New ACOG Opinion on Home Birth Touts Rights, Nixes HBAC and CPMs
Friday, January 21, 2011 at 7:54AM
By Jill Arnold
ACOG issued a Committee Opinion yesterday on planned home birth which emphasized respect for the rights of a woman to make medically informed decision about birth.
Here is the summary of the opinion:
Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.
The Wax meta-analysis was prominently featured in the opinion, with limitations of the current body of research noted.
The relative risk versus benefit of a planned home birth, however, remains the subject of current debate. High-quality evidence to inform this debate is limited. To date there have been no adequate randomized clinical trials of planned home birth.
VBAC is considered a contradiction to home birth.
Although patients with one prior cesarean delivery were considered candidates for home birth in both Canadian studies, neither report provided details of the outcomes specific to patients attempting vaginal birth after cesarean delivery at home. Because of the risks associated with a trial of labor after cesarean delivery and that uterine rupture and other complications may be unpredictable, the American College of
Obstetricians and Gynecologists recommends that a trial of labor after cesarean delivery be undertaken in facilities with staff immediately available to provide emergency care. The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice considers a prior cesarean delivery to be an absolute contraindication to planned home birth.
CPMs are not recognized as suitable care providers because “recognition and regulation of certified professional midwives and lay midwives varies tremendously from state to state.”
According to the National Center for Health Statistics, more than 90% of attended home births in the United States are attended by midwives. However, only approximately 25% of these are attended by certified nurse–midwives or certified midwives. The remaining 75% are attended by other midwives; the category used by the National Center for Health Statistics that includes certified professional midwives, lay midwives, and others. The recognition and regulation of certified professional midwives and lay midwives varies tremendously from state to state. At this time, for quality and safety reasons, the American College of Obstetricians and Gynecologists does not support the provision of care by lay midwives or other midwives who are not certified by the American Midwifery Certification Board.
ACOG speaks favorably of integrated health care systems which facilitate timely intrapartum transfer to a hospital with an existing arrangement. Because the U.S. does not have this, international observational studies are not considered generalizable to current practice in the U.S.
Another factor influencing the safety of planned home birth is the availability of safe and timely intrapartum transfer of the laboring patient. The relatively low perinatal and newborn mortality rates reported for planned home births from Ontario, British Columbia, and the Netherlands were from highly integrated health care systems with established criteria and provisions for emergency intrapartum transport. Cohort studies conducted in areas without such integrated systems and those where the receiving hospital may be remote with the potential for delayed or prolonged intrapartum transport generally report higher rates of intrapartum and neonatal death. The Committee on Obstetric Practice believes that the availability of timely transfer and an existing arrangement with a hospital for such transfers is a requirement for consideration of a home birth.
Additional Reading:
Editor of The Lancet Discusses Controversial Wax Home Birth Paper
OB/GYN Journal Fast Tracks Anti-Home Birth Study in Advance of Pro-Midwife Legislation
New Study Identifies Need to Distinguish Planned from Unplanned Home Births
Read the Subtext: ACOG’s Position on Home Birth
“The Wax Paper: Home Birth Science or Propaganda?” (The Big Push)
Reader Comments (37)
This is pretty good, for them.
But-this kind of integrated system is what the home birth movement has been trying to get them to allow since the 1970's! And they have fought it every step of the way.
There never will be a "randomized" study of home birth vs hospital birth outcomes, because that would mean the individual woman would have no choice, whereas individual women and their spouses have strong feelings one way or the other about this subject.
As I have said before here, there was a very well conducted matched risk study done by Lewis Mehl in the 70's. I see no reason why that kind of study can't be done again.
Susan Peterson
ACOG will never completely admit to home birth being a safe alternative for low risk woman because of that" what if" factor. There is always mystery behind birth wether your birthing at home in a hospital or at a birth center. Birth isnt predictable but its part of what makes it so intriging! This country should have homebirths and homebirth transport as a part of this countrys health care system its not just convient but a matter of public safety for woman who choose to birth at home.
Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth.
Really!? I have had two planned home births and have had not one issue. I think that the rate of neonatal is higher in the hospital than in a well planned home birth with a very qualified midwife of whom the individual has done there research on. And plus if you as the individual have a knowledgeable midwife she is looking at your diet and how it effects your pregnancy, among a variety other things . For example a midwife looks at your urine to see if you are putting out protein for her a little bit is a concern, where as a doctor doesn't really look at that unless its over a certain amount. If you know anything if you are having any protein in your urine it can be a precursor to preeclamsiam your midwife will tell you to increase you intake of protein. Doctors don't not look at that, for one their not train to, and two gasp it would reduce c-section rates and of course we wouldn't want that now would we that we it would hurt their bottom line.
I could go on and about all that the medical community lacks in knowledge but I will leave it at that.
They are not supportive of CPMs as in many states they do not operate under the auspices of a dr, as all the other midwives do -- they have more professional standing in some cases due to that. Most CNM & CMs still operate under the medical model, which is what many are trying to avoid through home birth. Too bad the ACOG still can't see beyond their own $$.
I wonder how much forced unassisted births affect the "twofold to threefold increased risk of neonatal death". (I'm speaking of women who feel forced to have an assisted birth because midwives are not "allowed" in their state. Not families who plan for an unassisted and are comfortable with the choice).
If the ACOG really felt this way, they would show support for midwives in states without licensing instead of fighting it. Not really sure what affect this position will have on anything. On a positive note, at least it shouldn't make it any harder to homebirth. And at least they are noting that it's a matter of choice and that women are smart enough to make decisions when given information. Or at least that's how I'm choosing to read it.
You have the right to a homebirth, as long as you fit all our criteria and as long as we didn't unnecessarily cut you in the first place, and as long as we approve of the birth attendant.
Nice.
I agree, they can't see beyond their own $$'s/other self interest.
I also like that they cite the Wax paper stat, as if that's the gold standard for measurement of neonatal death, in spite of all the problems with that paper. Moreover, I think we can all agree that neonatal death although tragic is rare, in the hospital or out. The risk is small either place. It may be elevated at home, or in the hospital, and that may vary from patient to patient and hospital to hospital and day to day. Too many variables to really determine that for every patient at every hospital on every day the risk is lower in the L&D unit than at home, even for a VBAC.
Interestingly, their recommendations against homebirths due to lack of integrated system in the US is their own fault. MW's in our area have a devil of a time getting someone to back them up.
And the whole CPM v. CNM thing blows my mind. People choose CPMs over CNMs (or the other way) for a reason...in my area the difference is pronounced. And people that are choosing this are generally aware that there is risk, we are just aware that there is risk no matter what choice you make. It's as if nothing *ever* goes wrong in a hospital that can't be prevented, and we all know that is patently false.
Maybe they should focus on absolute rights to determine care, not the right to determine care so long as ACOG approves of your decision.
Ok, rant off.
Susan already made the point I wanted to, in that bitching about a lack of "randomized trials" is irrelevant, because you can't randomly assign women a method of birth. Though I wonder (tangent) if you could find a cohort of women willing to be randomly assigned a birth method...hospital v. home....and what the results would be? It could have the effect of having many women have a homebirth who would never have tried one before, and possibly liking it.
But even if you could set that up, I firmly believe ACOG would disapprove of it as "dangerous", allowing them to keep bitching about a lack of randomized trials without ever letting one take place.
"I agree, they can't see beyond their own $$'s/other self interest."
I never understand this argument. Homebirth represents less than 1% of births, so the amount of money that obstetricians are losing to homebirth is only a few dollars per obstetrician per year.
On the other hand, homebirth represents 100% of the income of homebirth midwives. If anyone has an economic incentive in this situation it is homebirth midwives and their organizations.
Honestly, which makes more sense: obstetricians exaggerate the dangers of homebirth to make an extra $10 per year or CPMs minimize the dangers of homebirth so they won't lose thousands of dollars per year, their entire income?
