medications are necessary
to prevent seizures and injury or death to the baby. Even at 33 and
34 weeks gestation, delivery is usual due to the severe risk.
Eclampsia is when the seizures begin. This can present life threats
to the mother and the baby.
Dysfunctional Labor: Multiple causes and issues, but in short, the mother’s uterus may not be able to effectively contract which can result in stresses on the baby or lack of oxygen for extended periods. Neurological damage can result.
Malpresentations: Delayed or difficult birth due to shoulder impaction above the mothers symphysis pubis bone, or other malpresentation such as breech or transverse. There is no true correlation to risk factors. Malpresentation is not predictable, unless there is known macrosomia (excessive infant birth weight). An urgent situation can develop with the umbilical cord being compressed between the baby and the pelvis. Time is essential. In the hospital, immediate preparations for surgical delivery begin while steps are taken to manipulate the baby to allow delivery before further impaction. This is often unforeseen as the baby can move at the last minute and become wedged.
Placenta Accreta: An abnormality with the placental adhesion to the mothers uterus. It can cause some bleeding and complications similar to placenta previa during the pregnancy, however it may not be diagnosed and hemorrhage may occur from the mother after the birth as the placenta does not separate, or separates incompletely allowing continuous bleeding. Such hemorrhage would require intrauterine surgery.
Prolapsed Cord: The presenting part (usually the head) of the baby does not always fit like a puzzle into the shape of the mothers pelvis. A prolapsed cord can slip down at the last minute, or with a simple movement of the baby, or with the water breaking. It may or may not be visible, but can be strongly suspected based on the changes in the decelerations of the baby’s heart rate. The pressure must immediately be taken off the cord to prevent the baby’s death. Unless birth is imminent and the cord can be protected manually by keeping the baby off of the cord, cesarean delivery is done to prevent death or brain damage to the baby. Every seconds counts with this complication.
Postpartum Hemorrhage: This can be caused by multiple factors, uterine atony (loss of uterine muscle tone), a partially retained placenta, or by blood coagulation abnormalities brought on by pregnancy such as DIC (disseminated intravascular coagulation). This is one of the leading causes of maternal death and it occurs in 4-6% of all deliveries. It is manageable but can progress rapidly apart from the hospital environment. The brain, heart and kidneys are vulnerable to hypoxia with the low blood pressure (shock) and the associated failure of the body’s compensating mechanisms. Lactic acidosis begins which dilates the blood vessels sending the mother into cardiac arrest. This is treatable but it requires constant monitoring, fundal massage, and possibly oxytocin to stop the bleeding, if it is persistent.
Endometritis / Puerperal Infection: A treatable infection after birth, a common cause of death if it goes untreated, especially in third world countries. Women with long labor and rupture of membranes that occur a longer time before delivery have an increased risk of up to 30% in those who don’t receive antibiotics ahead of time as compared to those who do receive antibiotics ahead of time. It is treated with IV antibiotics if diagnosed. If not treated, it can spread to abdominal cavity and cause major damage, sepsis and death.
Newborn Needs: There are a myriad of conditions that could be found on a fragile newborn at birth and some require urgent interventions. There are too many to list. One never knows what health problems the newborn may have. Additionally, 10% of newborns require basic neonatal resuscitation, and 1% of births require extensive resuscitation measures. As an aggregate number, 9% of all newborns require intensive care. Conditions such as bronchopulmonary dysplasia, meconium aspiration syndrome, unidentified fistulas, cardiac shunting issues, retained lung fluid, or other congenital anomalies require immediate treatment, endotracheal intubation and other urgent treatments. There are many conditions in which you do have enough time to call the paramedics and get transport to a hospital for an intervention.
Dysfunctional Labor: Multiple causes and issues, but in short, the mother’s uterus may not be able to effectively contract which can result in stresses on the baby or lack of oxygen for extended periods. Neurological damage can result.
Malpresentations: Delayed or difficult birth due to shoulder impaction above the mothers symphysis pubis bone, or other malpresentation such as breech or transverse. There is no true correlation to risk factors. Malpresentation is not predictable, unless there is known macrosomia (excessive infant birth weight). An urgent situation can develop with the umbilical cord being compressed between the baby and the pelvis. Time is essential. In the hospital, immediate preparations for surgical delivery begin while steps are taken to manipulate the baby to allow delivery before further impaction. This is often unforeseen as the baby can move at the last minute and become wedged.
