Response to “ACOG Statement on Home Birth”

By Emily Jones
February 7, 2008

The ACOG recently issued a statement declaring its opposition to home births. Their statement is misinformed and presumptuous of women’s attitudes who might choose home birth. This statement is, in my opinion, motivated by the increasing pressure on the medical community, whom the ACOG represent, to provide better services or face losing business. It seems that they are not interested to improve the service they provide. Let me break it down for you.

Washington, DC — 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.

It appears the ACOG is under the misconception that births that take place in the home are without monitoring. All birth attendants, including midwives, would agree that monitoring the woman and fetus during labor is essential to protecting the health of both and predicting potential problems. Now, if by monitoring the ACOG is referring to constant ELECTRONIC fetal monitoring, maybe they should try researching and reading the many studies that have been done BY THE MEDICAL PROFESSION that shows no improved outcomes for mother or fetus with the use of routine electronic fetal monitoring.

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. Nor does ACOG support the provision of care by midwives who are not certified by the American College of Nurse-Midwives (ACNM) or the American Midwifery Certification Board (AMCB).

This statement is contradictory. ACOG acknowledges a woman’s right to make informed decisions, and yet does not support programs that inform them of their choices, including the choice to birth at home? Furthermore, if ACOG’s goal is to support the health and safety of women and children, why are they refusing to extend training, support, education, and approbation to alternative women’s health care providers? Would it not make more sense to make sure that ALL midwives and other birth professionals are well-informed, properly trained, regulated and licensed to provide the best care for women? It sounds to me like someone is afraid of a little competition from those who neither pay dues to their organizations nor generate income for them.

Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre.

Oh, like elective c-sections? Which, by the way, the ACOG refuses to directly condemn or commit to regulating.

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.

Another ridiculous, presumptuous statement. There does not exist, to my knowledge, any midwife, other birth professional or rational human being that will claim that there are no life-threatening risks to home birth. If you know of one, please message me immediately.

Attempting a vaginal birth after cesarean (VBAC) at home is especially dangerous because if the uterus ruptures during labor, both the mother and baby face an emergency situation with potentially catastrophic consequences, including death. Unless a woman is in a hospital, an accredited freestanding birthing center, or a birthing center within a hospital complex, with physicians ready to intervene quickly if necessary, she puts herself and her baby’s health and life at unnecessary risk.

What astounds me about this statement, and others like it, is the last part of the sentence, emphasis by me. The medical establishment again and again refuses to acknowledge ANY of the unnecessary risks inherent in a hospital birth, with all the procedures and tests that have been repeatedly shown at best ineffective in improving outcomes, and at worst more harmful than the negative outcome they purport to prevent. This is not to say that there is no risk involved in VBAC – of course there are. But it is short-sighted and self-aggrandizing to publicize that there are risks inherent in one choice (at home) and refuse to acknowledge those inherent in the other (in hospital).

Advocates cite the high US cesarean rate as one justification for promoting home births. The cesarean delivery rate has concerned ACOG for the past several decades and ACOG remains committed to reducing it, but there is no scientific way to recommend an ‘ideal’ national cesarean rate as a target goal. In 2000, ACOG issued its Task Force Report Evaluation of Cesarean Delivery to assist physicians and institutions in assessing and reducing, if necessary, their cesarean delivery rates.

As in elective c-sections, the ACOG refuses to commit to trying to reduce the rate of cesarean delivery, claiming that there is no way to recommend an “ideal” national cesarean rate. It seems that they are completely unaware of an organization called the World Health Organization, who stated that “no region in the world is justified in having a cesarean rate greater than 10 to 15 percent.”

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.

