Read the Subtext: ACOG's Position on Home Birth
Monday, September 13, 2010 at 11:26AM
Guest post by Rachel_in_WY
Until recently I had never read ACOG’s statement on home births. I expect these kinds of things to be routinely depressing, so I tend to avoid them. I pretty much know what they’re going to say. But recently, Jill sent me an email with a link to ACOGs statement and a request to pick it apart, to critique it the way I teach my Logic and Critical Thinking students to critique arguments. And this, of course, is fun. So here we go.
First, a couple of procedural notes: when I’m teaching students how to analyze and critique an argument, one of the places we start is with implied premises and unstated assumptions that are essential to the argument. It’s often the case that these implied premises and hidden assumptions are not shared by both sides of a debate, but they are precisely the thing that prevents the opposing parties from ever being able to reach a consensus, or even really respond to each other in a meaningful way (think of the abortion debate, here). The result is a huge mess of a non-conversation that goes on and on with increasing vitriol but little progress. This is clearly the case here. As we’ll see, home birth and natural birth advocates start with very different assumptions, values, and goals from those of medicalized birth advocates.
Another thing I train my students to watch for is how terms are defined. There can be a lot of subtle meaning packed into a word, and so carefully defining your terms, and watching how others define terms is essential. Generally speaking, the party who defines the terms will have the upper hand in the debate. Notice how people who are anti-abortion but pro-war and pro-death penalty call themselves pro-life? Notice how conservative groups that spread bigoted attitudes claim that they are the sole proprietors of “family values”? It’s a masterful use of language, and it’s often quite effective, so it’s an area where we should be particularly wary.
ACOG begins with this:
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’s position is that complications are always possible, and it’s these potential complications that make medicalized birth necessary. And this seems really reasonable, right? But here’s your first point of departure. A home birth advocate is going to point to studies that show that each instance of medical birth management and intervention actually increases the chances of complications. For a mother who chooses home birth, avoiding the complications that are often caused by the actions of medical professionals counts as a reason to avoid a hospital birth. Induction, epidurals, pitocin, fetal monitoring, etc, all lead to higher rates of complications and interventions. And here’s where the underlying goals, values, and assumptions conflict. An advocate of medicalized birth doesn’t see a problem with higher rates of complications and interventions as long as the outcome – a seemingly healthy baby – is reached. Most natural birth advocates, on the other hand, see complications and interventions as inherently unhealthy, and something to be avoided if at all possible. From this stance, the natural processes that occur within the mother’s and child’s body during labor and birth have their own unique contribution to the long-term health of the mother and baby, so merely producing a live baby over which the hospital/doctor cannot be sued is an inadequate goal to strive for.
The relevant question here might be “how do you define healthy?” If you simply mean “not dead,” then sure, a hospital birth probably will produce a healthy baby. But if you mean a baby who has had a birth that was not traumatic, that didn’t involve exposure to unnecessary pharmaceuticals and environmental toxins, that will be most likely to result in a baby who thrives over the long-term, and who doesn’t have a mother who was traumatized by her birth experience, then reducing medical interventions is a central goal. And if reducing medical interventions is a goal to you then, generally speaking, you’re not going to prefer a hospital birth. So in this first case we have a fundamental difference between the two sides that could be summed up as complication treatment vs complication prevention.
ACOG goes on to make this statement:
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. … 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.
The first line here seems a bit contradictory, right? ACOG wants mothers to be able to make choices, as long as they choose the choice ACOG chooses for them. So here the concept of “informed decisions” is in question. If you’ve ever been involved in raising a toddler, you’ve been through this, right? You want to give your child choices to encourage their sense of autonomy, but you know they’re not mature enough to make certain choices. The restaurant has soda on the menu, but you only ask them if they want milk or juice. Because a toddler isn’t ready to make informed decisions about nutrition. They don’t know what you know about the long-term effects of soda consumption on their little pancreases. So you limit their choices, for their own good. And this is OK, because you’re the parent and they’re the child. Except that the relationship between ACOG and adult women is not a parent-child relationship. True informed consent and informed decision-making is inconsistent with the machinery of curtailed choices that characterizes parent-child relations. Unless you believe that adult women are the equivalent of toddlers, this analogy, and the accompanying behavior, is inappropriate. The rest of this excerpt furthers the theme of infantilizing adult women and belittling their choices. By implicitly stating that women who choose to give birth at home or in a less medicalized environment are only choosing to do so because it’s fashionable and trendy, ACOG neatly categorizes adult women as irrational and childish. Of course she couldn’t have any good reasons to object to the medical machinery surrounding childbirth. She’s a woman, after all, and a pregnant one at that! This subtly and effectively delegitimizes a woman’s choice to avoid the medicalized route even if it was based on research and solid scientific evidence and thoughtful discussions with friends, family, and experienced care providers.
