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

Read more ...

Code Mec! Code Mec!

*Now with more links*

Not only are home birthers irresponsible, selfish, and reckless, they are now, according to the Today Show, hedonists who are seeking a spa treatment experience during labor! (Never mind that it's okay for hospitals to market their maternity wards' spa-like amenities...)

The Today Show recently investigated the supposed "Perils of Midwifery" and their shoddy reporting is in for a drubbing.

The ACNM responded with a discussion of The Non-Perils of Midwifery. "Not only does it follow the heart-breaking account of a birth gone horribly wrong; it exploits the couple’s tragedy—turning it into a sensationalized story that scares women and grossly misrepresents midwifery," the ACNM commented.

Nicole at Your Birth Right wrote about The Perils of ACOG: "[D]uring narration about home birth advocates they decided to use the word alleged as if homebirth advocates are somehow perhaps liars or criminals....The word alleged is somehow missing when the DOCTORS are quoted,"  she wrote.


Speaking of perilous obstetrics, Jill at The Unnecessarean noted that ACOG just released survey data indicating that many obstetric practices are influenced by fear of litigation and ultimately harm the patient.

Radical Doula wrote that ACOG is making me nauseous.

Citizens for Midwifery claimed that the Today Show is in bed with ACOG.

The Big Push campaign hit back with its own (alarmist) rhetoric: Physicians take anti-midwife smear campaign to the airwaves. (PDF)

And I love (Keyboard Revolutionary) Jill's response: Iridescent tile makes all the difference.

Reality Rounds called Code Bullshit on Matt Lauer. She pointed out some of the many inconsistencies and flaws in the report, with comments of her own in italics:

• A talking male head “expert” comparing home births to spa treatments.  “Yes, I will have my full body avocado massage while I am crowning please.”
• Same talking male head talking about the “Hedonistic” style of birthing.
• Flashy pictures of celebrities who have given birth at home.  Every  women I know has chosen their birthing options from reading US magazine.
• ACOG says childbirth decisions should not be determined by what is flashy, trendy, or the latest cause celeb.  But it is OK for childbirth decisions to be dictated by defensive medicine, personal golf schedules, and “because I have always done it this way,” reasoning.
• When the investigator speaks of midwives he uses terms like “they allege” medical births cause X,Y and Z.  As if the anger over the medicalization of birth is all a big conspiracy.
• When the narrator states that studies by the CDC show home births to be safer than hospital births, they leave us with this quote:  “But doctors say it is impossible to compare the safety of home births with hospital births, becasue hospitals care for so many high risk cases.”  Really?  It is impossible to compare  similar low risk patient populations’ outcomes for delivery?  It is impossible to just remove the high risk populations from the comparative study?  This is called research idiots!

Amy Romano of Science & Sensibility just wrote Home Birth: The Rest of the Story. In this piece, she argued that home birth has been held to standards that not even hospitals can meet and that implementing Lamaze's Six Healthy Birth Practices would make both hospital and home birth safer:

I continue to believe that if hospitals provided the Six Healthy Birth Practices as the standard of care and offered evidence-based treatments for women and babies experiencing complications, hospital birth would be safer and so would home birth. That’s because midwives would initiate transfers with more confidence that it would improve the outcome, women would transfer more willingly, and care at the receiving facility would be safe and effective. What’s not to like about that plan, ACOG? Now, let’s make it happen!

I have an idea for Reality Rounds: let's up the ante a little. I can think of no stickier, gooier, ickier fecal substance than infant meconium. So from now on, anything particularly outrageous or ignorant or downright stupid, when it pertains to birth, gets a big old...

CODE MEC! CODE MEC!

Anyone care to make a "Code Mec" button for me?

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The AMA on Home Birth (updated)

Those of you in the birth world have probably heard about the AMA's recent position statement on home birth. I've come across a multitude of responses to the AMA, and I'll try to repost as many as possible here. Ricki Lake was interviewed by the AP about the resolution, which mentioned her specifically. (The AMA has since removed the reference to Ricki Lake.)

Responses to the AMA have come from all over: midwifery and childbirth-related organizations, physicians, midwives, journalists, and, of course, bloggers. If you come across other responses worth mentioning, please include a link in the comments section.

