Friday, January 21, 2011

ACOG issues new opinion on home birth

ACOG position statement quoted in full; see additional reading below.

The American College of Obstetricians and Gynecologists Issues Opinion on Planned Home Births

Washington, DC -- The American College of Obstetricians and Gynecologists (The College) issued a Committee Opinion today that says although the absolute risk of planned home births is low, published medical evidence shows it does carry a two- to three-fold increase in the risk of newborn death compared with planned hospital births.* A review of the data also found that planned home births among low risk women are associated with fewer medical interventions than planned hospital births.

"As physicians, we have an obligation to provide families with information about the risks, benefits, limitations and advantages concerning the different maternity care providers and birth settings," said Richard N. Waldman, MD, president of The College. "It's important to remember that home births don't always go well, and the risk is higher if they are attended by inadequately trained attendants or in poorly selected patients with serious high-risk medical conditions such as hypertension, breech presentation, or prior cesarean deliveries." Based on the available data, The College believes that hospitals and birthing centers are the safest place for labor and delivery.

Although The College does not support planned home births given the published medical data, it emphasizes that women who decide to deliver at home should be offered standard components of prenatal care, including Group B Strep screening and treatment, genetic screening, and HIV screening. It also is important for women thinking about a planned home birth to consider whether they are healthy and considered low-risk and to work with a Certified Nurse Midwife, Certified Midwife, or physician that practices in an integrated and regulated health system; have ready access to consultation; and have a plan for safe and quick transportation to a nearby hospital in the event of an emergency.

The recommendations state that a prior cesarean delivery is an absolute contraindication to planning a home birth due to the risks, including uterine rupture. Women who want to try for a vaginal birth after cesarean are advised to do so only in a hospital where emergency care is immediately available. Attempting a home birth also is not advised for women who are postterm (greater than 42 weeks gestation), carrying twins, or have a breech presentation because all carry a greater risk of perinatal death.

Committee Opinion #476, "Planned Home Birth," is published in the February 2011 issue of Obstetrics & Gynecology.


*Referring to the Wax meta-analysis, whose conclusions excluded the largest study of home birth and included flawed studies known to include unplanned home births.

For related reading on home birth position statements, please visit:
ACOG & AAP position statements on place of birth
Code mec! Code mec!
AMA on home birth
RCOG and RCM on home births
Responses to ACOG
10 responses to ACOG's position statement on home birth


  1. I could cry. I want to say all kinds of inappropriate words to describe how I feel about ACOG. Will they never learn?

    Until hospitals are free of unnecessary interventions, they will not be safer to birth in, particularly for VBACs and breech babies.

  2. *sigh...I suppose my post term (42 1/2 weeks), VBAC homebirth was entirely dangerous. Shame on me for risking our lives just because of some ideal. (note sarcasm)

  3. This ruling is really condescending. With the exception of planned unnassisted births and HBACS, the majority of home births follow all the recommendations they laid out. My CNM had an emergency plan, administered all the minimum standard tests and would not have attemped a breech birth. Really, ACOG, tell us something we don't know.

  4. Breech birth should not be an automatic c-section, which it is in a hospital. It is highly unfortunate that parents who desire a vaginal breech birth must either go it alone or find a care provider who is willing to risk their license (and/or jail time) by doing it illegally. Something needs to change.

  5. well, it is a step up from the last statement. Maybe, just Maybe, they are coming around REALLY SLOOOOOWLY.

  6. Arural - Attending breech birth is not illegal everywhere. I know in Oregon at least it's completely legal to do at home, but for some arbitrary reason is not legal to do in a birth center.

    As for the recommendations for screening, patients still hold the right to decline all screening and exams. I admit fully that I had gestational diabetes and could have very well been "risked out" of going to a birth center had I agreed to formal testing. I did my research, I monitored myself and I refused testing so there was nothing in my chart to legally force my birth center to drop me as a patient. The problem with ACOG is that things they consider to be "high risk" are blown way out of proportion and in many cases, those things are only risks because of the way the majority of OBGYNS handle them, such as breech birth.

  7. Why would anyone expect them to ever recommend something that would take $$ out of their members' pockets? More homebirths generally = less $$ for hospitals and OBs...

  8. I believe (although I don't know if there are studies to back me up) that one of the things that make homebirths most risky is not having a hospital that you can trust when transfer is indicated. In a fully integrated system, homebirths are not higher risk for mothers or babies (barring certain individuals with certain medical conditions). This statement doesn't seem to be moving toward that goal.

  9. I have to agree with Mrs. Schaible - ACOG seems to be moving in a reasonable direction, even against interest. Of course, this is a fairly conservative group that prioritizes/recognizes certain types of risks (shoulder dystocia, Erb's palsy, mortality) over others (breastfeeding problems, birth trauma) and these recommendations reflect that. However, I have some hope that a statement like this that "legitimizes" at least some home births might go some of the way toward making transfers safer as Amy rightly points out is necessary for home births to truly be as safe as possible.

  10. Like others have said... it all comes down to the almighty dollar. I've had 2 OBS that were ACOG members and they did things that ACOG clearly is against. One of those two doctors is highly regarded in ACOG. I've left them all for a midwifery group and I may even try a home birth midwife (as the midwifery group doesn't do home births but delivers in their own suites in a hospital but under the Midwifery Model of Care).

  11. Once again I'm grateful to be living in another country. It's so nice to be in a place with free health care because it removes many of the incentives that create the behaviors of groups like ACOG. The state of all health care (and especially maternity care) in the US is very worrying, it seems like it worsens every year despite scientific gains.

  12. Kimberly,
    You don't have free health care - it is paid out of your taxes and the quality of care is by far substandard to that of all the health care given in the U.S. Your assumption that U.S. Health care worsens every year is not founded by fact - the United States has the best and highest quality of health care in the world and that is why people come from all over the world to get it. I am sorry that you are so misinformed - stop watching the news and find out for yourself. As usual, education is needed to turn the tide of ignorance and dependence on government intervention back to self reliance and self governance. The government isn't the answer and neither is ACOG. To be grateful for your free health care over the "freedom" to choose for yourself who treats you or cares for you when you are sick or are having a baby is the issue here. FREEDOM is the key and there is no freedom from government intervention and control. GOD BLESS AMERICA!

  13. I am an American living in Italy! We have "free" government healthcare! The quality of care is atrocious. The wait time for treatment is ridiculous (I just booked an appt for my very ill daughter and they will not see her until August!!!), the condition of the facilities is totally decrepit. We were completely in shock when we first moved here a year ago, now sadly we are almost getting used to the substandard conditions. Our conclusion= some things are most certainly worth paying for! The American medical system is NOT perfect however we miss it dreadfully! I agree with Rocky- there is nothing as precious as freedom to choose!


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