Finally, we have ACOG’s concluding statement (the part Jill highlighted to me, and boy is it a doozy):
Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.
Wow is there a lot to unpack here. We are told, first of all, that one must make a choice between the outcome and the process. It’s the old healthy baby vs desired birth experience false dilemma. “You must choose!” we’re told over and over again. And obviously any mother who would choose anything other than a healthy baby is an unfit mother. How could you not choose a healthy baby?!? But of course, in reality these aren’t mutually exclusive. In fact, they’re not even incompatible in the vast majority of cases. And they’re not unrelated. An informed natural or home birth advocate will point to evidence that the birth experience of both mother and baby is a significant factor in the long-term health of the baby. If the birth experience is traumatic and micro-managed and intervened in at every turn, the outcome is less healthy in a variety of ways. That is of course, if you’re defining healthy as more than just “breathing.” And so here we have to prod this implicit claim that mothers who choose natural birth don’t care about the outcome, only the process. Of course they care about the outcome – they just define a successful outcome differently than ACOG does. For a medical professional or a hospital administrator, success boils down to lower liability, smooth and convenient timelines, passive, docile “patients,” and larger profit margins. And of course, profit margins increase with each additional intervention. Insurance companies pay every time another procedure is added to the list. Given that the hospital is a business that’s staffed with people who work set shifts and have other patients to tend to, these are all totally reasonable outcomes to be desired from an administrative standpoint. The problem is, they’re not consistent with the outcomes that it’s rational for a mother to desire. For her, the long-term health and well-being (mental and physical) of both her and her baby are of the utmost importance. Profit margins and hospital schedules and lawsuits have nothing to do with her values and goals concerning childbirth. So the implication that mothers who choose natural births don’t care about outcomes is absurd. Sure they don’t care about the hospital’s goals and desired outcomes. Obviously. But that’s very different from not caring about the outcomes, short-term and long-term, of the birth.
Once you unpack the rhetoric involved here you get a pretty clear picture of ACOGs view of women, and of the processes they go through when planning their birth experiences. You also see the subtle manipulation they’re willing to engage in in order to secure compliance and submission of pregnant women. And they wonder why some of us regard them with caution and distrust…
Reader Comments (44)
**applause**
That was wonderful. I especially liked the way you exposed their paternalism.
AWESOME!
Thanks!
Well done! I find it hilarious that ACOG describes home birthing as "trendy" and a "cause celebre." Less than 1% of women give birth at home, and many don't even know that home birth exists! Yes, very trendy!
IMHO, if ACOG really cared about women, they'd try a lot harder to make the hospital more attractive to them. I get it that they equate an OR down the hall to safety (not that I agree). So why not try to make it just like home? You know, get rid of the stupid food and fluid restrictions, no mom/baby separation, no/low intervention, etc. but have an OR within easy reach. If they are so worried about the well-being of 1% of women and babies who birth at home, why don't they try harder to make policies that would attract those women to the hospital?
Thanks for this posting. You did a FAB critique!!! I too have failed to actually read the ACOG statement on home birth (going there now) and I am appalled, yet not at all surprised at the paternalistic and condescending tone of the statement. It reeks of ACOG and their typical tactics to give misleading, degrading information to the public and to their membership. The toddler in the restaurant analogy is perfect. That is exactly the way many ACOGers approach not only childbirth but women's health issues/concerns in general. There may be 5 viable options but they only share 2.
The worst of it all…. "Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre" WTF!!! Are they SERIOUS!!! This does not even sound like a professional paper/statement. Who wrote this crap!!!! I guess it sounds like what it is. The ranting of an angry man upset that his wife/daughter has made a decision to do something that he disagrees with. I think I need to go puke now!!!
"Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby."
We at The Big Push for Midwives Campaign like to call it "the bad mother card"--it's an oldie, but a goodie. ACOG and its allies have been using it to malign home birth mothers in legislative hearings on CPM licensure for many years, accusing us of valuing the birth "experience" over the health and safety of our babies, an assumption that, as Rachel points out so well, is based on a set of false dichotomies and opposing values (in addition to being both paternalistic and insulting).