Placenta Accreta: An abnormality with the placental adhesion to the mothers uterus. It can cause some bleeding and complications similar to placenta previa during the pregnancy, however it may not be diagnosed and hemorrhage may occur from the mother after the birth as the placenta does not separate, or separates incompletely allowing continuous bleeding. Such hemorrhage would require intrauterine surgery.
Prolapsed Cord: The presenting part (usually the head) of the baby does not always fit like a puzzle into the shape of the mothers pelvis. A prolapsed cord can slip down at the last minute, or with a simple movement of the baby, or with the water breaking. It may or may not be visible, but can be strongly suspected based on the changes in the decelerations of the baby’s heart rate. The pressure must immediately be taken off the cord to prevent the baby’s death. Unless birth is imminent and the cord can be protected manually by keeping the baby off of the cord, cesarean delivery is done to prevent death or brain damage to the baby. Every seconds counts with this complication.
Postpartum Hemorrhage: This can be caused by multiple factors, uterine atony (loss of uterine muscle tone), a partially retained placenta, or by blood coagulation abnormalities brought on by pregnancy such as DIC (disseminated intravascular coagulation). This is one of the leading causes of maternal death and it occurs in 4-6% of all deliveries. It is manageable but can progress rapidly apart from the hospital environment. The brain, heart and kidneys are vulnerable to hypoxia with the low blood pressure (shock) and the associated failure of the body’s compensating mechanisms. Lactic acidosis begins which dilates the blood vessels sending the mother into cardiac arrest. This is treatable but it requires constant monitoring, fundal massage, and possibly oxytocin to stop the bleeding, if it is persistent.
Endometritis / Puerperal Infection: A treatable infection after birth, a common cause of death if it goes untreated, especially in third world countries. Women with long labor and rupture of membranes that occur a longer time before delivery have an increased risk of up to 30% in those who don’t receive antibiotics ahead of time as compared to those who do receive antibiotics ahead of time. It is treated with IV antibiotics if diagnosed. If not treated, it can spread to abdominal cavity and cause major damage, sepsis and death.
Newborn Needs: There are a myriad of conditions that could be found on a fragile newborn at birth and some require urgent interventions. There are too many to list. One never knows what health problems the newborn may have. Additionally, 10% of newborns require basic neonatal resuscitation, and 1% of births require extensive resuscitation measures. As an aggregate number, 9% of all newborns require intensive care. Conditions such as bronchopulmonary dysplasia, meconium aspiration syndrome, unidentified fistulas, cardiac shunting issues, retained lung fluid, or other congenital anomalies require immediate treatment, endotracheal intubation and other urgent treatments. There are many conditions in which you do have enough time to call the paramedics and get transport to a hospital for an intervention.
Some Common Objections Answered
To
answer the proponents of home birth when there is access to a
competent facility, my initial thoughts are on the burden of proof.
Why would a person not use a trained obstetrician and and equipped
hospital to provide safe care for the mother and fragile newborn?
The following is a list of some commonly disclosed motivations for
having a home birth.
Reason:
I would like to have control of the experience.
Rebuttal:
Beware that the drive to control the birth experience has its roots
in the feminist movement in the 1960s. Although all women may not
have the feminist perspective, the pioneers in the movement are not
ashamed of that philosophical motivation.
Reason:
I do not like the loss of privacy in a hospital environment.
Rebuttal:
Perhaps there is an unbiblical view of modesty in the treatment of
disease and injury of the human body. Competent medical personnel
are trained to respect the patient’s need for privacy as much as
possible as well as give prompt care in dangerous conditions.
Furthermore, many hospitals are continually working to improve the
labor and delivery environment to respect the wide variety of
cultural and religious preferences in our society.
Reason:
Hospital deliveries are very expensive.
Rebuttal:
People will spend their money on what they value. What about life?
If there are no complications a delivery can cost $7000-10,000
without insurance at most Midwest hospitals. That’s is not an
unreasonable expense compared to many other common expenses such as
transportation. Families will spend that much or more on a good used
car.
Reason:
We don’t want interventions. Childbirth is a natural process.
Rebuttal:
The patient’s definition of “natural” is important to clarify.
