Commentary on ACOG’s most recent anti-PHB paper: Understanding the issues & beginning a dialogue

by faithgibson on January 4, 2013

in Contemporary Childbirth Politics

The full and final version ACOG’s position paper called “Planned home birth: the professional responsibility response” was posted yesterday, January 5th.

This paper by Frank A. Chervenak, MD, et al. was first presented at European Congress of Perinatal Medicine, Paris, France, June 13, 2012 and published in the American Journal of Obstetrics and Gynecology (AJOG) November 13, 2012.

Introductory comments ~

Today’s post is an overview of the paper. The next one on this topic will provide background remarks.

After that, I will post the text and my comments to each section, one by one,  in order to solicit feedback from mothers, midwives, and other birth activists in regard to each of the AJOG 5-part propositions. Some but not all are described in briefest detail below.

Some but not all are described in briefest detail below.

Readers will have to make themselves familiar with the full text of this document in order to grasp the potential impact of this issue. I believe this a watershed moment and that now is the time to end the Hundred Years War on normal childbirth and all birth attendants that provide physiologic management.

There is no question — physiologically-based care is the scientific model for childbirth practices when providing care to healthy women with normal pregnancies who are requesting normal, non-medicalized care for spontaneous labor and birth.


Overview of ACOG’s latest anti-OOH birth, anti-direct-entry midwifery ‘position’ paper

Synopsis of positive and/or interesting recommendations:

  • Promotes a reduction in routine medicalization, with increased supportive & non-interventive care for normal labor and birth

  • Promotes ‘home birth centers’ within hospitals staffed by nurse midwives

  • Recommends universal standard from Netherlands that any necessary obstetrical intervention can be initiated within 15 minutes

  • Aludes to a recommendation that all hospitals providing childbirth services be staffed with 24-7-365 with obstetrical hospitalists and anesthesiologist. This situation would require closing down all community hospitals w/ 500 or less births a year, to be replaced by large regional centers.

    This kind of arrangement requires multips and those living a long way from the hospital or during winter weather or hurricane season to be induced as a matter of policy due to very long drive times.

The anti-PHB positions taken in this most recent (and most elaborate) of ACOG’s policy statement reflects the same negative positions that they have regularly published since 1979, when the organization first began to aggressively lobby against non-medical birth settings and non-nurse midwifery. In earlier decades, they often characterized planned OOH birth as “the earliest form of child abuse“.  The authors of this paper were apparently trying to out-do these early statements by expanding the number and nature of their criticisms and complaints and being as extreme as possible.

For example, this politely-worded diatribe included a remark published in the BMJ, opining that a childbearing woman’s right to choose where and how she gave birth but did include the right to put her baby at risk.

Obviously, members of the obstetrical profession would be the only ones authorized to decide whether or not a mother was ‘risking’ her baby’s wellbeing. While it would be considered to be far too ‘risky’ to let a mother choose community-based midwifery care, it would be fine with them if she chose elective induction, a ‘maternal choice’ Cesarean. The obstetrician/hospital’s refusal to ‘allow’ a mother to have a VBAC would also be seen as an appropriate policy, despite the ballooning maternal mortality rate in the US associated with the increase in inductions and Cesarean sections.

Several of the studies used to ‘prove’ that PHB was unsafe are same old same olds — the Wax meta-analysis with its dependence on the fatally-flaw, junk science of Pang (Outcomes of Planned Home Birth In Washington State – 2002). However, this paper added quite a few new studies from the EU, which were interpreted to unequivocally support their claim that yes Virginia, midwives who attend planned OOH birth are still killing babies.

Their conclusion was that:

” … planned home birth has unnecessary, preventable, irremediable increased risk of harm for pregnant, fetal, and neonatal patients.”

Planned home birth should not be considered medically reasonable in professional clinical judgment. 

Women should be informed of the high transport rate and increased, preventable risks to herself, her fetus, and her infant, as well as the psychosocial harms of emergency transport.

Obstetrical profession uses anecdotal events and incorrect information as scare tactics

However, I was most disturbed by the use of antidotal events — an instance of something that went wrong in relation to a PHB — which were cited as ‘proof’ that the whole area of OOH birth was irresponsibly dangerous. Imagine if midwives demand that no childbearing woman should ever be again be admitted to the hospital based on a bad outcome after an epidural, induction or Cesarean, or a fatality due to a hospital-acquired infection?