Unfortunately, though, it can be a very effective rhetorical strategy if the assumptions on which it is based aren't challenged. In recent years, though, midwifery advocates have been undermining its use by pointing out that it's ACOG's own policies in opposition to regulating home birth midwifery care and limiting women's access to CPMs, who are specially trained to provide it, that put mothers and babies at risk of receiving substandard care in the 23 states with no regulation, oversight, transparency or accountability for the majority of midwives providing out-of-hospital maternity care.
It's no coincidence that the recent piece of junk science published in AJOG conveniently found improved outcomes for mothers giving birth at home but worse outcomes for babies, which prompted the Lancet editorial lambasting home birth mothers for putting their babies at undue risk. We know that the study will be used as a platform for the "bad mother card" in the 10 state legislatures that will be introducing CPM licensure bills next session, so we've created this response for midwifery advocates to use at: http://bit.ly/thewaxpaper
I've also asked Heidi's question ("Why not try to make it just like home?")
ACOG is spending energy fighting homebirth and trying to legislate it into illegality, and, I'm rather gleeful to see, they're really not having much success at the moment. I don't think they want to see homebirth gone as badly as a growing number of women want to see it available as a option.
If instead, ACOG spent its energy figuring out WHY women are voting with their feet and choosing out of hospital birth in increasing numbers, and encouraged its members to change their practice to address these issues, I think they'd have far more success.
Of course, in an ideal world, ACOG would also spend time figuring out how to facilitate midwife-OB relationships in a way that maximized homebirth safety, rather than driving a wedge between the two groups. I can dream, can't I?
Yes, ACOG I'll have what she's having: Father knows best, meets mother may I?
oh wait, there is a second opinion?
excellent post Rachel in WY.
What becomes more clear as ACOG keeps spinning its wheels on this issue is:
they have mysteriously and conveniently misplaced all their own "suboptimal" outcomes and can offer no good reason why babies die in hospitals. It is just a sad tragedy apparently foisted upon unfortunate parents.
they cannot offer any plausible and reasonable rebuttal for all the babies born safely, mundanely and without incident at home
their policies and (cock) blocking of legislation most definitely keeps mothers and babies at risk of having inadequately trained providers attending births or risk going it alone because of the illegality of home birth coupled with the lack of affordable health insurance.
SaanenMother, I went unassisted on a VBAC for the exact reason you said (almost). My midwife was trying to force me to have a CS, despite having a sucessful NCB VBAC only 12 months prior. I told her I refuse and she tried going through the courts, but I gave birth AT HOME, all by myself while my husband was deployed to Iraq and my children were sleeping in their rooms.
@ Courtney- I am not surprised that a person was harassed by what I gather from your post is a military health system. Talk about father knows best/mother may I. I have seen posts here by other fellow mothers whose families serve in the military. All I can do is shake my head in disgust. I am relived to hear your birth unfolded without incident.
“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.”
Know what’s funny about this? A freestanding birth center isn’t really any different than a home birth with a trained midwife. The equipment is exactly the same (except for the baby French fry warmer) and a transfer is a transfer. Birth centers have a relationship with the nearby hospital that makes a transfer a little easier in terms of identifying who is coming in. But in states in which out-of-hospital midwifery is “legal” and midwives don’t fear persecution when handing over charts, a home transfer and a birth center transfer would be similar.
I get that this organization wants to keep an eye out for safety by endorsing only standardized or approved locations-- that doesn't sound nefarious to me at all. However, if the main concern with location is that home birth puts too much distance between a woman and a hospital in the chance of a rare obstetric emergency, it's odd that they endorse birth centers but not home. Clearly it really has nothing to do with distance from the hospital and everything to do with only approving one type of midwife... the certified nurse-midwife.
But whatever. Three cheers for freestanding birth centers!
Titillating reading! I said it and I meant it! Titillating!
Thanks for the breakdown.
Thanks, SaanenMother. My husband asked why I did it that way and I told him (he came home on R&R 6 days later. He said he was proud that I stood up to the "big man".
Another point that jumped out at me here was how much ACOG is emphasizing a healthy baby. They seem to value the health of the baby over the mother and see the mother and baby as being at odds here. Homebirth/NCB advocates believe the mother is equally important, and that the mother and baby are intimately linked. ACOG's language plays into the "bad mother card" another commenter mentioned. A "good" mother puts her baby first; apparently only a "bad" mother also prioritizes her own health. I see this a lot in anti-VBAC rhetoric where the mother is described as selfishly putting her baby's life at risk. Never mind that a mother is 2-3x as likely to die in a repeat cesarean than a VBAC; but apparently to consider her own life and the fact that she already has a living child to care for makes her a bad mother. A mother is allowed to consider her own well-being and value as a person. She is not always subordinate to her child. I think the way our society values children's well-being over mothers so much does a real disservice to mothers--and therefore to their children.
