ACOG

So, as some of you may have heard, the American College of Obstetrician and Gonycologists have released a statement recently in regards to home birth:

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 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).

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. 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.

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. 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.

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.

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. 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.

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. 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.

I guess, having read this, some things pop out to me. The first paragraph states that “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.” So, in essence, they are saying, it’s normal, but because there is a chance that some women might have complications, all women should be monitored as if a complication will occur.

And such has their viewpoint been. Why do we give antibiotic eye ointment to ALL our children in the hospital? Because some mothers may have syphilis, or another STI that could be transmitted and might cause blindness. Why do we adiminister IV antibiotics to a woman who is GBS positive? Because there’s a .18% (ACOG, 1996) chance that the child may become infected with GBS. I do not deny that antibiotics can save lives in this instance, but again, it is an example of ‘over-treating’ the populace to save the few.

I also find it interesting that they recommend (nurse) midwives to are certified through ACNM or AMCB, while they don’t even mention midwives accredited through NARM. For those of you who are unfamiliar with NARM, it stands for the North American Registry of Midwives. Both Nurse-Midwives and Certified Professional Midwives are certified and registered through NARM. In fact, NARM, despite its name, is an international certification board with standards that measure up to the midwives to practice in Europe. Even the World Health Organization recognized midwives as competent care providers, generallizing that “if the education programme is recognized by the government that licenses the midwife to practice, that person is a midwife” (WHO, no date given).

The next paragraph is thoroughly insulting. Stating that “ Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre”. I agree with this statement wholeheartedly, but the intended effect is ridiculous. ACOG is attacking homebirth advocates as pushing the ‘next big thing’ in birth, which is totally untrue. On the other hand, OBs across the country are allowing women to delivery at or before 36 weeks by Cesarean Section, thus choosing to have their child be born prematurely. Some of the complications arising from this disturbing ‘trend’ are: They “tend to grow more slowly than term babies. They also may have problems with their eyes, ears, breathing, and nervous system. Learning and behavioral problems are more common in children who were preterm babies” (ACOG 2004).

The author goes on to state that “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”. It sounds as if Uterine Rupture is prevalent during VBAC, while in fact, the rate of uterine rupture during VBAC is approximately .7% according to Vaginal birth after cesarean: a 10-year experience, a study published in the Obstetrics and Gynecology Magazine in August of 1994. There were 17,000 women involved in that study.

This next statement typifies the medical model, stating that unless she delivers “with physicians ready to intervene quickly if necessary, she puts herself and her baby’s health and life at unnecessary risk”. I find the very idea that doctors are my ‘savior’ distasteful. And the fact that this statement contradicts the statement that birth is a natural process is obvious. This statement relegates women to a role of sedate non-involvement with her birth. She needn’t know what is going on as long as her health care professionals are there to save her – by her choice or not – in case of ‘complications’.

But what about the vast overuse of Cesarean section, for whatever reason? ACOG gives a noncommital answer that “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”. Interesting because the World Health Organization has. They have made a statement that “no region in the world is justified in having a cesarean rate greater than 10 to 15 percent”. In fact, they created the set of objectives for the ‘Healthy People 2000’ Campaign that listed lowering the cesarean rate to 15%. The cesarean rate in the US as of 2005 was 30.2%. It’s approximated that 20% of those are elective. If my math is correct, that mean only 6% of all births in the US are by elective Cesarean. I do not begrudge this 6% their elective section. I just wonder why?

The New York Times ran an article in 2004 entitled “Too Posh to Push?” in which is lists a multitude of celebrities both American and European who chose to have a cesarean birth. Some of the reasons that Times was provided for why they chose a section were “to avoid conflict with her final exams,” to “ensure that her child’s head had a nice round shape”, while others were “terrified of labor pains and complicated deliveries or want to avoid the wear and tear on their bodies”. The article goes on to say that “With malpractice premiums hovering at $150,000 to $200,000 per year, obstetricians can no longer afford to take even the slimmest risk associated with natural childbirth”. It’s a very sad day in history when the cost of malpractice insurance dictates the care a person is ‘able’ to receive from their doctor.

The statement continues with “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”. They cite so studies, show no evidence and don’t elaborate on what they mean by ‘bad outcome’. Further more, they block any argument by stating that “ 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”.

How is one to argue the credibility of a statement with statistics when the credibility of all statistical information is deemed unreliable? This is the equivalent of the ACOG patting all women on the head and telling them “don’t worry, I know what’s best”. Isn’t liberty to question our government what makes the United States so great? Why then can we not question our perceivedly infallible physicians? Have they risen so high above our government’s very foundations that they may no longer be questioned? One study that has been dismissed here, by ACOG is that of ‘The Farm’ in Tennessee. From 1970-2000 they kept records of all births, attended by midwives, on their property. 2028 birth were recorded total. 95.1% of these births were completed at home, with a cesarean rate of 1.4%. In those 30 years, there were no maternal mortalities, and just 8 neonatal mortalities, which is about .4%. In these statistics 15 sets of twins were born, all of them vaginally.

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 true that home birth midwives cannot, or do not perform cesareans, rarely (depending on the location and laws) perform episiotomy, and do not have the equipment to perform forceps or vacuum births. But, is that so bad? Women choose home birth because they don’t have to worry about these interventions being forced on them. This does not mean, however that midwives are not trained thoroughly in other skills that can make these interventions unnecessary. Furthermore, midwives are trained in CPR and Neonatal Resuscitation, which requires the same training that nurses and doctors receive.

Lastly, the concluding paragraph is an insult, once again. It lulls us with the mention of a birth plan – which has become an empowering tool for birthing women, but is often ignored in the hospital setting- and then goes on to say that “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 obviously an attack on women who choose to birth at home. Home birth is a legal choice in most states, and in Europe it is a standard of care. So, why then, is it safe to give birth at home in Denmark or France, but not here in the US?

Home birth has been around and abundantly practiced throughout the world for millennia. Why now is it so dangerous? Now, when our midwives are more prepared and better trained than ever before? What would our grandmothers say, if they knew that home birth was now dangerous and a decision only a reckless women obsessed with her own vision of birth would make? I imagine they would laugh, and tell us about how they gave birth at home, put their child in the oven to keep them warm, and went about their lives.

The point of this analysis is to make you consider, why have we let birth fall into the hands of other than the birthing mother? Why have we allowed people who make money from our births in the hospital to tell us that birthing at home is unsafe? In any other market, wouldn’t this be called a monopoly?

I am not a professional writer, and my words may not be eloquent, but the anger that stirs in my heart at these attack on womanhood must be expressed. As all women should stand up and shout: “Leave my birth alone!”

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2 Comments »

  1. Rubiy Said:

    Hear hear!!!! Very eloquent. You have my utmost admiration for your advocacy, and my support for a safe, sacred, and informed birth.

  2. Brooke Said:

    Joe and I were just talking about writing our appeal to our insurance company and I mentioned the ACOG’s statement. Then these exact words came out of my mouth.

    “The American College of Obstetricians and Gynecologists doesn’t think that anyone should give birth without a surgeon near by. In my opinion, I don’t want to be anywhere near a surgeon when I give birth. They’re too fascinated by their sharp shiny knives not to use them.”

    I thought you might enjoy that.


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