• Our Bodies, Ourselves (aka the Boston Women's Health Collective) responds
• Ricki Lake, Jennifer Block, and Abby Epstein wrote a response to the AMA in the Huffington Post: Docs to Women: Pay No Attention to Ricki Lake's Home Birth.
• In Responses to AMA/ACOG Strong-Arming Women, author Jennifer Block includes responses from family-physician-turned-obstetrician Andrew Kotaska (who is one of my obstetrician heroes--you can read more about him in Pushed) and the UK-based National Childbirth Trust and the Independent Midwives' Association. An excerpt from Kotaska's response:
  
• "We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not “offering” VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, RCT.(randomized controlled trials)....If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women’s autonomy and patient-centered care."
• This release from Ohio Families For Safe Birth contains comments from several physicians who support women's right to choose home birth.
• A lengthy response to the ACOG and AMA statements on home birth from OB/GYN Stuart J. Fischbein. Also mentions VBAC policies--worth the read!
• Author Tina Cassidy writes about Making Home Birth Illegal?
• The Big Push For Midwives calls it Father Knows Best Meets Big Brother Is Watching.
• Navelgazing Midwife argues that "it is the hospital system itself that writes the homebirth script." I don't entirely agree with her argument that home birth's existence is only a function of the current hospital birth climate, but it is definitely a strong factor.
• Family physician Denise Punger discusses why she will not join the AMA. In the post, she writes:
• "When ACOG came out with their statement Permission to Mother was not published yet, but now I can say I have a book that describes in a stepwise, logical progression from medically managed birth to my breech homebirth (where no doubt I was in the safest place for my circumstances). Permission to Mother is my response to this financially & selfishly motivated statement which does not look out for the best interest of women and their families."
• Midwife Pamela Hines-Powell responds briefly and includes other responses to the AMA.
• Hathor the Cowgoddess has devoted several recent comics to the topic.
  

Some of the many blogger responses to the AMA statement:

• The Bee In Your Bonnet calls it a Civil Rights Issue
• A Doula Too
• Firefly Mama
• Mentioned in a post about medical rape by Feministe
• Fearless Birthing urges us to Protect All Safe Birth Options
  

Below is an email Ricki Lake sent out on June 18 about the AMA resolution:

June18, 2008

Dear BOBB Friends and Supporters:

We wanted to make sure you are all aware of the news story that has exploded over the last 24 hours regarding the recent AMA Resolution against homebirth and Ricki's response to being named in it.

In February of this year, one month after the premiere of BOBB, the American College of Obstetricians and Gynecologists (ACOG) reiterated its long-standing opposition to home births. In an obtuse reference to The Business of Being Born, ACOG stated, "Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre." If that wasn't enough, ACOG, this past weekend, introduced a resolution to the American Medical Association (AMA) at their annual meeting. The resolution commits the AMA to "develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital...". The reasoning for this resolution begins, "Whereas, There has been much attention in the media by celebrities having home deliveries, with recent Today Show headings such as "Ricki Lake takes on baby birthing industry: Actress and former talk show host shares her at-home delivery in new film...". (Resolution 205, click here to read).

Since when did Ricki become an evidence-based data point? What are they so afraid of?

Just last week, Medical News Today reports that "about 8.2% of infants born in the US in 2005 had low birth weights, the highest percentage since 1968." US infant mortality rates continue to rank us below 30 other countries, 22% of pregnancies are induced, and most worrisome of all, in the last 4 years, the maternal mortality rate has risen above 10 per 100,000 for the first time since 1977. To us, these seem like the troubling trends, not home birth.

News outlets including the AP quickly picked up this story yesterday as it hit TMZ, E! USA Today, Daily News, FOX.

Ricki will be featured on Good Morning America this Saturday discussing the controversy. (If you Google "Ricki Lake, AMA" you will see the bloggers are all over this!)

Filmmakers Abby Epstein and Ricki Lake teamed up with journalist and Pushed author Jennifer Block to pen the response (following at the end of this email) for the Huffington Post (click here to read).

Late yesterday, the AMA changed the final wording on resolution 205 to omit the mention of Ricki. (Hmmm...) The AMA says that the American College of Obstetricians and Gynecologists (ACOG) drafted the initial statement so any issues should be taken up directly with them.

Stay tuned for more news to come...

The BOBB Team

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RGOC and RCM on Home Births

Compare the below statement (long but worth reading) from the Royal College of Obstetricians and Gynecologists and the Royal College of Midwives with ACOG's recent statement about home birth. I hope for the day when ACOG can produce a similar document that actually examines the evidence and listens to what women are saying. Imagine what we could achieve if ACOG were an ally to all birthing women!

