Saturday, February 09, 2008

Latest ACOG statement against home birth

On Feb. 6 the American College of Obstetricians and Gynecologists issued the statement below on how the group is opposed to home birth. What is interesting to me is why they are issuing the statement now. A clue comes in the paragraph that begins: "Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre." Does this mean ACOG ackowledges that home birth is suddenly trendy? Did you all see the article in Vogue a couple months ago, a favorable essay by a New York City mom who gave birth at home? Perhaps the people at ACOG saw that and got worried... home birth was literally in Vogue...Then of course there is also the Ricki Lake documentary, "The Business of Being Born," which comes out this month on Netflix! I would be worried if I were ACOG, too, as the film makes a compelling case against The System.

The statement goes on to say: "Advocates cite the high US cesarean rate as one justification for promoting home births. The cesarean delivery rate has concerned ACOG for the past several decades..." (SO WHY DOES THE RATE KEEP GOING UP, NOW EXCEEDING 30 PERCENT, WHEN THE WORLD HEALTH ORGANIZATION ESTIMATES THAT ANY RATE ABOVE 10-15 PERCENT IS DOING MORE HARM THAN GOOD?)..."Multiple factors are responsible for the current cesarean rate, but emerging contributors include maternal choice" (THIS IS A SMALL PERCENT BUT GROWING AS DOCTORS BOTH ALLOW AND ENCOURAGE SECTIONS FOR NO MEDICAL REASON; SCARE THE DAYLIGHTS OUT OF WOMEN WHO THEN THINK THEY MUST HAVE A SECTION; AND REFUSE TO ATTEND VBACS) "and the rising tide of high-risk pregnancies due to maternal age, overweight, obesity and diabetes." (SO BLAME THE MOM). Nowhere in this statement is there any mention of malpractice fears among OBs, how overly managed labor is resulting in countless iatrogenic problems, leading to even more sections, etc.

Finally, where ACOG questions studies about the safety of home birth (there have been many large-scale ones, recognized around the globe as being well done)it is important to note that in the UK, the government there is actually advocating for MORE home birth, precisely because it is safe and because they recognize that birth in the hospital will almost always end up being more complicated because it is made so by the people who work there. Period.

Anyway, here is the ACOG statement in full. Feel free to write a letter. The address is at the bottom.

Washington, DC -- The American College of Obstetricians and Gynecologists (ACOG) reiterates its long-standing opposition to home births. While childbirth is a normal physiologic process that most women experience without problems, monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies.

ACOG acknowledges a woman's right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births. Nor does ACOG support the provision of care by midwives who are not certified by the American College of Nurse-Midwives (ACNM) or the American Midwifery Certification Board (AMCB).

Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby. Attempting a vaginal birth after cesarean (VBAC) at home is especially dangerous because if the uterus ruptures during labor, both the mother and baby face an emergency situation with potentially catastrophic consequences, including death. Unless a woman is in a hospital, an accredited freestanding birthing center, or a birthing center within a hospital complex, with physicians ready to intervene quickly if necessary, she puts herself and her baby's health and life at unnecessary risk.

Advocates cite the high US cesarean rate as one justification for promoting home births. The cesarean delivery rate has concerned ACOG for the past several decades and ACOG remains committed to reducing it, but there is no scientific way to recommend an 'ideal' national cesarean rate as a target goal. In 2000, ACOG issued its Task Force Report Evaluation of Cesarean Delivery to assist physicians and institutions in assessing and reducing, if necessary, their cesarean delivery rates. Multiple factors are responsible for the current cesarean rate, but emerging contributors include maternal choice and the rising tide of high-risk pregnancies due to maternal age, overweight, obesity and diabetes.

The availability of an obstetrician-gynecologist to provide expertise and intervention in an emergency during labor and/or delivery may be life-saving for the mother or newborn and lower the likelihood of a bad outcome. ACOG believes that the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets the standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.

It should be emphasized that studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous. Moreover, lay or other midwives attending to home births are unable to perform live-saving emergency cesarean deliveries and other surgical and medical procedures that would best safeguard the mother and child.

ACOG encourages all pregnant women to get prenatal care and to make a birth plan. The main goal should be a healthy and safe outcome for both mother and baby. Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby. For women who choose a midwife to help deliver their baby, it is critical that they choose only ACNM-certified or AMCB-certified midwives that collaborate with a physician to deliver their baby in a hospital, hospital-based birthing center, or properly accredited freestanding birth center.

ACOG Office of Communications



Amy Tuteur, MD said...

"there have been many large-scale ones, recognized around the globe as being well done"

No, there is not even a single study that shows homebirth to be as safe as hospital birth for comparable risk women. Sure there are studies that CLAIM to show that homebirth is as safe as hospital birth, but they ACTUALLY show that homebirth has an increased rate of preventable neonatal death.

For example, the most widely cited study, the Johnson and Daviss study in the BMJ 2005, ACTUALLY shows that homebirth with a CPM in 2000 had a neonatal death rate almost TRIPLE the death rate for low risk hospital birth in 2000. Read the study, and you will see. Well, you won't see right away, because Johnson and Daviss left out the hospital neonatal death rate in 2000, hoping that no one would notice. Instead, they compared homebirth to hospital births in previously published papers extending back as far as 1969.