Heart attacks, strokes, maternal death and infant death are natural
process as well and are more common where medical interventions are
not available. Is it possible the definition of “natural” is
centered on avoiding the pain or discomfort of an institutional
setting to be in more familiar and comfortable surroundings? Perhaps
this stems from a misunderstanding of the speed of response required
to manage the many potential complications needing immediate
intervention.
Reason:
Home birth is safe as midwives are trained professionals.
Rebuttal:
They are trained professionals, but incapable of providing many of
the lifesaving interventions necessary for complications. Let us be
direct — if there are no complications, almost anyone can catch a
baby. Even in deliveries where midwives recognize that they are in a
situation outside of their capabilities and lives are at risk, the
time necessary to transport the patient to appropriate care can cause
further damage.
Reason:
I do not want my newborn to be subjected to so many vaccinations so
soon after being born.
Rebuttal:
As far as I know, Hepatitis B is the only immunization recommended to
be given at birth. There is no substitute for having a good
relationship with your family doctor. Your doctor is a powerful
advocate for your health needs and desires. Discuss it with your
doctor if you are that concerned about it, or want to refuse or delay
immunization until the child is older. Planning ahead and making
your doctor aware of your requests is the best way to deal with these
situations.
Reason:
Home birth is safe as long as it is a low-risk pregnancy.
Rebuttal:
While certainly high-risk pregnancies make necessary even further
monitoring and interventions, most of the immediately life
threatening complications for the mother or the newborn are not able
to be foreseen, and can develop without warning. Without the
preparedness or resources to appropriately respond to the condition,
life, limb or brain function may be lost.
It
is a challenge to compare the raw statistics of the deaths of infants
in a home birth environment versus the deaths of infants in a
hospital. Recent studies suggest the home birth mortality rate is at
least 2-3 times higher than hospital infant mortality. The actual
rate may be higher as some home birth fatalities are reported as
hospital deaths as that was where the death was recorded. Some links
to postings are at the end of the paper.
Conclusion
Conclusion
In
closing, I offer an example of some Christians who have strong
convictions but saw the need to change their perception on home
birth. In our local region the Amish community reversed its
preference for home birth after realizing their preference was
resulting in loss of life and health. But, not wanting to compromise
their convictions, they put their resources to work to bless their
families who would need to be at the hospital for deliveries as well
as be a blessing to the wider community. To accommodate their
families the Amish community donated all their labor for the
construction of a hospitality house adjacent to the hospital so that
there would be a private place for their families using the hospital
as well as other families who had loved ones hospitalized. There are
no guarantees that a baby or mother will not die giving birth even
with a competent facility. But the Scriptures call us to be reverent
and teachable. Let us be faithful to examine all of life in the
light of God’s word and redeem our time on earth.
Some
thoughts on the risks associated with home birth and midwife-assisted
birth:
Update 7 February 2013
After receiving some feedback from the blog's readers, Mike and Matthew Brewer have offered the following clarifications:
After receiving some feedback from the blog's readers, Mike and Matthew Brewer have offered the following clarifications:
1) Theological Basis - We wanted to point to the Scriptures first to lay out the moral principles involved. The particular application will be different for different circumstances. We acknowledge that home birth may be wise where you have poor hospitals or a hostile medical community. Our brothers in some communist and third world countries may need to avoid the government health system.
2) Data - As we mentioned, the amount of research data is not large. The data we found, even cited by midwifery associations, disclosed an increased infant mortality rate with identifiable home births when compared with hospital births. We avoided using anecdotal knowledge for the paper.
3) Risks - We disclosed what are medical risks of an urgent nature that are difficult to manage even in a hospital. Our desire was to help non-medically trained fathers be aware of the medical conditions that their doctor is trying to manage in the treatment of their wives and children.
3) Relationships - We recommended a good relationship with your doctor to seek accommodation for your concerns and convictions. This is so helpful in the event there is a death of an infant regardless of where the birth occurs. The civil authorities have a duty to investigate the deaths of children. Your doctor can advocate on your behalf that you have acted with integrity in the care of your wife and child should death occur. Although we did not quote John Frame, we found his book "Medical Ethics" very helpful. He exhorts Christians to seek the assistance of their elders/pastors in navigating difficult medical situations. We think this is a theological sound recommendation. There is a perception in the homeschool community that we have a hard time listening to the counsel of others.
Thank you to all for taking to time to read a lengthy document for a blog. Keep seeking the things above in your service to God and others.
Thank you for you kind attention to our blog.