Amy, are you familiar with the CPM 2000 study, published in the BMJ? It did a great job of presenting the risks and benefits of home birth.
I'm pretty sure that if anyone is familiar with any study on home birth, it's Amy Tuteur. Head on over to her blog and talk to her about it.
"On the other hand, homebirth represents 100% of the income of homebirth midwives"
Erm... since when? I don't know a single "homebirth midwife" who attends 100% homebirths, in fact over 90% are in hospital.
Seriously, why is Dr. Tuteur always bringing up the fact that homebirth midwives get paid for their services? It would be great if we could all do what we love to do and not get paid for it and be perfectly fulfilled and make a living, but that's not how the world works.
I agree that it's not the financial aspect (loss of income) that makes most doctors not like home birth, though. I really think it's either out of ignorance of the benefits of home births, or because their ego demands that they are the saviors of all laboring women. (or most of them, at least, because birth is ALWAYS DANGEROUS).
It should come as no surprise that this statement was issued the day after the first Health and Human Services committee hearing of the 2010 Department of Regulatory Agencies Sunset Review of the Colorado rules and regulations for Certified Professional Midwives. All the recommendations in the sunset review, plus a couple more grassroots-driven recommendations, were approved by the committee for the initial draft of the new bill. These recommendations are driven by homebirth/CPM advocates. These advocates have written and called their Representatives and Senators, asking to be heard about expanding and maintaining their choices and safety in birth.
You can bet that as future hearings are held, and the bill goes through the state House and Senate, Colorado ACOG will be there, opposing all the way. ACOG's opinions are undoubtedly politically and financially motivated. 1% of maternity care in this country accounts for BILLIONS of dollars.
Our local midwives earn income in many ways other than attending homebirths. In fact I think they attend more hospital births as doulas than they attend homebirths! They also offer placenta encapsulation, birth pool rentals, and belly casting. Although I'm sure attending a homebirth is a larger paycheck per "item" than others, I'd have to inquire whether that or everything else constitutes more of their earnings.
As a homebirth midwife and occasional doula, I might (emphasis MIGHT) earn $8 an hour for all the time I put into face-to-face appointments, attendance at labor and birth, postpartum and newborn care, lactation counseling, placenta encapsulation, phone calls, e-mails, and text messages. More often than not, I am literally giving my time and skills away. I don't know any wealthy homebirth midwives.
Its not just about the money. Its about the control. Money is a side benefit. The American Way of Birth did a great job of presenting what happened to homebirths in the first place. I don't know one homebirth midwife who isn't struggling financially. I have paid out of pocket for every home birth I have had. I pay in full and I pay on time and I have had midwives thank me for that because so many of their clients can't afford to pay (I would love to see a dr give the kind of breaks a mw does...never would happen!). Meanwhile my insurance would cover a hospital birth into the thousands, plus the prenatal care. Citing the ACOG's statement on out of hospitals births (the last one, not this one obviously) my insurance won't cover any birth center or homebirth. It doesn't make great business sense for insurance companies given how much they would save. But then where is there ever logic in our health care system.
"You can bet that as future hearings are held, and the bill goes through the state House and Senate, Colorado ACOG will be there"
I hope they are there, and I hope they call attention to the fact that Colorado's licensed homebirth midwives have an extraordinarily high and rising rate of perinatal mortality.
Last year I wrote about the horrifying death toll of homebirth in Colorado:
" ... [T]he perinatal death rate of LICENSED homebirth midwives in Colorado, caring for low risk patients, exceeded the perinatal death rate of 6.4/1000 for the entire state (all races, all gestational ages, all birth weights, 2003-2007)! Homebirth was the most dangerous form of planned birth by far."
Where did I get that information? From the newsletter of the Colorado Midwives Association.
