This editorial has been gathering momentum in my mind since I heard about a resolution introduced by the American College of Obstetricians and Gynecologists (ACOG) to the House of Delegates of the American Medical Association's (AMA) annual meeting in June 2008. American College of Obstetricians and Gynecologists's resolution #205 was adopted by the AMA and is titled “Home Deliveries.” So that I cannot be accused of misquoting the AMA or ACOG, you will find the text of the adopted resolution at the end of this editorial. In his “College News” column of ACOG Today (September 2008), ACOG Executive Vice President Ralph W. Hale reported on his attendance at the AMA Annual Meeting and wrote, “Also, there was model legislation related to home deliveries supporting the ACOG position against home births.” The point of this resolution is to lobby against home birth as an option for women and against providers of home birth services. This type of resolution by “authoritative” bodies such as ACOG and AMA will certainly influence decisions made by third-party payers when women request home birth services and by liability insurance carriers when providers seek coverage for home birth services.
Rumor has it, as stated in the Los Angeles Times on July 9, 2008, that in the original ACOG resolution, there was another “whereas” that was deleted before adoption. It read, “Whereas, there has been much attention in the media by celebrities having home deliveries, with recent ‘Today Show’ headings such as ‘Ricki Lake takes on baby birthing industry.’” You may not be aware that in 2007 producer Ricki Lake and director Abby Epstein released a documentary film The Business of Being Born. The film asked the question “Should most births be viewed as a natural life process, or should every delivery be treated as a potentially catastrophic medical emergency?” If you have not seen this film, I encourage you to do so and to view it with an open mind, an open intellect, and an open heart. The DVD can be purchased for a modest price at http://www.thebusinessofbeingborn.com/
Evidently, ACOG felt it necessary to highlight Ms. Lake's coverage of this issue as a potential threat to the safety of mothers and babies. It is beyond the scope of an editorial to review the international and national data about maternal and infant outcomes and the relationship of these outcomes to location of birth. However, one instructive example is a prospective cohort study of maternal and infant outcomes in British Columbia during the first 2 years after women were given the choice to plan a home birth with regulated midwives (Janssen et al., 2002). After controlling for appropriate confounding variables, the data showed no increased maternal or neonatal risk for the 862 planned home births compared with 1,314 planned hospital births. The overall transfer rate to hospital care was 21.7% in the home birth group with 16.5% transferred during labor. The multivariate analysis showed that the women who planned to have home births were significantly less likely to undergo induced or augmented labor, epidural analgesia, episiotomy, or cesarean delivery.
I was born in the United States and I am very proud to be an American, but I am embarrassed that our country founded on the ideals of individual liberty and freedom, can also support “authoritative” initiatives such as these by the ACOG and AMA, initiatives that are founded on neither science nor an understanding of the physiologic and psychosocial needs of mothers and babies. What is most risky about home birth in the United States is that for most women who desire it there is a scarcity of qualified providers of home birth services. There is no system of care that provides the needed safety net if transfer to a different type of care is required during labor. Rather, women who desire to birth at home sometimes chose providers unwisely, and those who require transfer are often treated with disdain and disregard as though their decision to give birth outside the hospital system is irresponsible, reckless, and perhaps immoral. There is nothing more inhumane or uninformed than this attitude toward women who desire to birth at home and the qualified providers who are willing to attend them.
When will we remember that pregnancy, childbirth, and lactation are normal healthy physiological processes that are a continuum and do not require medical intervention unless there is a medical problem? A woman's body and the physiology of pregnancy, labor, birth, and lactation are designed to promote the well-being of the fetus and newborn. When will we establish optimal outcomes as the goal of health care during the childbearing cycle, rather than attempting to reduce by small increments the incidence of morbidity and mortality that is compounded by the very interventions we use to attempt to avoid such problems? We all know that in our current health care milieu for childbearing women, the protection of normal is not valued or supported, except in a very few locales. Those who support normalcy are usually swimming upstream against a system that treats every laboring woman as a surgical case. The idea that a normal spontaneous birth is by design the best outcome for a healthy woman and her infant is neither believed nor entertained as a basic concept. Most U.S.-trained physicians and sadly most U.S.-trained nurses have minimal experience with normal labor and birth. Without fetal monitors, intravenous lines, infusion pumps, epidurals, pitocin, endless charting, and rules theses individuals are helpless and unskilled to provide the kind of informed human support and wise guidance that a laboring woman needs while the normal process of labor and birth unfolds.