One example that i found particularly egregious was the tragic maternal death in Australia of a PHB supporter. The authors confidently reported this as a “preventable death from hemorrhage of an Australian midwife home-birth advocate”.

However, this was wrong. The only logical explanation for Caroline Lovell’s sudden cardiac arrest at the time of the birth is an amniotic fluid embolism. This means her tragic death had nothing to do with the place of birth — it wasn’t because she was laboring at home or in an OOH setting at the time of the incident.

AFE is an unpreventable and untreatable lethal complication (fatal in 60 to 80% of case),  regardless of where the mother is or who is caring for her. An obstetrician I worked with for many years had a second-time mother who died from an AFE right in the middle of giving birth naturally at a major, and highly respected hospital. None of the obstetricians on staff suggested this tragic outcome was the fault of the doctor or the hospital.

Furthermore, my exhaustive search of the internet failed to turn up a coroner’s report or any other definite information, even though its been almost a year (Caroline died Jan 23, 2012, two days after the birth). In addition, I followed the link that the authors’ used to cite their statement and it lead to a newspaper report in which the reporter asked “a senior midwife” what she thought was the most likely explanation and she said: “probably postpartum hemorrhage“.

I again wonder what the obstetrical profession would say if we accorded the casual opinions of people with no personal knowledge of events or formal connection to the case as having the same irrefutable standing as an official report by the coroner or empaneled cause-of-death inquiry?

The Beat Goes on, and on and on!

In addition to the topic of relative safety, these authors also claim that PHB does not ‘deliver’ on its promise of patient satisfaction, citing “psychological trauma” whenever a woman has to transfer during labor.

Another rationale for their anti-OOH labor/birth is to insist that it is not cost-effective when you factor in the lifetime costs of all those brain-damaged babies (the ones that we ‘failed’ to kill despite our best efforts to be negligent and incompetent). However, I know of no studies that identify an increase in neurologically-damaged babies due to some association to a professionally-attended PHB in healthy childbearing women with normal pregnancies. New notions of the obstetrician’s professional and ethical ‘right’ to as superior to those of the mother’s rights to determine the manner and circumstance of the care she or her baby receive are shocking, as is the idea that ACOG’s anti-PHB policies should be used by state medical boards to take disciplinary action against obstetricians who support PHB.

Obstetricians claims they are being harm when pregnant women will not ‘let’ them intervene

New notions of the obstetrician’s professional and ethical ‘right’ as superior to the mother’s right to determine the manner and circumstance of the care are shocking.  ACOG claims that its anti-PHB policies should be used by state medical boards to take disciplinary action against obstetricians who support PHB.

These authors also promoted the idea that an “amicus brief” rebutting the finding of the EU Courts that healthy childbearing women have an ethical right to control the manner and circumstance of their normal childbirth.

But not everything in this paper was outlandish.  There were also some interesting and revolutionary positions:

  • that hospitals reconsider policies that perpetually increase the level of medicalization with no improvement in outcomes and at added expense,
  • develope the ability to provide physiologically-based care by midwives and other birth attendants in what the paper refers to as “home-birth centers”.

This means that at least a few obstetricians have gotten the message – many women choose OOH birth not because they want to be at home, but because they can’t get the kind of care they want – normalized, non-medical care for normal labor and spontaneous childbirth — in the hospital.

“Much can and should be done to create a home-like, psychologically, and socially supportive hospital birth to support the legitimate expectations of women for a humane, safe, and undisrupted labor experience with full back-up immediately available.37

Hospital managers and obstetricians should be aware of the fact that a home-like equipped delivery room can reduce the woman’s need for pain relief, even reduce the rate of operative deliveries or episiotomies and increase patient satisfaction”. 38

Teaching of noninvasive care and mode of delivery should become an essential part of training. Physician leaders must be especially watchful for trends of clinically unjustified increased intervention that results from inappropriate self-interest in reducing liability, convenience, or financial gain. 44, 60

This opens up a potential PR opportunity in that profession midwives who are skilled in providing OOH birth services have every good reason to request and insist that we be part of the education process and have admitting and practice privileges for these hospital-based “home birth centers”.

OOH/PHB midwives really are the ‘experts’ in physiological management. When it come to normalizing intrapartum care, midwives have so much to teach the obstetrical profession and so much to contribute to the care of childbearing families, not only intrapartum but relative to immediate PP care of mothers and on-going care of the baby and assistance with breastfeeding and other ‘new baby’ issues.



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