Home BirthsRCOG and Royal College of Midwives Joint Statement No.2.April 2007

Summary

The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.^1–3

1. Introduction

1.1 The rate of home births within the UK remains low at approximately 2%,^4–6 but it is believed that if women had true choice the rate would be around 8–10%.7
1.2 The development of maternity polices over the last four decades, combined with frequent reorganisations of service structure, have impacted on the availability of home birth and have concentrated on births in hospitals.^8–10 Reasons for this appear to include:

• financial constraints
• the values and beliefs of organisations about maternity care
• lack of staff with the appropriate competencies.¹¹

1.3 Throughout this time, women and voluntary organisations have challenged the onedimensional approach to options for place of birth and have influenced the portfolio of evidence now available to support a return to a more diverse range of childbirth environments.^12–15

2. Review of the evidence: benefits and harms

2.1 The review of the diverse evidence available on home birth practice and service provision demonstrates that home birth is a safe option for many women.^2,16,17 However, this is not to define safety in its narrow interpretation as physical safety only but also to acknowledge and encompass issues surrounding emotional and psychological wellbeing. Birth for a woman is a rite of passage and a family life event, as well as being the start of a lifelong relationship with her baby. Home births will not be the choice for every woman.⁷
2.2 Randomised controlled trials to assess the safety of home births are not currently feasible. The observational data available show lower intervention rates and higher maternal satisfaction with planned home birth compared with hospital birth. Overall, the literature shows that women have less pain at home and use less pharmacological pain relief, have lower levels of intervention, more autonomy and increased satisfaction.^1,12,18–20 The studied interventions included induction, augmentation, perineal trauma and episiotomy, instrumental delivery and caesarean section. These are not insignificant interventions and may have considerable impact on a woman’s long-term health and emergent relationship with her baby, as well as her satisfaction with her birth experience.
2.3 Furthermore, the studies into women’s descriptions of home birth experiences have produced qualitative data on increased sense of control, empowerment and self esteem, and an overwhelming preference for home birth.^3,21–27
2.4 A distinction needs to be made between women who plan for a home birth and those who have an unintended home birth, as unintended home births or women who received no antenatal care are linked to a higher rate of both maternal and perinatal complications.²⁰
2.5 A proportion of women who plan a home birth are transferred to hospital,^9,13,14,19 most commonly for slow progress or needing pain relief not available at home, such as epidural anaesthesia. The most serious reasons for transfer are maternal haemorrhage, concerns about fetal wellbeing and the neonate born in an unexpectedly poor condition. Delay in transfer under these circumstances may have serious consequences. Owing to poor collection of maternity data, the comparative statistics for women being transferred in labour are unclear. Higher transfer rates are associated with nulliparity.^13,14,19,28 The discussion with women regarding their potential transfer in labour should include consideration of the distance between birth settings and of other local circumstances which may introduce delay in transfer.

3. Achieving best practice

3.1 Both the RCM and the RCOG believe that to achieve best practice within home birth services it is necessary that organisations’ systems and structures are built to fully support this service. These will include developing a shared philosophy, fostering a service culture of reciprocal valuing of all birth environments.
3.2 Comprehensive involvement by local multidisciplinary teams and users to underpin home birth practices within a clinical governance framework results in a quality service which demonstrates commitment to supporting women in their choices.^4–6 Equally, it supports the development of responsible and responsive practices that are maintained by effective clinical decision making.

4. Provision of information, informed choice and user involvement in planning the services

4.1 The key principles include providing unbiased information on birth environment options and being transparent about the potential advantages or disadvantages of home birth.^14,29–33 Written information regarding place of birth should be available for all women, all women should be encouraged to participate actively in the full range of antenatal care and women can make the choice for a particular place of birth at any stage in pregnancy.¹⁴
4.2 The support for women’s choices is linked to clinical assessments during pregnancy and labour, to update the care pathway.¹² It is acknowledged that there are no known risk assessment tools which have an effective predictive value concerning outcomes in the antenatal period and labour.^34,35
4.3 Home birth provision should take into account women’s individual needs, especially women from socially excluded, disadvantaged and minority backgrounds,^4,36–38 as they are less likely to access services or to ask for home births
4.4 The involvement of fathers/partners in planning and attending home birth is encouraged as pregnancy and birth are the first major opportunities to engage fathers/partners in the appropriate care and upbringing of their children.⁴