Once again, the ACOG refuses to admit any iatrogenic causes for the current cesarean rate. The medical establishment has defended the cesarean rate for years, reasoning that in the past, women died in childbirth because of poor health and lack of medical technology. Now they are trying to claim that women suffer WORSE poor health, and must therefore now require cesarean section. It is circular logic. Not only that, but this statement is illogical when compared with cesarean rates in the past. In 1988, TWENTY YEARS AGO, c-section rates hit an (then) all-time average high, at 24.7%. Is the ACOG prepared to say that the “rising tide” of these new risk factors were present then? Or were the doctors then simply psychic in predicting that the number of women with said risk factors would increase?

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. 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.

What is the ACOG’s definition of a “bad outcome?” If you include morbidity as well as mortality, the studies actually show the opposite. Since the popularization of birthing in hospitals, the United States has consistently ranked badly or in some years, worst overall in the WORLD in infant and maternal mortality and morbidity. If you define “safest setting” as the one in which women and babies suffer the least amount of injury, illness, and death, the studies still show hospital births as having worse outcomes than home births. While home birth advocates regularly discuss risks and problems with home births, the medical community continues to ignore risks and problems with hospital births.

It should be emphasized 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.

Notice the ACOG only recognized studies occurring IN THE US. You may or may not argue that those studies were “scientifically rigorous.” But this does not take into account the MANY studies performed outside of the United States which corroborate the findings of the “dubious” US studies – that outcomes in home births with professional attendants are equal to or better than outcomes in hospitals. It also does not take into account that the countries with the lowest infant and maternal mortality and morbidity rates also have the highest number of births that occur with a midwife or other qualified birth professional, and the highest number of planned home births. In fact, in the same period of time that c-sections began to rise (1980-today), the maternal mortality rate in the United States has also begun to rise. You should read that statement again: In the last 30 years, the number of women dying in or after childbirth is RISING in the US. What does that say about our “modern” medicine practices?

Moreover, 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.

It is semantics at its best. Notice how the ACOG writes “lay or other midwives” – putting the word LAY first and not even acknowledging midwives who are certified or licensed. This has the visual effect of “confirming” the stereotype of the modern midwife: a local village woman who goes around waving incense at pregnant women. As far as midwives being unable to perform surgery, NO DUH. Of course midwives can’t perform surgery. That’s what doctors do. That’s why midwives bring women to the hospital who need surgery. Once again, this is another presumptuous statement that implies that women die at home because surgery is unavailable to them, without regard to efficacy and availability of hospital transfer/transport.

ACOG encourages all pregnant women to get prenatal care and to make a birth plan. 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 is the most outrageous and offensive statement in the entire document. Can the ACOG be seriously suggesting that women who choose to birth at home are putting personal motive above the health and safety of their babies? Are they really implying that women who choose to birth at home are unaware of or unprepared for the risks? This assertion, more than any other in the entire statement, should be sufficient to cause an outcry from the entire home birth establishment.

For women who choose a midwife to help deliver their baby, it is critical that they choose only ACNM-certified or AMCB-certified midwives that collaborate with a physician to deliver their baby in a hospital, hospital-based birthing center, or properly accredited freestanding birth center.

It is not the location that we should be fighting over. It is the system. The reason women have birth at home is because the system is flawed. We’d love to go to the hospital and avail ourselves of all this “life-saving” technology if we thought we could enjoy it without the atmosphere of fear, bullying, and disrespect. Okay, well, I guess some of us prefer to just be home in a familiar place. But I think so many of us choose home because the hospital gives us no other choice. They refuse to admit risk, take responsibility, or try to be even a little accommodating to the one person who has to do all the work and assume all the consequences. There are risks inherent in whichever birth choice a woman makes. But until the medical establishment takes responsibility for the risks and problems they themselves cause, women will continue to be at greater risk to birth in the hospital, since the very people that promise to protect them are either unaware or unwilling to admit that they sometimes cause more harm than good.

