Out-of-hospital birth Seminar work Subject: Healthcare Ethics Name and surname: Bc. Michaela Bořutová Academic year: 2021/2022 Introduction Out-of-hospital deliveries are an increasingly discussed topic. Such births mainly include home births and births in birth centers with a midwife. Many women choose these options because they have previous bad hospital experiences. The essay analyzes research worldwide studies that point to the safety of physiological out-of-hospital childbirth. Out-of-hospital childbirth For most women in developed countries, the choice of place of birth is not possible, as hospital delivery is stated as a certain cultural norm. During the 20th century, most countries experienced a dramatic shift in births. Home births have moved to hospitals. For example, in the UK in the 1920s, 80% of births took place at home, in 2011 only 2.3%. In the USA in 1938, almost 50% of births took place at home, but in 1955 less than 1% (Zielinski et al., 2015, p. 361). Hospital birth - this is a maternity hospital that is staffed by medical staff (doctors and midwives) who provide maternity services to women with and without complications. A birth center - offers women to give birth in a more domestic environment, where the emphasis is on physiological childbirth. Midwives are employed in the birth centers, who will arrange for a transfer to the hospital in case of danger. The centers are usually close to hospitals or directly in the hospital (maternity hospital). Home births are provided by midwives in private practice, but we may also encounter cases where the assistant is employed by a health service (Scarf et al., 2021, pp. 1-2). Out-of-hospital deliveries can be planned or unplanned. Many planned births take place at home with the assistance of a midwife or in a birth center. International studies show comparable results between planned hospital births and planned outpatient births (Lang et al., 2021, p. 672). In the Czech Republic, currently planned outpatient deliveries are not allowed. Experts describe such births as non “lege artis”, but pregnant women have a different view, as they want the best way of birth for themselves and their baby (Karaba, 2020, p. 16). The World Health Organization recommends giving birth in institutional health services to prevent maternal and neonatal mortality. To ensure a safe birth, medical staff must be trained and have adequate material. Only in this case can it intervene adequately (Del Mastro et al., 2021, p. 2). Ethical aspect We do not find out what is ethically correct in the professional literature. We must always find a good and correct solution ourselves. Neonatal mortality statistics and physician interventions are not critical. Within ethics, we address categories such as: conscience, norm or justice. On the one hand, there is the woman with her values ​​and subjective opinions, on the other hand, the interest of the child, ie justice to the fetus. It can therefore be said that the conscience of a woman stands here against justice. But how should a paramedic view this situation? We cannot force a pregnant woman to give birth in a hospital. If the health care provider accepts the planned home birth, he automatically takes the fetus a chance to cope with the complications. In this case, it can be said that he prefers the mother to the fetus. If the healthcare professional thinks that the treatment of complications is the same at home or hospital delivery, he or she will deliver the delivery. The ethical dilemma remains whether it is fair for the fetus (Matějek, 2014, pp. 109-110). Home birth Home birth is still a controversial topic as it raises concerns among pediatricians and obstetricians. Hospital delivery is considered the basic prevention of mother and child death. However, the overall reduction in mortality has led to increased demand for home births. Global studies from Australia, the Netherlands, the United Kingdom, Canada and the United States, for example, show that giving birth at home can provide some benefits to both mother and child. Home births themselves must be provided by sufficiently qualified professionals with perfect material resources. To maintain safety, there must be coordination with the maternity and non-analogy departments of hospitals (Sánchez-Redondo et al., 2020, p. 266.e2). The US review study, which examined the results of 55 studies from 10 countries in 2004-2014, concluded that there were no differences between neonatal morbidity or mortality in planned home births and in hospital births (Karaba, 2020, p. 19). The advantages of planned home births include, for example, the absence of postpartum hemorrhage and postpartum hemorrhage, and perineal lacerations. Women who plan to give birth at home report a higher level of satisfaction and a sense of greater control over the experience (Zielinski et al., 2015, p. 361). An Australian study suggests that women often choose to give birth at home because of a negative experience with hospital staff. They consider delivery outside the hospital to be safe, as they take the use of medical facilities as a riskier option. Women say they have more knowledge of what is best and safest than maternity care professionals. In the future, there should be systemic changes that would allow only the midwife to manage the birth in the hospital (Jackson et al., 2020, p. 254). The negative experience with the hospital is also confirmed by a study that took place in the Amazon and focuses on births, which take place almost always at home. The aim of the studio was to understand the reasons why they give birth at home. It discusses their preferences, procedures during childbirth or subsequent care of the newborn. The preference for home births over hospital births discusses the fact that hospitals were mistreated and mothers lacked cultural rituals, such as waiting for a godfather to cut the umbilical cord. Participants in the study said that feeling safe is the main reason to give birth at home. Other factors affecting home birth include fear of the hospital, financial problems, transportation to the hospital site and long waiting times for admission. The basic operation before starting