ACOG Place of Birth Policies Limit Women's Choices Without Justification and Contrary to the Evidence
What place of birth policy did ACOG set in "Out-of-Hospital Births in the United States" (October 2006)?The earlier statement asserted that "studies comparing the safety and outcome of U.S. births in the hospital with those occurring in other settings are limited and have not been scientifically rigorous." ACOG also claimed that the hospital "is the safest setting for labor, delivery, and the immediate postpartum period." Consequently, it concluded, ACOG "strongly opposes out-of-hospital births" and "does not support programs or individuals that advocate for or who provide out-of-hospital births." However, the statement failed to cite any evidence to support the assertions and failed to acknowledge impressive existing evidence regarding the safety of planned home birth and out-of-hospital birth center birth.
What place of birth policy did ACOG set in its revised statement, "Home Births in the United States" (May 2007)?The revised statement was identical to the previous statement with the exception of limiting the focus to home births rather than to all out-of-hospital births and acknowledging the safety of birth in out-of-hospital birth centers that meet standards of relevant accreditation organizations. The revised statement concluded by stating that "ACOG strongly opposes home births" and "does not support programs or individuals that advocate for or who provide home births." Again, no study was cited to support this position, and existing research in support of planned home birth was overlooked.
What was the response to the earlier statement?Some ACOG members objected to the policy, and numerous organizations submitted letters of concern and posted the letters online. These included American Association of Birth Centers, American College of Nurse-Midwives, Consumers United for Evidence-based Healthcare, Lamaze International, and White Ribbon Alliance for Safe Motherhood. In addition, Childbirth Connection and other consumer advocacy organizations together sent a letter identifying special concerns from a consumer perspective (see this letter in Quick Links box, above). Joining together with Childbirth Connection were Center for Medical Consumers; National Partnership for Women and Families; National Women's Health Network; and Our Bodies, Ourselves, as well as the Executive Director of Families U.S.A. signing as an individual. In general, the letters asked ACOG leaders to review the policy in light of the plethora of high-quality scientific evidence supporting the safety of planned out-of-hospital birth.
What were the major concerns of the consumer groups?The joint letter (PDF) from organizations writing from the perspective of best interests of mothers and babies expressed several concerns. First, the groups were troubled that the policy would undermine women's choices and legal right to informed consent about where to give birth and noted that ACOG's own document, Ethics in Obstetrics and Gynecology (2004), strongly supports women's right to informed consent.
Moreover, the groups were troubled by the complete lack of evidence to support the statement's assertions and its failure to acknowledge impressive existing evidence. With respect to home birth, they noted a large prospective study of 5,418 American women planning home births with Certified Professional Midwives (Johnson and Daviss 2005), and a systematic review of home birth (Olsen 1997). With respect to birth in out-of-hospital birth centers, they pointed to the large prospective National Birth Center Study of 11,814 mothers who began labor in out-of-hospital birth centers (Rooks et al. 1989) and a systematic review of care in out-of-hospital birth centers (Walsh and Downe 2004). Notably, both of the large studies achieved 4% c-section rates whereas about one mother in three now gives birth by major surgery in the United States. All four studies found very low rates of many widely used obstetric interventions and no sign that the settings or conservative use of obstetrical procedures involved extra risk when out-of-hospital births were compared with low-risk women giving birth in hospitals. The systematic reviews concluded that there is no a priori basis for denying planned out-of-hospital birth. The large prospective studies were published in the most prestigious general medical journals, New England Journal of Medicine and BMJ.
The letter from the consumer groups also pointed out that in rejecting the strong available evidence ACOG displayed a double standard. The letter referenced an analysis of ACOG's recent obstetric practice recommendations that found that just 23% are Level A, that is, "based on good and consistent scientific evidence," whereas 35% are Level B -- "based on limited or inconsistent scientific evidence," and fully 43% are Level C, "based primarily on consensus and expert opinion" (Chauhan et al. 2005). In evidence-based medicine, expert opinion when not backed by sound research is the lowest and least reliable level of evidence (Oxford University 2001). Despite the weak scientific evidence for over three-quarters of ACOGís professional practice recommendations, some obstetricians feel that they are vulnerable to malpractice claims and suits if they deviate from ACOG policies, and recent research supports this (Ransom et al. 2003).
Finally, the letter to ACOG from the consumer groups pointed out that the policy endangers the health and well being of mothers and babies in two ways. First, in opposing those who support out-of-hospital birth, ACOG could jeopardize appropriate physician back-up for the considerable number of women who will continue to choose out-of-hospital births. All health professionals need to be able to call on other health professionals for specialized services that are beyond their expertise and scope of practice. Obstruction of such professional collaboration jeopardizes the welfare of mothers and babies and is of grave concern. Second, in taking the position that all women should give birth in hospitals, the statement would consign low-risk women to the high rates of invasive procedures and other interventions that are now the norm in U.S. hospitals, as measured in Childbirth Connectionís Listening to Mothers II survey (Declercq et al. 2006).
Did the revised policy statement address concerns of the consumer groups?The revised policy statement reflects the best available evidence about planned birth in out-of-hospital birth centers, but continues to reject home birth without justification and contrary to the best evidence. After describing results of the best available research and concern about typical maternity care in U.S. hospitals, the consumer groups wrote:
The current ACOG policy statement about place of birth continues to raise troubling questions about: current standards of maternity care in the United States, ACOG's disregard for best available evidence, and ACOG's infringement on rights of childbearing women.
Note: ACOG policy statements are not posted in a location that is accessible to the general public. Those who wish to read the current policy about place of birth, "Home Births in the United States" (May 2007) are encouraged to call the ACOG office at (202) 638-5577 to request a copy.
American College of Obstetricians and Gynecologists. Ethics in Obstetrics and Gynecology, 2nd ed. Washington, DC: ACOG, 2004.
American College of Obstetricians and Gynecologists Executive Board. ACOG Statement of Policy: Home births in the United States. Washington, DC: ACOG, May 2007.
American College of Obstetricians and Gynecologists Executive Board. ACOG Statement of Policy: Out-of-Hospital Births in the United States. Washington, DC: ACOG, October 2006.
Chauhan SP, Berghella V, Sanderson M, Magann EF, Morrison JC. American College of Obstetricians and Gynecologists practice bulletins: An overview. American Journal of Obstetrics and Gynecology 2006;194:1564-75.
Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences. New York: Childbirth Connection, October 2006.
Johnson KE, Daviss B-A. Outcomes of planned home births with Certified Professional Midwives: Large prospective study in North America. BMJ 2005;330:1416.
Olsen O. Meta-analysis of the safety of home birth. Birth 1997;24:4-16.
Oxford University, Centre for Evidence-Based Medicine. Oxford Centre for Evidence-Based Medicine levels of evidence, 2001. Available at http://www.cebm.net/index.aspx?o=1025 (accessed June 20, 2007).
Ransom SB, Studdert DM, Dombrowski MP, Mello MM, Brennan TA. Reduced medicolegal risk by compliance with obstetrical clinical pathways: A case-control study. Obstetrics & Gynecology 2003;101:751-5.
Rooks JP, Weatherby NL, Ernst EK, Stapleton S, Rosen D, Rosenfield A. Outcomes of care in birth centers: The National Birth Center Study. New England Journal of Medicine 1989;321(26):1804-11.
Stotland NE, Declercq ER. Safety of out-of-hospital birth in industrialized nations: A review. Current Problems in Obstetrics, Gynecology and Fertility 2002;25:134-44.
Walsh D, Downe SM. Outcomes of free-standing, midwife-led birth centers: A structured review. Birth 2004;31:222-9.
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