Written by Emily Jones · Filed Under Editorials

Comments

17 Responses to “Response to “ACOG Statement on Home Birth””

Editor on February 7th, 2008 4:47 pm

One point that I’d like to reiterate: More women would birth in hospitals and birthing centers IF they were allowed to do so without being pressured, coerced and threatened to yield to hospital “policies.” And, more women would choose hospital VBACs if they were a) allowed and b) not treated like they carried the plague.

The ACOG speaking on homebirth is like the Beef Association of America commenting on vegetarianism. Are we really surprised?

I am surprised that they’re so threatened by a small percentage of women. Less than 1% of women birth at home, and yet they’re focusing on this, rather than the 30+% who have cesareans which are proven to be more harmful to mother and baby and future fertility. It shows their priorities.
Shannon on February 7th, 2008 5:56 pm

Great response! I was so mad when I first read the ACOG statement that I could hardly form a coherent thought. You have taken that statement point by point and shown how ridiculous it is. If only they would all stop caring so much about themselves and start really caring for the women and babies they claim to.
NoNonsenseMama on February 7th, 2008 6:46 pm

The fact that ACOG is supporting it’s own supporters is, of course, no shock. What really peeves me is that they rule the market of the birthing business, and they feel so threatened as to write an entire statement on the “dangers” of homebirth *gasp* lay midwives. A lay midwives has years of apprenticeship and many many births under her belt before practicing on her own. What experience does a fresh out of medschool ob/gyn have? REAL experience. NORMAL birth experience? I don’t give a crap about what some text book told you about birth, I want to know about REAL birth and how much you’ve seen and “handled”. I’m not a book, it’s not pages that are going to be coming out of me, it’s real life.
Mommy Dearest on February 8th, 2008 5:50 am

This is an excellent response, and I would like to repeat this:

“One point that I’d like to reiterate: More women would birth in hospitals and birthing centers IF they were allowed to do so without being pressured, coerced and threatened to yield to hospital “policies.” And, more women would choose hospital VBACs if they were a) allowed and b) not treated like they carried the plague.”

Right on!!
Johanna Holmes on February 8th, 2008 11:04 am

Ummm… I live in the state of Texas. A birth center has exactly the same equipment that my midwife carried into my home. How is the accredited, freestanding birth center preferable to home again? They didn’t even bother to try to quote the bogus Pang study to support their ridiculous claims. Utterly ridiculous. They would have better credibility if they had, say, better outcomes. I actually went to an OB whom I really liked but he nearly lost hospital privileges over intentionally assisting at a vaginal breech birth where NOTHING happened to the mother or the baby. Everyone was healthy and he still nearly lost his privileges. That’s why I switched to home birth, and that’s why I’ll stay giving birth at home.
saritabeth on February 8th, 2008 1:56 pm

Thank you for this thoughtful breakdown of ACOG’s statement. I keep reading the statement and I get more insensed each time I read it. It was nice to read someone else’s thoughts point by point that so closely reflected my thoughts also.
Lynn Ratcliffe on February 8th, 2008 3:35 pm

I think your comments are great & I feel really sorry for American women with your dreadful Health Industry which is dominated by FOR PROFIT insurance companies.

I thought you might like to read the Royal College of Obstetrics & Gynaecologists/ Royal College of Midwives statement on homebirth, which is what we have in the UK.

It might be more to your taste.

http://www.rcog.org.uk/index.asp?PageID=2023

Good luck!

Lynn
non-practising UK midwife & childbirth educator
tienchinho on February 8th, 2008 7:28 pm

HBACM Statement on Home Births (A Parody)

Fresno, CA – As a home birth after cesarean mom (HBACM), I reiterate my support of home births. While complications can arise with little or no warning even among women with low-risk pregnancies, childbirth is a normal physiologic process that most women experience without problems. Continuous monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center has not improved maternal or fetal outcomes.

I acknowledge ACOG’s right not to support programs that advocate for, or individuals who provide, home births, but I do not support a system that denies families the essential information to make informed decisions regarding maternal care. Nor do I support a system that lacks the resources to make VBAC a viable option for all women and ensure the quality of the mother-child dyad immediately after birth.

Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by hospital birth advocates, a highly medicalized labor and delivery can physically and emotionally scar both the mother and baby. Attempting a vaginal birth after cesarean (VBAC) at the hospital is especially dangerous because seemingly benign interventions such as epidural anesthesia or Pitocin augmentation can lead to complications with potentially catastrophic consequences for both the mother and baby, including death. Unless a woman is in a supportive birth environment that allows the birth process to unfold on its own schedule, she puts herself and her baby’s health and life at unnecessary risk.

Advocates cite the lack of rigorous scientific studies as one justification for promoting hospital births. Consistent dismissal of existing Level I evidence defining the risks of unnecessary interventions such as episiotomy, epidural anesthesia, and amniotomy has concerned proponents of natural childbirth for the past several decades and we remain committed to changing this. Birth advocates throughout the world use childbirth education, grassroots childbirth networks, and recently, the media to provide mothers and caregivers with the evidence. Multiple factors are responsible for the persistent exceptions to evidence-based medicine in maternal care, but emerging contributors include a fear-based climate that skews mothers’ decision-making abilities and forces caregivers to follow “standards of care” that ignore the scientific evidence.

The availability of a birth attendant to provide continuous labor support and of a midwife to provide expertise and intervention may be life-saving for the mother or newborn and lower the likelihood of a bad outcome. I believe that the safest setting for labor, childbirth, and the immediate postpartum period is one that respects and trusts the birthing process, that meets the Baby-Friendly and Mother-Friendly standards jointly outlined by the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), and the Coalition for Improving Maternity Services(CIMS) and is supported by birth advocacy groups.

It should be emphasized that childbirth comes with inherent risks. Implying otherwise is misleading and unjust to a birthing mother and her family. Although able to perform live-saving emergency cesarean deliveries and other surgical and medical procedures, board-certified obstetricians have been cornered into practice styles that perpetuate the need for these same measures. They have lost skills such as detecting and adjusting a baby in the occiput posterior position. Untreated, this condition can result in prolonged labors mislabeled as “dystocia” and in cesarean sections. They minimize the profound impact of a woman’s birth experience on her future relationship with her children as well as her own view of herself. Since suicide and substance abuse are leading causes of maternal mortality, disregard for a mother’s emotional health can lead to tragic consequences for her and her baby.

I encourage all pregnant women to get prenatal care and to make a birth plan. Safeguarding the process of giving birth promotes a healthy and safe outcome for both mother and baby. Every woman should seek balanced information to guide her decisions throughout pregnancy, childbirth and parenting. For women who despair in the lack of choices, they should look for hope in mothers who have navigated this climate of fear successfully. We are here.
Editor on February 8th, 2008 10:56 pm

tienchinho: Great parody!
mamaloo on February 9th, 2008 8:34 am

Thank you for this very succinct rebuttal. I totally agree.

Regarding this bit: “Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.” I would also like to point out to the ACOG that process is in great part responsible for the healthy baby! I can’t believe they can’t see that? Perhaps what most/many home birth parents and midwives know is that for low risk mothers/pregnancies birthing at home allows for the process that is most able to result in a healthy baby (and healthy mother).
SierraM on February 9th, 2008 8:12 pm

Excellent response!!!
Demetria on June 22nd, 2008 4:05 am

Keep up the GREAT work!!!

I made a little video response.
http://www.youtube.com/watch?v=2pN58kf3Ims
Astonished parent on June 24th, 2008 9:20 am

I can’t belive the article or comments here, and I know this is a website that is extremely pro home birth. While I agree that it is the mother (or parents) decision, this article is so one sided it is worse than the release from the ACOG. But that is enough about this article.

My question for everybody here is, even if you are a low risk pregnancy, what if the worse case scenario happens? In the time it takes you to get to a hospital you could be risking your baby’s and possible even your life, for what? Because you don’t like the healthcare system, you don’t like how the hospitals are run. Isn’t your baby’s life more important than that?