Karen Robinson, CPM [President of the Colorado Midwives Association] was in denial. In her report on the mortality statistics, she said:
"I don't believe we have a poor perinatal mortality rate, but if solid data shows we do, then I will be at the forefront of the effort to improve our practices and lower the perinatal mortality rate for homebirth in Colorado."
But as I pointed out in my post:
"If she's going to be at the forefront, then she had better get out there. The just published statistics for the year 2008 are even worse. Last year, licensed Colorado midwives had a perinatal mortality rate at homebirth of 8.6/1000. These numbers are nothing short of horrifying."
Amazingly, the 2009 statistics are far worse. In 2009 Colorado licensed midwives provided care for 799 women. Nine (9) babies died for a homebirth death rate of 11.3/1000! That is nearly DOUBLE the perinatal death rate of 6.3/1000 for the entire state (including all pregnancy complications and premature births).
The data is conveniently broken down by type of death and place of death. For example, there were three intrapartum deaths for an intrapartum death rate of 3.8/1000, more than TEN TIMES HIGHER than the intrapartum death rate commonly experienced in hospitals. There were 4 neonatal deaths for a neonatal death rate of 5/1000. That's TEN TIMES HIGHER than the national neonatal mortality rate for low risk hospital birth with a CNM. One hundred women were transferred in labor or after delivery for a transfer rate of 12.5%. The neonatal death rate in the transfer group was 50/1000, an appalling neonatal death rate one hundred times higher than that expected in a group of low risk women.
When I write about the fact that homebirth increases the risk of neonatal death, it is data like this that I am referencing.
Amy, I've looked many times and asked you several times for something to verify what the intrapartum mortality rate is in hospitals, and have never found the answer myself, nor have you answered me. Will you please cite your source now?
Don't just cut and paste the parts you like, AT.
Here's the CMA newsletter passage addressing PERInatal mortality:
--- Also at the meeting in June, I requested a set of changes to the way we report our statistics to DORA at the end of each year. Currently we all answer a set of questions regarding the number of women we care for, the number of births we attend, the apgar scores of the babies we catch, etc. In looking back over the past couple years of statistics, I see that there were 5 perinatal deaths reported each year for 2006 and 2007.
This represents a perinatal death rate of 8 per 1000 for those two years, and that is too high for the low-risk population we serve. The state perinatal mortality rate for all births from 2003 to 2007 was 6.4 per 1000.
However—I question the basis for our statistics and want DORA to improve the way they collect data regarding homebirth in Colorado. There is no other agency in Colorado collecting data on the outcomes of planned home births in our state. And the questionnaire we fill out each year is subject to interpretation because there are no instructions given to us about how to answer the questions. For instance, the question, “Number of women who received only midwifery care” is sometimes answered as zero by midwives who believe that referring for laboratory testing or ultrasounds means other practitioners have provided care to their clients. Other midwives have different opinions and answer the question differently. This makes the data invalid as there is no standardization in the answers; this scenario is true of many of the questions on the survey.
So, there is room for improvement in the statistics gathering that DORA is doing, and my hope is that a new questionnaire will be in place this November when we renew our licenses. My goal is to get the most solid data possible so that we can take an informed look at the outcomes of homebirth in Colorado. I don’t believe we have a poor perinatal mortality rate, but if solid data shows we do, then I will be at the forefront of the effort to improve our practices and lower the perinatal mortality rate for homebirth in Colorado. ---
Source: http://www.coloradomidwives.org/images/stories/pdfs/cma_fall_2009_newsletter.pdf
I look forward to the day when all your trolling actually helps you get it right, without skewing the information.
As the daughter of a physician, I am always hesitant to assign the motivations of OBs to greed. I honestly don't think that cold, calculating money-hunger is common among them (though it exists). Of course....
1) ACOG, on the other hand, is not an individual human being with possibly altruistic motivations. It's a professional organization.
2) Yes, homebirth is just 1% of the total, Dr. Tuteur. Which is why now is the best time to squash it, or at least stop or slow its momentum-- before it becomes 10%, or, G-d forbid, 25% or more.