Johnson and Daviss have recently publicly acknowledged the validity of my analysis. According to their website Understanding Birth Better:

"... Since our article was submitted for publication in 2004, the NIH has published analysis more closely comparable than was available at that time, and some have tried to use it as a comparison. While we still do not offer the comparison as a completely direct one, as it is the closest we have and the comparison is occurring regardless of our cautions, we offer the following adjustments that have to be made to provide the comparison of the CPM2000 analysis in as accurate a manner as is possible with the published NIH analysis."

Johnson and Daviss offer disingenuous excuses for their failure to appropriately analyze the data. Consider this claim: "Since our article was submitted for publication in 2004, the NIH has published analysis more closely comparable than was available at that time". However, the relevant data was published in 2002, long before their paper was submitted (Infant Mortality Statistics from the 2000 Period Linked Birth/Infant Death Data Set, published August 29, 2002). Moreover, even before publication of the analysis, Johnson and Daviss had the raw data in their possession. They used that raw data from 2000 to calculate the rates of hospital interventions, so they were fully aware of the mortality data at all times.

Moreover, people deserve to know that Johnson and Daviss are long time public advocates of homebirth, Johnson is the former Director of Research for MANA (Midwives Alliance of North America) and Daviss, his wife, is a homebirth midwife. The study was done in collaboration with MANA and was funded by money from a homebirth advocacy foundation.

Their own comments are quite illuminating. In a NARM bulletin from summer 2005, Johnson and Davis actually advise midwives how to generate publicity for the paper, and how to spin the data. This is not what you would expect from researchers who were independent.

For example:

"We invite you, if you have not already done so, to contact your local radio stations and newspapers this week about the study,..

When contacting the media take the time to educate them on the CPM credential and make sure they know that NARM, MEAC, CfM, MANA, and NACPM have information on these maternity care providers."

On spinning the data:

"We purposely reported transfers as: "over 87% of mothers and neonates did not require transfer to hospital," and most of the transfers were for lack of progress, because the mother was tired or wanted pain relief. This kind of detail is especially important when communicating with the media. For example "over 87% of the mothers…" conveys a sense of confidence, while "thirteen per cent of women still had to be transferred," which one television broadcast did (even though it was overall a positive study) focuses on the negative end of the curve."


"Policy Implications: The study suggests that legislators and policy makers should pay attention to the fact that this study supports the American Public Health Association’s resolution to increase out of hospital births attended by direct entry midwives. The American College of Obstetricians and Gynecologists still opposes home birth, but has no valid evidence to support this position. The Society of Obstetricians and Gynecologists of Canada and several provinces have written statements either acknowledging that women have the right to choose their place of birth or supporting it.

For continuing information on creative and effective ways to highlight this study in the policy arena, consider joining the BirthPolicy listserve. It is a great resource for midwifery policy discussion. Plus list moderators Katie Prown and Steve Cochran have their own personal tips on how to become more media savvy..."

Needless to say, "policy implications" which dovetail with the author's pre-existing advocacy, are not the typical purview of a truly independent researcher. Furthermore, it is my understanding from reading the bulletin, that this letter was unsolicited. It was the authors' idea to offer tips on how to publicize the article, how to spin the data, and how to exploit the paper for policy purposes.

Whatever you may think of ACOG's opinion, it is important to understand that their factual assertions are correct. Virtually all the existing scientific evidence to date shows that homebirth has an increased rate of preventable neonatal death compared to hospital birth.

Natalie said...

It's not the opinion, it's the wording and the language.

By the by- we know you're here- if we want to talk to you, we'll visit your site-


Tina Cassidy said...

For those who found Dr. Amy's response confusing or tedious (show of hands, please)Here is the link to the British Medical Journal study by Johnson and Daviss -- the largest study of planned home birth to date. Readers can decide for themselves whether it is a good study or not.

This was a prospective cohort study of 5,418 home births (98% of the births attended by direct-entry midwives with a common certification in the United States and Canada). The planned home births had similar rates of intrapartum and neonatal mortality to those of low-risk births, but the medical intervention rates for planned home births were lower than for planned, low-risk hospital births. The cesarean rate in the home birth-group was 3.7%, substantially lower than in the hospital cohort. A high degree of satisfaction was reported, and <12% required transfer to a hospital.

Midwife Mama said...

Who cares what ACOG says! This is the same organization that strapped women down, routinely shaved and gave episiotomies, now required constant fetal monitoring... all things that had NO scientific reasoning or proven benefit. The same organization that 'allows' women to choose major abdominal surgery to deliver their babies, where some of these women may be making that choice because celebrities are too posh to push... (but following those celebrities is ok because they agree with them). I say we just boycott ACOG and its affiliates.

randiedoula said...

Although boycotting ACOG sounds like a great idea, in reality 80% of the women I work with see MD's for their obstetric care. So unfortunately, what they say does matter.
However, the facts that ACOG even released that statement and Dr Amy bothers herself with Tina's blog shows me that they realize we who support homebirth are threats. Not physical, of course, but threats to where it hurts the most: the pocketbook! ACOG is not at all worried about safety, they are worried about losing money!

Holly R. said...
This comment has been removed by the author.
DiDi said...

I seriously doubt the ACOG is concerned about losing income to the tiny number of home births in this country. A threat to OB/GYNs?
I don't think so.

Meg said...

Ugh. This Amy chick drives me crazy. I am glad she has taken up the cause for the 1% of 1% of women who have had homebirths go bad. Why she is not giving her soul as passionately to improving her own professions lousy outcomes is curious.

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