5. Continuity and communication

5.1 Continuing communication between health professionals, women and their families is requisite for continuity of care. ‘A midwife providing care to women, regardless of the setting, must take care to identify possible risk and pre plan to mitigate those risks through her approach to care, knowledge of local help systems and communication with colleagues and the woman and her family’.¹⁵ Planned referral pathways in pregnancy are designed to facilitate effective communication and feedback at all levels and with any agency involved in providing care.
5.2 UK maternity policies recognise that, for the majority of women, pregnancy and childbirth are normal life events and that promoting women’s experience of having choice and control in childbirth can have a significant effect on children’s healthy development.^4–6 The improved relationships built upon continuity of care and carer can lead to considerable advantages in the promotion of breastfeeding, reduction in smoking in pregnancy and improved nutrition for women.
5.3 Continuity of care is a complex concept as it can mean continuity of care from a team of midwives or continuity of carer by a single known midwife. Organisations need to explore ways of promoting home births within these care schemes, especially for socially excluded women.^36–39
5.4 Another aspect in ensuring effective communication is clear and detailed documentation of the care plan for home birth.^32,36

6. Service structure support

6.1 The recent recruitment and retention problems of midwives within the maternity services have led to some NHS trusts withdrawing home birth services or informing women at the last minute that staff are not available. For women to believe throughout their pregnancy that they will have a home birth and for this option to be withdrawn late in pregnancy or in labour is not acceptable and will lead to further pressure on labour wards and midwives, as they have to manage women who are disaffected by the service at the start of their labour. Any possibility of not being able to provide the service should be highlighted in early pregnancy.
6.2 It is essential that formal local multidisciplinary arrangements are in place for emergency situations, including transfer in labour and midwives referring directly to the most senior obstetrician on the labour ward and/or to the paediatrician. The midwife is responsible for transfer and must remain to care both for the woman and the baby during transfer and, where possible, continuing on in the transferred unit. These protocols need to encompass the independent practitioners providing home birth service. The use of ‘flying squads’ is no longer supported and in the event of an emergency, transfer in is the only option.
6.3 Other agencies have an integral role in the collaborative management of home birth services, particularly the regional ambulance service. Therefore, developing a service agreement with these agencies will provide an improved risk management framework; for example, in the event of emergency transfer ambulances should take women to the consultant obstetric unit rather than the accident and emergency department. Babies need to be transferred to maternity units where there are appropriate neonatal services.
6.4 The clinical and personal safety of the midwife practitioner at home birth requires extra resources. For example, it is the employer’s responsibility to set minimum agreed levels of equipment for carrying out the role, including equipment for communication.^33,40 In addition, midwives working alone in the community should have appropriate lone-worker arrangements provided by their local NHS trust or employer.
6.5 Midwifery supervision is integral to any midwifery practice and all organisations must ensure that there are adequate numbers of supervisors of midwives to ensure 24-hour access.⁴¹ Where a woman has a risk factor which may deem her unsuitable for a home birth it is advisable that the midwife involves a manager and supervisor of midwives.

7. Skills and competencies

7.1 Midwife practitioners must be competent within the home birth environment and may require enhancement or updating of their existing midwifery skills prior to providing home birth services.¹⁵ Midwives’ personal accountability for only undertaking duties for which they have competencies, is governed by Midwives’ Rules and Standards.⁴¹ The organisation’s responsibility is to provide resources for acquiring new or maintaining existing skills associated with home birth practices, both linked to facilitating and observing physiological labour, as well as acting on emergencies. The mandatory ‘drills and skills’ training must include environments outside labour ward and simulation models should be available to encourage practising of skills. Up-to-date registers should be kept of those participating in skills drills to ensure that all staff participate regularly in a rolling programme.⁴²
7.2 The advanced courses in obstetric emergencies and neonatal resuscitation require adequate funding for further training.
7.3 Risk assessment must take place with what limited tools are available. Careful selection of low-risk maternities is important to minimise complications. Ideally, this should be by senior midwifery and obstetric staff.

8. Record keeping, audit and user surveys

8.1 Contemporary and accurate record keeping is vital; as for all aspects of health care.^33,41,43 The health records maintained on various sites need to be stored as a complete set and most organisations now require computer input for the birth records and obtaining the baby’s NHS number. These computer programmes aid auditing practices, both personal and organisational. Areas of service or practice for audit should include home birth, transfer and intervention rates as a minimum. User satisfaction surveys and focus groups need to be linked with home birth services. There should be robust clinical governance systems for monitoring the quality of home birth services. These should include both qualitative and quantitative audit data. Consideration should be given to women’s experiences, stories, transfer rates, ambulance response times and emergency scenarios. In the case of serious adverse outcome a detailed root cause analysis should be undertaken.⁴²

9. Conclusion

9.1 The RCM and RCOG support the provision of home birth services for women at low risk of complications. If the service is provided by midwives committed to this type of practice within continuity of care schemes and appropriately supported, outcomes are likely to be optimal. Services need evidence-based guidelines, where possible. Good communications, adequate training and emergency transfer policies are vital.

