The Homebirth Choice

*Image from The Business of Being Born

I haven't blogged much about birth lately. This isn't because nothing is going on in birth politics; oh ho ho, quite the contrary. It's because so much is going on that it makes me tired just to think about it. But, because the things I've seen in hospitals have convinced me that only the most dire circumstances would lead me to give birth in a hospital, and the right to make that choice is currently under aggressive attack, I'll give it a try.

The American Medical Association (AMA) and The American College of Obstetricians and Gynecologists (ACOG) have passed a resolution to "advance model legislation" stating that the "safest" setting for birth is the hospital. Meaning, they are attempting to make it the LAW that the ONLY legal setting for birth is the hospital. Meaning IT WOULD BE A CRIME to birth your baby at home, or for a midwife or a doctor to attend you there. They state that this is in response to the "risk" created by celebrities' publicizing their homebirths (that would be one celebrity, Ricki Lake, in The Business of Being Born. Which, if you haven't seen yet, shame on you and go do so!).

Note that despite this fatherly concern they feel for pregnant women, they fail to comment on the far greater numbers of celebrities (Britney Spears, Christina Aguilera, Denise Richards, Victoria Beckham, to name a few...) who choose elective primary Cesareans--a procedure associated with far greater risk of death and injury to mother and newborn than an uncomplicated homebirth attended by trained personnel. On the other hand, this point is aptly made by Britain's Royal College of Nursing, who are quick to point out its potential harms. Could this be because in our healthcare system, elective C-section is associated with more convenience and higher fees for the doctors, while homebirth represents a potential loss of revenue? Anyway, you can read the whole resolution here.

Side note: it's interesting to me that doctors never talk about "birth," only "deliveries," perhaps an implicit way of staking their claim in a process that rightfully belongs primarily to the mother. Come on- if nobody was there to "deliver" the baby, was the baby still born?? Here, they insist on referring to homebirths as "home deliveries," perhaps a tongue-in-cheek reference to a snide and oh-so-professional bumper stickers ACOG gave out to members last year, which read "Home delivery is for pizzas, not for babies." No sir, no bias there. None at all. (On the other hand, midwives are fond of saying "Pizzas are delivered; babies are born." The verbage goes both ways.)

In other words, they would mandate it that the only place to deliver a baby is where doctors practice and get paid. As an old SNL sketch used to say: how conveeeeenient. When you read what other physicians, from this and other countries, have to say about the safety and desirability of homebirth, and consider the fact that just a couple of generations ago most people were born at home with a midwife, it's hard to conclude that this is motivated by anything but greed, spite, and a turf war.

Many eloquent responses have been written, including ones by concerned citizens and one by Ricki Lake (whose name has since been removed from the resolution) and Jennifer Block; but one of the best has to be this one from an obstetrician and member of ACOG. Please read it through, because it's worth it.

Douglas H. Kirkpatrick, MD
The American College of Obstetricians and Gynecologists
PO Box 96920
Washington, DC 20090-2188
Dear Sir:

I am a practicing OB/ GYN in southern California and Fellow of ACOG and recently was informed by midwife colleagues of your recommendation and encouragement for the AMA to lobby Congress for a law banning out of hospital birth.

Funny, that I had to hear of this decision from outside sources and was never approached by my college to see how I or my local colleagues felt about it. I have grave concerns regarding my organization taking such a stand. I think we are all agreed that ACOG has a statement regarding patients rights to informed consent and informed refusal. Yet, it seems with every decision our organization moves further away from that basic tenent. ACOG’s little “guideline” paper on VBAC in 2004 where the word readily was changed to immediately has had the chilling effect of doing away with VBAC options at hundreds if not more hospitals. Not due to patient safety, or the ideal of giving true informed consent but really, let’s be honest, to fear of litigation. I have seen how patients have become counseled by obstetricians at facilities where VBAC has been banned. They are clearly given a skewed view of the risks of VBAC but rarely told of the risks of multiple surgeries. If you think this is untrue you are, sadly, out of touch with real clinical medicine.

As to out of hospital birthing, please give me the courtesy of an explanation as to the data you used and the process by which an organization which is supposed to represent me came to this conclusion. Any statement saying that it is as simple as patient safety and that one-size fits all hospital birth under the “obstetric model” of practice should be applied to all patients is, putting it nicely, not really in line with what best serves all our patients. In many instances, hospitals are not safe, certainly not nurturing and have a far worse track record for disasters than home birth. Even when emergency help is nearby this is true. The focus of all of us in medicine should be on reigning in trial lawyers and tort reform and lobbying Congress for that. The best interest of the college members and the patients we serve would be for my organization to spend its time and energy on something that has true benefit. Removing choices from well-informed patients and caring doctors and midwives is wholly un-American.