In fact, knowledgeable women often must fight to defend the normalcy of the process and their desire to labor and birth spontaneously without medical technology or intervention. In many ways it is reminiscent of the 1960s when many of us who were young women at the time fought for our right to natural childbirth without general anesthesia and to have our husbands accompany us into the delivery room. Breastfeeding was not the norm and was not supported by hospital care. During my 5-day postpartum stay after a vaginal delivery in 1969, I had to repeatedly insist that my newborn son be brought to me during the night for breastfeeding because as I was told by the nurses, “Dr. X's patients are to sleep at night.” How audacious authority can be. Amazingly, a few years later a headline in the science section of the Chicago Tribune declared, “Science finds Breast is Best.” Since that time the accumulation of scientific evidence has overwhelmingly validated that physiologically obvious statement, and the system, including its “authorities,” finally caught up to actively support breastfeeding. Will it take a similar declaration: “Science finds spontaneous labor and normal vaginal birth is best” to change the course that we are currently on and to change the rhetoric of the authorities?
Why do 1% to 2% of U.S. women even want to birth at home? For most it is simply because they sincerely believe that the process is normal and healthy and does not require the environment of an “illness” system to support it. For these women, birth has a unique, earthy, and frequently spiritual component that they want to experience fully under their own terms. They want to actively labor and birth, rather than to have labor happen to them, give over control to a system and people with their own rules, and be delivered of their babies. Some desire home birth because of the subculture of their religious communities, while others are overtly afraid of what may happen to them in the hospital. They may be “on the edge” of the allopathic medical system and be very resistant to interventions that the system thinks are in their best interest. Does this make them wrong? No, it simply means that the system is not meeting their needs for holistic care that supports normalcy.
The point is that we have no system of maternity care in the United States that provides a healthy woman the choice of giving birth at home and if she needs to transfer to a different type of care during labor, the transfer is easy. We do not have a system in which this woman is treated with respect and kindness, and her provider either maintains responsibility for her care or professionally and respectfully is able to transfer responsibility to another provider. Interestingly, while ACOG and AMA have declared that hospital grounds are the only safe place to give birth in the United States, the National Perinatal Association (NPA) adopted a position paper in July 2008 titled, “Choice of Birth Setting.” The paper supports a woman's right to home birth services and concludes that, “The National Perinatal Association (NPA) believes that planned home birth should be attended by a qualified practitioner within a system that provides a smooth and rapid transition to hospital if necessary. Safety for all births must be evaluated through an objective risk assessment, especially for non-hospital births. NPA supports and respects families' right to an informed choice of their birth setting” (available at http://nationalperinatal.org/). Further, in Canada following the model of British Columbia, the province of Alberta has recently expanded its health care system to include women's access to midwifery services “in a variety of locations including hospitals, community birthing centers, or in their homes” (http://www.health.alberta.ca/regions/midwifery.html).
Some of you who are reading this know me personally, most do not. I am a nurse-midwife committed to the midwifery philosophy of care, however, I have never attended a home birth. I gave birth to my own children in hospital, and my daughter is a board certified obstetrician-gynecologist. I am part of the U.S. system. Yet the very core of my being, my scientifically trained brain, and four decades experience in the business of mothers and babies tell me it is our system that is not serving mothers and babies well. There is not some inherent danger lurking for healthy American women who desire to give birth at home. The primary danger is that the “system” does not support this choice. To pretend that a normal healthy woman cannot give birth safely without the trappings of a U.S. hospital is not only audacious but also uninformed. Perhaps it is time for a new woman's movement, one that embraces the normalcy of childbirth and puts mothers and babies back on the center stage rather than the system's need to defend the interventionist subculture it has developed and that it must financially support. This system has not improved outcomes for mothers or babies while the cost of care has continued to escalate keeping pace with unnecessary intervention. The recent initiatives of our medical colleagues, the “authorities,” simply highlight the painful reality that the “Emperor has no clothes!”
|205. HOME DELIVERIES|
|Introduced by American College of Obstetricians and Gynecologists|
|HOUSE ACTION: ADOPTED AS FOLLOWS|
|RESOLVED, That our American Medical Association support the recent American College of Obstetricians and Gynecologists (ACOG) statement 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 standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, The Joint Commission or the American Association of Birth Centers”; and be it further|
|RESOLVED, That our AMA support state legislation that helps ensure safe deliveries and healthy babies by acknowledging 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 standards jointly outlined by the 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.|