References

1. Wiegers TA, Keirse MJ, Van der Zee J, Berghs GA. Outcome of planned home birth and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ 1996;313:1309–13.
2. Olsen O. Meta-analysis of the safety of the home birth. Birth 1997;24:4–13.
3. Ogden J, Shaw A, Zander L. Deciding on a home birth: help and hindrances. Br J Midwifery 1997;5:212–15.
4. Department of Health. The National Service Framework for Children and Young People. Maternity Services. Standard 11. London: Department of Health; 2004 [www.dh.gov.uk/assetRoot/04/09/05/23/04090523.pdf].
5. Welsh Assembly Children’s Health and Social Care Directorate. National Service Framework for Children, Young People and Maternity Services in Wales. Cardiff: Welsh Assembly Government; 2005 [www.wales.nhs.uk/sites/documents/441/ACFD1F6.pdf].
6. 6. Scottish Executive. A Framework for Maternity Services in Scotland. Edinburgh: Scottish Executive; 2001 [www.scotland.gov.uk/library3/health/ffms–00.asp].
7. Department of Health. Changing Childbirth: Report of the Expert Maternity Group. London: HMSO; 2003.
8. Department of Health and Social Security. Standing Maternity and Midwifery Advisory Committee (Chairman J. Peel). Domiciliary midwifery and maternity bed needs. London: HMSO; 1970.
9. Campbell R, Macfarlane A. Where to be Born: the Debate and the Evidence. Oxford: National Perinatal Epidemiology Unit; 1987.
10. Tew M. Safer Childbirth? A Critical History of Maternity Care. 2nd ed. London: Chapman and Hall; 1998.
11. Demilew J. Homebirth in urban UK. MIDIRS Midwifery Digest 2005;15:4(Suppl 2).
12. Edwards N. Choosing a Home Birth. London: Association for Improvements in the Maternity Services; 1994.
13. Chamberlain G, Wraight A, Crowley P. Home Births: The Report of the 1994 Confidential Enquiry by the National Birthday Trust Fund. Carnforth: Parthenon; 1997.
14. National Childbirth Trust. NCT Home Birth In the United Kingdom. London: NCT; 2001.
15. Nursing and Midwifery Council. Midwives and Home Birth. NMC Circular 8–2006. London: NMC;2006 [www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=1472].
16. Springer NP, Van Weel C. Home birth. BMJ 1996;313:1276–7.
17. Olsen O, Jewell MD. Home versus hospital births. Cochrane Database Syst Rev 1998;(3):CD000352.
18. Northern Region Perinatal Mortality Survey Coordinating Group. Collaborative survey of perinatal loss in planned and unplanned home births. BMJ 1996;3:371–5.
19. Davies J. The Midwife in the Northern Regions Home Birth Study. Br J Midwifery 1997;5:219–24.
20. Confidential Enquiry into Stillbirths and Deaths in Infancy. 5th Annual Report. Focus group place of delivery. London: Maternal and Child Health Research Consortium; 1998.
21. Viisainen K. Negotiating control and meaning: home birth as a self-constructed choice in Finland. Soc Sci Med 2002;52:1109–21.
22. Andrews A. Home birth experience 2:births/postnatal reflections. Br J Midwifery 2004;12:552–7.
23. Munday R. Women's experience of the postnatal period following a planned home birth; a phenomenological study. MIDIRS Midwifery Digest 2004;13:371–5.
24. O’Brien M. Home and hospital: a comparison of the experiences of mothers having home and hospital confinements. J R Coll Gen Pract 1978;28:460–6.
25. Goldthorp WO, Richman J. Maternal attitudes to unintended home confinements: a case study of the effects of the hospital strike upon domiciliary confinement. Practitioner 1974;212:818–53. Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No.2 5 of 6
26. Alment EA, Barr A, Reid M, Reid JJ. Normal confinement: home or hospital? The mother’s preference. BMJ 1967;I:52–53.<>
27. Paddison J. Home Birth a Family Affair: A Qualitative Research Case Study of Home Birth and Social Boundaries. Wigtownshire: Impart Publishing; 2005.
28. Campbell R, Macfarlane A. Where to be Born? The Debate and the Evidence. 2nd ed. Oxford: National Perinatal Epidemiology Unit, 1994.
29. Emslie MJ, Campbell MK, Walker KA, Robertson S, Campbell A. Developing consumer-led maternity services: a survey of women’s views in a local healthcare setting. Health Expectations 1999;2:195–207.
30. Hundley V, Rennie AM, Fitzmaurice A, Graham W, Van Teijlingen E, Penney G. A national survey of women’s views of their maternity care in Scotland. Midwifery 2000;16:303–13.
31. Singh D, Newburn M. Access to Maternity Information and Support: the needs and experiences of pregnant women and new mothers. London: National Childbirth Trust; 2000.
32. Royal College of Midwives. Home Birth Hand Book: Volume 1: Promoting Home Birth. London: RCM; 2002.
33. Royal College of Midwives. Home Birth Hand Book: Volume 2: Practising Home Birth. London: RCM; 2003.
34. Enkin MW, Keirse MJ, Renfrew MJ, Neilson JP. A Guide to Effective Care in Pregnancy and Childbirth. 2nd ed. Oxford: Oxford University Press;2000. p. 52.
35. Campbell R. Review and assessment of selection criteria used when booking pregnant women at different places of birth. Br J Obstet Gynaecol 1999;550–6.
36. Hutchings J, Henty, D. Caseload practice in partnership with Sure Start: changing the culture of birth. MIDIRS Midwifery Digest 2002;(Suppl 1):538–40.
37. Sandall J, Davis J, Warwick C. Evaluation of the Albany Midwifery Final Report. London: Florence Nightingale School of Midwifery, King’s College; 2001.
38. Royal College of Midwives. Making Maternity Services Work for Black and Minority Ethnic Women: A Resource Guide for midwives. London: RCM; 2004.
39. Hodnett ED. Continuity of caregivers for care during pregnancy and childbirth. Cochrane Database Syst Rev 2000;(2):CD000062.
40. Royal College of Midwives. Safety for Midwives Working in Community. Position Paper 12. London: RCM; 1996.
41. Nursing and Midwifery Council. Midwives Rules and Standards. London: NMC; 2004 [www.nmc–uk.org/aFrameDisplay.aspx?DocumentID=169].
42. National Health Service Litigation Authority. Clinical Negligence Scheme for Trusts, Maternity. Clinical Risk Management Standards. London: NHSLA; 2007 [www.nhsla.com/NR/rdonlyres/F8184718–3AF9–400E–A3F3–5D9309E2 AA72/0/CNSTMaternityClinicalRiskManagementStandardsApril2007website.pdf].
43. Royal College of Midwives. Litigation: A Risk Management Guide for Midwives. 2nd ed. London: RCM Trust; 2005