So please send me detailed information on how ACOG decided outlawing home birth was a wise thing to do. You must have scientific data to take such a drastic stand. Please make it available to me so that I may share it with likeminded colleagues. I would also like to know the process by which this came to pass. Who first raised this issue and why? What committee reviewed all the data and did its due diligence in interviewing those of us with longstanding experience in backing midwives who perform out of hospital births. There must be a fine, non-confidential paper trail you can share with your members. Specific names of committee member who voted for this would be enlightening and I am requesting this information. I would like to know the background and expertise regarding out of hospital birth for each member who had a hand in the decision to go to the AMA.

We live in an odd era where once something is said or recommended by a legitimate organization such as ACOG it has deep ramifications never intended such as becoming fodder for trial lawyers trying to squeeze the lifeblood and dignity out of your members. Or forcing women to travel hundreds of miles in labor to find a supportive facility. Or even worse, to have them arrive in a VBAC banned hospital and refuse surgery. Can this be the best we can do for our patients? Remember, your VBAC statement was meant to be only a recommendation but quickly became the rule by which hospital administrators, risk managers and anesthesia departments of smaller hospital banned this option for thousands of women. An option, that in proper hands, was the safe and accepted standard of care for 30 years. In fact, you still have an ACOG VBAC brochure that recommends this option! For those of us working at smaller hospitals where VBAC was banned due to lack of emergency help (anesthesia, OR crews, etc.) there is a big question that has perplexed us that no administrator seems to be willing or able to answer. That question is: “If a hospital cannot handle anemergency c/section for VBACs, and most emergency are for fetal bradycardia, hemorrhage (ie. abruption) or sholder dystocia not for ruptured uteri, then how can they do obstetrics at all?” For they seem to still be able to have a maternity ward without in house anesthesia. Will someday ACOG, in their great wisdom but seeming disconnect from reality, make a “recommendation” that little hospitals stop providing obstetric services? Will this better serve women and their communities throughout America?

I am frightened and angered by what you have done in my name. Now I ask you to defend your position in encouraging the AMA to lobby Congress for another restriction on the freedom of choice that belongs to women and their families. Those choices include midwifery and the right to have the most beautiful and life changing event occur wherever best fits their desire. Midwives are well trained and required to have obstetrical backup. They have very special relationships with their patients and want the very best outcomes for them. They do not need me or you to police them. We have a habit in out country over the past 40 years of thinking we can legislate out stupidity. All that has done is erode the individual freedoms that belong, by birthright, to each of us. I would hope you trust your Fellows to know their specialty, their colleagues, and what is best for the patient as an individual. These decisions do not belong to politicians or faceless committees. You should have more faith in your members to give balanced informed consent. Again, my recommendation to you is to put all your considerable energy into changing our legal malpractice system. Those of us actually practicing medicne and caring for patients know this to be the greatest threat to the mission and responsibility we have chosen to undertake.

I look forward to your response and possibly the beginning of a meaningful dialogue.

Sincerely,

Stuart J. Fischbein, MD FACOG
Medical Advisor, Birth Action Coalition

I came across it via the Enjoy Birth blog, who also includes a link to an online petition you can sign opposing the resolution.

Honestly: I get it that not everybody agrees with homebirth, or would feel comfortable with it. (Which is why I would never propose, say, MANDATING it!) BUT, it sickens me to think that in a country ostensibly founded on freedom, we would allow physicians' greed and/or fear of the unknown to sabotage what studies have proven is a safe, not to mention cost-effective (certainly a consideration, in this day and age!) and family-friendly, choice for this most private and miraculous of events. A Canadian physician had this to say (from Jennifer Block's site):

I would invite ACOG to join the rest of us in the 21st century. Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficience, whether such recommendations are founded on sound scientific evidence or the pre-historic musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not “offering” VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, randomized controlled trials.

Science supports homebirth as a reasonably safe option. Even if it didn’t, it still would be a woman’s choice [...]

Andrew Kotaska
Yellowknife

And, compare ACOG's position with that of the physicians in Britain's Royal College of Obstetricians and Gynaegologists:

The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman's likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.

I love how their position statement is carefully crafted and supported both scientifically and ethically. ACOG's and AMA's statements, on the other hand, come across as petty, spiteful, and paternalistic. "Homebirth is dangerous, you idiots...because I said so."

And to think I thought that dropping out of law school meant I wouldn't be involved in politics...