childbirth is to wash your hands with soap and clean all surfaces. Newborn care involves immediate drying of breastfeeding, bonding, and cutting of the umbilical cord (Del Mastro et al., 2021, pp. 6-10). Many women also want to give birth at home because of greater financial savings, as they think that hospital birth is more expensive. A study from South Wales points to the fact that vaginal delivery without complications is almost financially similar. From a financial point of view, it does not matter whether a woman is giving birth at home, in a birth center or in a hospital (Scarf et al., 2020, p. 286). An observational study from the Czech Republic based on the analysis of women who were hospitalized in connection with the planned home birth in the years 2016 to 2017, deals with complications that occurred in 45 women. Complications most often developed during the third stage of labor and after childbirth. Complications occurred more frequently in women living in larger cities, with higher education, and in older women who had one or more risk factors (eg, birth after the 41st week, mother was over 40, etc.). There were also 4 prenatal deaths. Further research is needed in the future to confirm or refute this study (Křepelka et al., 2020, p. 230, 235). An Australian study from 2021 points to the fact, that planned home births are preferred by older women over planned births in a birth center or hospital. Most first-time mothers preferred the hospital (Scarf et al., 2021 pp. 4-5). As part of the COVID-19 pandemic, there are far more women who want to give birth at home. Some women have even decided to give birth on their own, without the help of a midwife, because they are afraid of transmitting the virus. During April and May 2020, a study was conducted on Danish women, involving a total of 17,995 pregnant women. 63% of these women feared they would become infected and ill during pregnancy, and 55% feared that the virus would be passed on to their baby. However, women are most prevalent due to fear of the absence of a man at birth (a total of 81%). At the time of COVID, the provision of services at home by the civil service was suspended, so many women chose between choosing a private midwife or giving birth at home without full assistance. The study shows that Danish women are concerned about the transmission of the virus to and from the child. Home births are hardly affected by a pandemic, but can cause the spread of home births without full assistance (Schroder et al., 2021, p. 664). The American article confirms the fact that during the COVID-19 pandemic, women began to think more about home births due to the reduction in hospital services. In 2017, every 62nd birth took place at home, but there are currently no relevant US studies to show that births at home or in birth centers have increased, although subjective information suggests (Daviss et al., 2021). Birth centre Birth centers are facilities where patients with uncomplicated pregnancies can give birth. If patients develop complications, they are immediately referred to hospital care. Examples of such symptoms are: cord prolapse, hemorrhage, Request for pain control, Fetal demise, <37 weeks, etc. Birth centers must be accredited and women are consulted during pregnancy to detect incapacity outside the hospital (Lang et al., 2021, p. 677). In recent years, there has been a significant increase in out-of-hospital delivery centers, mainly in the United States and Canada. Studies in recent years have shown that women who give birth in hospitals would like to use birth centers. A study from the United Kingdom speaks to the fact that women should be offered more places to give birth. Studies from the UK, New Zealand and Australia show high levels of satisfaction for women who have given birth outside the birth ward. The selection and location of labor is a very complex process. Canadian studies that have assessed the outcome of planned out-of-hospital deliveries with registered midwives have strong arguments that care is of sufficient quality and professional care if it is adequately integrated into the integrated system (Wood et al., 2016, p. 12-19). The Dutch cross-sectional study, which involved a total of 23 birth centers, took place in 2013. A total of 1134 women completed the questionnaires, of which 263 were women with a planned birth at the birth center, 350 women with a planned home birth and the rest with a planned hospital delivery. The aim of this study was to evaluate the care provided for women who are planning to give birth in a birth center, compared with women who are planning to give birth at home. Women who planned to give birth in birth centers were often first-born and women highly educated compared to other women who planned another alternative. As part of the midwife's care during and after the birth, there were no significant differences between the choice of the birth environment. The centers had a very good rating in terms of providing a home environment, hotel services and the possibility to use the bath. 93% of women said that the experience of the birth center and the work of a midwife met their expectations. They also point positively to the arrival and departure from the birth center at the preferred time and continuity of the care provided (Hitzert et al., 2016, p. 70-78). Conclusion Out-of-hospital births have become very common in recent years. New birth centers are being set up all over the world, but most in the USA and Canada. Available sources indicate that out-of-hospital deliveries are safe if the delivery is physiological and trained staffs are present during the delivery (a midwife with appropriate training). Women do not want to give birth in hospitals due to previous negative experiences. The home environment also feels more safely and the birth may be more spontaneous without intervention. Studies show that out-of-hospital deliveries are generally preferred by more educated women. Bibliography 1) DAVISS, B. A. et al. Pivoting to Childbirth at Home or in Freestanding Birth Centers^ in the US During COVID-19: Safety, Economics and Logistics. 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