Friday, January 25, 2013

Biblical Ethics and Medical Perceptions Pertaining to the Home Birth Practice

Note: The following article was written by two men (a father and son) who are members of Immanuel Baptist Church, where I am privileged to serve as the primary teaching elder. If you are considering home birthing, I hope you will also consider their thoughts about this important matter.

Biblical Ethics and Medical Perceptions Pertaining to the Home Birth Practice

(An Appeal to Fathers to Apply Wisdom)

By Mike Brewer and Matthew Brewer, RN, PHRN


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

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

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.

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.


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:
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.  

Friday, January 11, 2013

A Shout Out to Housewives

I am pastor who is happily married to a beautiful housewife. And, the more I learn about her job the more I am amazed at her high calling in life. I am beginning to think that it may be a housewife that God has ordained to sit on the right side of the Lord in glory. At least I wouldn’t be surprised, nor would I object.

A housewife is typically overworked, underappreciated, poorly paid, and often despised. Her work is never done, but she is treated by our culture as if she does not work at all. Sadly, success is not measured by dirty diapers and loads of laundry but by income, social status, degrees, and yearly promotions. It is a shame that the world has turned family values upside-down. Although the world does not value housewives, here are a few reasons why we should value them.

1. They are Servants

Cook, clean, laundry and back to back to cooking is just a small portion of the job description of a homemaker. In other words, serve, serve, and serve is what housewives do. Cleaning bottoms and toilets does not seem noble at all. In fact, this is one the lowest of all the positions in the eyes of the world. Low it may seem, but not in the eyes of our Lord. Christ Himself, as King of Glory, did not come into this world to be served but to serve others. The Lord instructs us that if we desire to be first in the kingdom, we must be willing to be last, and if we want to be great, we must be willing to be made small. Therefore, whenever we see someone serve, we should never despise that high calling, because God sure doesn’t.

2. They are Underappreciated

Sadly, housewives are not viewed as valuable and beneficial contributors to society. Amazingly, housewives are often viewed as if they waste their lives sitting at home—as if they do nothing. However, it could be argued that one of the major reasons that society is so dysfunctional is because institutions now raise our children rather than mothers. Unless you are making money, then you are not contributing, so society seems to think.

Yet, it is the lack of appreciation that makes this calling even more beautiful in God’s eyes. It is honorable to work hard when no one notices, but even more honorable to work hard when your labor is despised. God sees all those little hurtful looks and awkward comments, which you receive when you tell others what you do and, don’t worry, God will make sure that your position will be publically praised on the Day of Judgment. Those of you who have denied yourself a career to stay at home with your children and have put the wellbeing of your family above personal aspiration for approval, financial gain, and some false sense of self-worth will be richly rewarded when you hear the praises of God saying, “well done my good and faithful servant”. So don’t grow weary in well doing—your day of praise is coming.

3. They Are Overworked

It is right, ‘a woman’s job is never done’—especially if she is raising a house full of munchkins. Multitasking is not a good thing, it’s a must. A baby in one hand and a spatula in the other hand is common practice for a housewife. The structure and discipline that it takes to order the day’s work around meals, children taking naps and husbands coming home from work are not easy when babies have no regard to time. Husbands come home from work, but wives must continue to work. Not working from 8 to 5, but twenty-four seven is the hours she works each day. Well, at least she has Sundays off? No, not even Sundays are off, and that can be the most difficult of all days of the week because the children have to be clean and tidy by 9:00 am to make it in time for church. Also, training the children to sit still and listen can be an utter nightmare.

But, as with all work comes reward, there is a reward for being a housewife—an excellent relationship with your family. First, there is joy that comes with raising your children. Many women wonder why they are so miserable when they drop off their joy(s) at daycare. Second, there is great reward in changing diapers for a living. What is a more important job than to love, spank, teach, spank some more, and feed the ones that you love the most? Being a professional doctor, cook, or teacher is great—very noble callings indeed. But what could be more rewarding than doctoring your child when he or she falls down, or cooking for the family and teaching your little toddlers how to walk? When your children are raised and out of the home, you will never regret all the long hours spent in the home. In short, life is too short to waste it outside the home.

4. They Have the Greatest Impact upon Those Who Mean the Most—Our Children

What is often overlooked about housewives is the heavy emotional taxation they face on a daily basis. Cabin fever is one thing, but hearing the Devil constantly whispering in your ear that you do not have much of a ministry is overwhelming at times.

Godly women desire a spiritual ministry as much as godly men and we are all prone to judge the value and worth of our lives and ministries by the volume of people we influence. The more people we touch and impact, the better, so it seems. The more people who know and appreciate us, the greater the value we feel we can place upon our lives.

It is not uncommon for a housewife to feel as if very few people outside their homes knows much more than their name. But as the wise pastor understands, it is not serving the universal church at large by writing books and getting a lot of hits on sermon audio that is rewarding, but counseling the new widow as he is about to preach her husband’s funeral. The real ministry is caring for souls that you love and that love you. In other words, the rewarding ministry is not found in a non-personal and emotionally detached service to people we do not know, but ministering and serving those whom we love the most. And although your ministry as a housewife may not expand much further than the walls of your home, your ministry penetrates deeper and often makes a more lasting impact upon people than if you would have written a bestselling book that reached thousands of strangers that was a hit one day and forgotten the next. It is not the amount of people who know you that makes your calling so great, it is who knows you.

On that great day, your children and husband will rise up and call you blessed. Most importantly, God will give more honor to the simple housewife who serves the Lord in fear than He will a thousand preachers who are full of pride due to the praises that he may have received in this world.