Poke fun at the ACOG, (some of it might even be justified) but my baby’s life is more important.

BTW - I came across this website while searching for something else, and I never leave comments on sites like this. But being a new parent of a child born with complication on a low risk pregnancy, I had to say something.
danotoyou2 on June 27th, 2008 7:33 am

Astonished parent,

I think that you’d find that in most women who choose to birth OOH (out of hospital), the first birth experience was one in a hospital. And all too often in those hospital experiences, it is the hospital staff and procedures themselves that place the baby at risk.

In my own situation, it was a panic-stricken doctor (who’d earlier that week had a patient truly sick, began treating every woman as a ticking timebomb) who broke my waters too early in labor (against my consent), and lodged the baby in an unfavorable position. It was that same doctor that ordered a too-strong dosage of magnesium sulfate, which over-dosed me and had the nurses preparing for the worst (and only told me later what had happened). It was the nurses that were unclean, unsanitary and scared the crap out of me when it came to possible infections.

I knew after that hospital experience, which ended in a cesarean, that I would NEVER birth in a hospital again unless I needed to for medical reasons. The difficulty breastfeeding, bonding and months of post-partum depression were (I believe) strictly because of the traumatic experience I had at the hands of hospital staff.

Why take on a relatively “sure thing” when it comes to depression, trauma and surgery? Why do that, when I take on a 99% chance of having a peaceful, quiet, wonderful birth in the comfort of home? And yes, 1% is a huge risk, but nearly all birth emergencies can either be treated by a midwife, or are apparent beforehand, which calls for a hospital transfer.

Don’t make the mistake in thinking that women who choose OOH birth do so for selfish reasons. In fact, we take on the pain of labor, scorn of family and friends, and often the financial costs of having a home birth, BECAUSE we want a safe (non-surgical) birth for our children.
Nadia Pavlovskaya on July 22nd, 2008 7:47 am

This is a very good responce indeed.
I have problems finding a WHO document where they recommend home birthing as an option. Do you think you can help me with that?
Nina on October 4th, 2008 5:55 pm

Ok gals,

I had one of those hosptial births that went TERRIBLY wrong. The only way it could have gone any worse is if I had lost my baby.

I was bullied into an induction that (of course) didn’t take, so after 36 hours of labor & only getting to 6cm, I was wheeled into the OR for a c-section. The c-section got infected in the hospital & ruptured 2 days after my release, landing me in the ER, terrified that I was about to die & leave my husband a widower with a newborn!!

Months later, I was able to attain a copy of my medical records, which were a nice work of fiction. I am in the process of suing the hospital & pulling the medical licenses of several nurses who put false information in my file to cover the hospital’s ass since it turned out, my c-section was completely unnecessary & was done for the doctor’s convenience so he could go on vacation. BTW, it took over 7 months for my c-section incision to close because the infection had set up so bad that they couldn’t stitch it back after it burst. It had to heal itself from the inside out & that gals, takes MONTHS!

I’m now pregnant with my second child & you couldn’t make me go to the hospital under threat of torture. I have a CPM & will be delivering this baby at home in my whirlpool tub like I should have done the first time.

SO when you think the hospital is safe & they have your best interest in mind, think again!!
Jessica on December 30th, 2008 4:32 pm

I think the fact that they accomodate freestanding birth centers in their statement is the most transparent part. The vast majority of free standing birth centers offer no more technology than a homebirth. In the event of a complication, transfer from a birth center is necessary just as from a homebirth. You know the one thing every freestanding birth center has that is not consistent with homebirth midwives? Doctor backup. There is a doctor consistently in the equation, maintaining control and able to assert every woman’s need for them (even if just as backup).

It’s all so transparent. As a friend of mine said, it’s like farmers advocating against home gardens.

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