I also agree with the previous poster who mentioned how ACOG is ok with freestanding birth centers, but not home birth. A birth center is equipped about the same as a home birth is. They do not have OBs on hand and cannot do emergency cesareans either. So why does ACOG feel that a home birth is more dangerous than a birth center? That tells me that ACOG's opposition to home birth is based more on politics and ideology than facts or rational thought.
I am offended as a physician that it is insinuated that I would not offer sympathetic, reasonable care to mothers should they labor at the hospital rather than at home. NEVER have I made clinical decisions upon what would be "best" for the hospital budget or better for my own pockets lest I be sued. This article is outrageous dialogue which encourages suspicion of medical care from professionals, and thus endangers women and may even lead them on the road to cesarean delivery or worse due to precipitous and dangerous complications.
I am, of course, a frequent reader of ACOG bulletins, etc and never have I found them to be sided toward lawsuit prevention, profits, and -most offensively - demeaning women which this article claims as apparent. ACOG employs the highest levels of evidence to provide the best possible recommendations of care, REDUCE interventions, provide the best possible quality of life and outcomes for women, and SAVE LIVES.
I am a frequent reader of this site - I feel it is very important to be in touch with what patients feel, think, etc regarding their experiences of pregnancy and birth. I will continue to visit, and I applaud some of the posts I've encountered . But - this article is absolute bullshit.
DocReader, you sound like a great physician if you are willing to read sites like this in order to stay in touch with your patients. There are many wonderful docs out there. But how can women trust the medical profession as a whole when it routinely tells them lies? Why shouldn't people be skeptical of a profession that lies to them?
Take the clear liquid diet during labor that hospitals require. Women are told by ACOG that they won't want to eat in labor--which is patronizing and a stupid overgeneralization. Individual doctors and nurses tell women that eating during labor is dangerous and they could die from it (I'm an l&d nurse, and I've heard this said more than once). ACOG patronizes them, and individual doctors lie to them, and in the meantime they are forced to labor and push out a baby while starving. This is just one of the lies that laboring women are told daily.
Yes, being afraid of doctors and medicine leads some people to stay away from life-saving treatment. But I think you are pointing the finger in the wrong place. Blogs like this expose the lies in medicine, but if the lies weren't there to begin with, there would be no need to expose anything.
Hear, hear! :-)
"This article is outrageous dialogue which encourages suspicion of medical care from professionals, and thus endangers women and may even lead them on the road to cesarean delivery or worse due to precipitous and dangerous complications."
So now even questioning or discussing ACOG policies is dangerous? So you prefer that all women believe what you and ACOG say to be the gospel truth? I am sure that would make life easier . . As a former L&D nurse, Women's Health NP, and current PhD student studying birth choices in our country, I found the author's presentation of another view of the position statement refreshing. I may not agree with it 100%, but I always welcome new views on any issue. Frankly DocReader, you are just repeating the party line.
"baby French fry warmer" .... love it!
I love rhetorical analysis (speaking as a former comp/rhet instructor). I'll have to bookmark this in case I ever teach composition again.
Hi DocReader,
“NEVER have I made clinical decisions upon what would be "best" for the hospital budget or better for my own pockets lest I be sued.”
OK, so you would have been one of the 37% who did not make changes to their practice based on fear of litigation. ACOG reported last year that “more than 63% of ob-gyns report making changes to their practice due to the risk or fear of liability claims or litigation; 60% have made changes to their practice because liability insurance is either unavailable or unaffordable.” I hope your patients appreciate you… I would.
“This is bullshit” isn’t a very sturdy counter to Rachel’s critique, but I hear that you’re pissed off. I’m not really understanding your admonition that this article will lead to the endangerment of women and put them “on the road to cesarean delivery or worse due to precipitous and dangerous complications” by encouraging suspicion of medical personnel.
Rachel succeeded in describing the extreme positions—some out-of-hospital birth advocates see hospital birth as inherently traumatic and dangerous due to environmental toxins (I believe the majority of women would disagree) and some hospitals focus heavily on profit, efficiency and protection from lawsuits. Everyone wants a healthy baby and healthy mother.
Please feel free to submit a rebuttal here.