10 responses to ACOG's statement on home birth

On the heels of ACOG's newest statement on home birth, I wanted to share my responses.

1) For the first time, ACOG has suddenly started supporting freestanding birth centers, a drastic shift from its long-standing opposition to out-of-hospital births. The research on birth centers has not changed—in fact, the outcomes from the National Birth Center Study are similar to those of the CPM 2000 study for things such as cesarean rates (4.4% vs 3.7%), hospital transfers (15.8 % vs 12.1%; urgent transfers were 2.4% vs 3.4%) and intrapartum/neonatal mortality (1.3 vs 1.7/1000). Although the data on out-of-hospital births has not changed in the past year and a half, compare ACOG’s 2006 statement with its recent position on home birth:

November 2006: "American College of Obstetricians and Gynecologists (ACOG) believes that the hospital, including a birthing center within a hospital complex...is the safest setting for labor, delivery, and the immediate postpartum period....Although ACOG acknowledges a woman’s right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births."

February 2008: "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....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...or in a freestanding birthing center."

2) ACOG claims that “Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre.” Ricki Lake’s documentary and The Big Push for Midwives, among other recent developments, are evidently unsettling to ACOG. The rate of home birth has remained relatively stable for the past several decades; I would argue that it is hardly fashionable or trendy in that sense. Women choosing home birth face significant social stigma. It is not an easy or socially acceptable path. Instead, it is a choice that some women will always make out of deeply held philosophical or religious beliefs. This statement also implies that women choose home birth for frivolous reasons without serious thought or carefully weighing the risks and benefits of various options.

On the other hand, one recent trend in childbirth—elective cesareans with no medical indication—is supported by ACOG as ethically justifiable “if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth.”

3) ACOG yet again pays lip service to “a woman’s right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider” while working to undermine women’s ability to make those very decisions. Vaginal birth after cesarean (VBAC), for example, is increasingly difficult to arrange in the United States as a direct result of an ACOG recommendation. Hundreds of hospitals have banned VBACs since 1999, when ACOG revised its recommendations on VBAC and stated that VBAC “should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”[1] In practice, this translated into 24-hour in-house anesthesia and OB coverage, a requirement that often only large, tertiary hospitals can guarantee.

Dr. Marsden Wagner has noted that ACOG “has no data to support it [the 1999 VBAC recommendations], no studies showing improvements in maternal mortality or perinatal mortality related to the characteristics of institutions or availability of physicians.” In fact, the studies that do exist show no elevated mortality rates among VBACs in smaller hospitals compared to large tertiary hospitals.[2] When the American Academy of Family Physicians reviewed all of the evidence on VBAC and the necessity of 24-hour OB and anesthesia, it recommended that "TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes." (Read the full report here).

Despite the fact that ACOG’s 1999 recommendation was not evidence-based, obstetricians and hospital administrators are under heavy pressure to comply with the recommendations. As a result of ACOG’s new position on VBAC, hundreds of smaller hospitals have instituted a no-VBAC policy, requiring women to have mandatory repeat cesareans or to travel elsewhere—sometimes very long distances—to give birth. ACOG’s active opposition to home birth and to non-nurse midwives also undermines a woman’s ability to choose her health care provider. It is akin to saying “We support your right to chose any color of car you want. But since we believe that only blue cars are safe, we will oppose any attempts to legalize the manufacture, sale, or distribution of non-blue cars.” In sum, ACOG’s supposed support of a woman’s right to autonomy is nothing more than thinly veiled paternalism.

4) ACOG claims that a woman “attempting” a VBAC at home “puts herself and her baby’s health and life at unnecessary risk.” This shows ACOG’s distrust in a woman’s ability to make her own decisions. Whether or not a HBAC—or a hospital VBAC or an elective cesarean—is unnecessarily risky is for each individual woman to decide, based on a complex set of factors, values, and life experiences. Again, this is an example of paternalism. Instead of respecting a woman’s ability and right to make her own decisions, ACOG has made a sweeping pronouncement that attempts to speak for women.

5) ACOG claims to be concerned about the rising cesarean rate and states that it “remains committed to reducing it.” However, several of ACOG’s actions actively promote higher cesarean rates, including its support of patient choice cesareans as ethically justifiable and its 1999 VBAC recommendation.

6) When all else fails, blame the woman: After stating its concern with rising cesarean rates, ACOG then places the blame back on women themselves: “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.”

7) ACOG repeats its claim 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.” It claimed this about out-of-hospital births (including freestanding birth centers) in 2006. Yet with no new research on birth centers in the past year and a half, ACOG has recently reversed its stance. ACOG also ignores the CPM 2000 study about midwife-attended home birth, a large, prospective study of all CPM-attended births in the year 2000.

8) ACOG states: “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.” I agree that access to emergency services when needed is essential, and unfortunately continued opposition to home births only makes that access more difficult. In states where midwifery is illegal, many midwives are forced to abandon their clients if they transfer to a hospital out of fear of being arrested. Midwives in many states cannot openly refer clients or consult with backup physicians. Surely these situations do nothing to improve safety for the birthing woman. Decriminalization of midwifery (and removing sanctions from collaborating physicians) would help remedy this situation.

9) ACOG states that “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.” Yes, this is true for all midwives and many family practice physicians, in and out of hospitals: a CNM or family doctor working in a hospital cannot perform a cesarean (unless the family doctor has done additional training in obstetrics). They must transfer care to an obstetrician if the need for surgery arises. Nurse-midwives cannot do forceps deliveries or vacuum extractions.

10) ACOG labels women who choose home birth as selfish and narcissistic. ACOG writes: “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.” This statement as insulting as it is misinformed, and it shows ACOG’s inability to recognize that women choosing home birth do it to safeguard their baby’s well-being. Accusing women of being “bad mothers” is both unprofessional and paternalistic.

This statement also reveals a fundamental rift in belief systems between obstetrics and midwifery. In the obstetric worldview, women’s emotional needs are often portrayed as pitted against the fetus’ physical well-being. In the midwifery paradigm, however, safety isn’t a matter of either/or. (Either you have an emotionally satisfying but dangerous home birth or you have a safe hospital birth where you sacrifice your own comfort and emotional needs for the good of the baby). It is an and/and situation where the well-being of mother and baby are inextricably intertwined.

[1] ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section.” According to the International Cesarean Awareness Network (ICAN), over 300 hospitals have banned VBACs since 1999. ICAN is currently compiling a comprehensive list of the status of VBAC in every U.S. hospital.
[2] Marsden Wagner. What Every Midwife Should Know About ACOG and VBAC. Midwifery Today. McMahon, M. (1996). Comparison of a trial of labor with an elective second cesarean section. New Eng J Med 335 (10): 689-695.