Valid until April 2010 unless otherwise indicated.
This statement was produced on behalf of the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives by: Miss JL Cresswell FRCOG, Chesterfield, and Ms E Stephens RM and peer reviewed by: Ms J Demilew, Ms C Dowling, Dr MCM Macintosh MRCOG, Ms P McConn, Dr MP Mohajer FRCOG, Mr RJ Porter FRCOG and Mr PJ Thompson FRCOG.

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Write to ACOG

If you have a response you would like to communicate to ACOG about their recent statement on home birth, please write or call:

ACOG Office of Communications
202.484.3321
communications@acog.org

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Responses to ACOG (updated!)

Responses are rolling in! Let me know if you see any others and I will post them:

• ICAN's response to ACOG and the AABC.
• The Big Push for Midwives asserts that ACOG is out of touch with the needs of childbearing families.
• Permission to Mother (a family doctor blogger): Time to deal with ACOG
• The Mommy Blowg talks about the latest from ACOG
• Midwifery World says it's a shocker (sarcasm intended)
• Friends of Missouri Midwives asks its readers what they think of the statement
• TrueBirth responds
• House of Harris points out the contradictions
• VBAC Warrior responds with a drawing
• Jill says ACOG makes her laugh
• Jennifer Block (author of Pushed) examines the notion of a cause célèbre
• Sagefemme briefly shares her thoughts
• Tina Cassidy (author of Birth: The Surprising History of How We Are Born) responds
• A new midwife shares her thoughts.
• Descent takes a somewhat earthy approach to ACOG
• BlogHer discusses the research
• A MDC mama writes a parody of the ACOG statement
• Hathor the Cow Goddess is drawing cartoons: Your choice and Protect our, um...women

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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.

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