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Midwives, birth OUT OF HOSPITAL proven safe - contrary to ACOG's false assertion
by Amy Gates
Last week I wrote about The Big Push for Midwives, a national grassroots campaign pushing for the regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, Puerto Rico and the District of Columbia. As it currently stands, there are 26 states that ban CPMs. If caught practicing there, midwives could be subjected to fines, jail time, even face the possibility of a felony conviction in Missouri.
Despite the fact that other developed countries in the world that have adopted midwives as the primary care providers for healthy pregnant women, the United States has yet to catch on. One percent of American women choose to give birth at home. Just last week the American College of Obstetricians and Gynecologists (ACOG), a trade union representing the financial and professional interests of obstetricians, released a statement reiterating their opposition to home births and CPMs, and suggesting that mothers who give birth at home with a midwife are choosing the birth experience over the health of their baby. Rather than advocating for "quality health care for women" as the group claims is part of their work on their about page, the entire statement perpetuates FUD; Fear, Uncertainty, and Doubt.
The Big Push for Midwives campaign countered with their own press release stating the ACOG is Out of Touch with Needs of Childbearing Families and said not only do they claim "out-of-hospital birth is 'trendy,'" but they also try to play the "bad mother" card. The International Cesarean Awareness Network also issued a statement "condemning" the ACOG for their statements, as did the Childbirth Connection who states ACOG Place of Birth Policies Limit Women's Choices Without Justification and Contrary to the Evidence.
In addition to these organizations, many other sites and blogs have done an outstanding job of weighing in on this topic and have covered it in much more detail than I can attempt in this single post. Therefore I'm going to stick primarily with addressing the safety "concern."
The ACOG says, "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." This, however, is a false assertion. According to Citizens for Midwifery, a number of rigorous scientific studies published in leading medical journals have found that for a healthy woman having a normal pregnancy, a planned, midwife-attended home birth is as safe as a hospital birth and with far lower rates of medical interventions. The most recent is also the largest study - with 5418 women participating - based on prospective reporting for all the births attended by Certified Professional Midwives in 2000, published in 2005 in the British Medical Journal. ("Outcomes of planned home births with certified professional midwives: large prospective study in North America." Kenneth C Johnson, senior epidemiologist, Betty-Anne Daviss, project manager. BMJ 2005;330:1416 (18 June).
The study also states:
What is already known on this topic
Planned home births for low risk women in high resource countries where midwifery is well integrated into the healthcare system are associated with similar safety to low risk hospital births
Midwives involved with home births are not well integrated into the healthcare system in the United States
Evidence on safety of such home births is limited
What this study adds
Planned home births with certified professional midwives in the United States had similar rates of intrapartum and neonatal mortality to those of low risk hospital births
Medical intervention rates for planned home births were lower than for planned low risk hospital births
If that study isn't convincing enough, then one need only look to other developed countries like Denmark, Sweden and the Netherlands, where midwifery is the primary model of care.
The organization of maternity services in Denmark, Sweden, and the Netherlands was studied under the sponsorship of the World Health Organization European Headquarters Office of Maternal and Child Health. Midwifery care is highly respected and is a central feature of obstetric care in each of these countries. In Denmark and Sweden, almost all births are in the hospital, and autonomous midwives are employed by national health services. About three-quarters of Dutch midwives are in independent practice, and 34% of Dutch women give birth at home. In each country midwives provide "the first line" of care for normal pregnant women and are viewed as essential to the excellent perinatal outcomes these three countries enjoy."- Models of midwifery care. Denmark, Sweden, and The Netherlands.
Also worth noting is Denmark's maternal mortality rate was 5 deaths per 100,000 live births according to the World Health Organization's Maternal Mortality in 2000 report. Compare that to the United States where the maternal death rate was 17 deaths per 100,000 live births.
The United Kingdom, another developed country, also supports home birth for women in uncomplicated pregnancies. The Royal College of Obstetricians and Gynecologists and the Royal College of Midwives Joint Statement No.2. from April 2007 states:
"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."
Thanks to Rixa at The True Face of Birth for looking up and sharing that information.
The World Health Organization (WHO) itself recognizes the important role that midwives play in prenatal and birthing care. In the WHO's Department for Making Pregnancy Safer 2006 Annual Report, it is noted that there is a great need for midwives in both the industrialized and developing nations. "Evidence for the decisive role of skilled birth attendants (SBA), and particularly midwives, in reducing maternal mortality is plentiful from both the industrialized and developing countries."
I found it particularly interesting that the WHO is working to reduce maternal mortality in these developing nations and is looking to the training of more midwives to achieve this task, citing an example of how midwives have already helped in Malaysia and Sri Lanka. "In a study of how Malaysia and Sri Lanka successfully reduced their maternal mortality rates since the 1960s, it was noted that the outstanding feature of maternity-related health services in the two countries has been 'the pivotal role of trained and government-employed midwives. They have been relatively inexpensive, yet they have been the cornerstones for the expansion of an extensive health system to rural communities. They have provided accessible maternity services in hospitals and communities, gained respect from the communities they serve, and are described with affection and admiration by the managers and policy makers in each country.'"
In summary, we have a large North American study citing midwife/home birth safety; Denmark, the Netherlands, Sweden, and the United Kingdom looking to midwifery as the primary model of care; Denmark with a home birth rate of 34% and a lower maternal mortality rate than the United States; as well as the World Health Organization supporting midwifery in many developing nations around the world. All of these things seem to indicate that midwives and home birth are a very safe choice. So why is the ACOG so against it in the United States? Are American pregnant women any different from pregnant women elsewhere in the world?
The truth is that safety is not the ACOG's biggest motivating factor. It's money. Money makes the world go around. As Belly Tales points out, "ACOG is a professional organization supporting and marketing the services of its members: obstetricians. In other words, a lobby. ...the bottom line is always the bottom line."
If the ACOG would acknowledge that these studies and practices in other countries are very relevant and support the legalization and regulation of midwives, as well as call on physicians to work with them and provide back-up support rather than against them, it is then that they would truly make birth safer for all women.
The positive thing here is that people are taking notice and questioning the status quo. Celebrities are talking openly about their home birth experiences and mainstream magazines are covering it. Women and their partners are seeing The Business of Being Born and learning that there IS another way. Women are talking. They are asking questions. And the ACOG is getting nervous. Let's keep the buzz going.
"In every country where I have seen real progress in maternity care, it was women's groups working together with midwives that made the difference." - Marsden Wagner, MD, MSPH
If you'd like to write a letter to the ACOG, please direct it to:
American College of Obstetricians and Gynecologists
409 12th St., S.W., PO Box 96920
Washington, D.C. 20090-6920
202-638-5577
Or email: communications@acog.orgFinally, if you've had a home birth and feel strongly about this, I encourage you to spread the word and write about it on your own blog, then leave a link to your post here in the comments. Also, if you've blogged about your home birth experience, please leave a link to that post in the comments as well. Thank you.
Additional resources:
The Big Push for Midwives
Citizens for Midwifery
International Cesarean Awareness Network - ICAN's Response to ACOG AND AABC Statements on VBAC and Homebirth
The Compleat Mother - Homebirth: As Safe As Birth Gets
The Birth Book Blog - Latest ACOG statement against home birth
Belly Tales - ACOG's statement on home births
Pushed Birth - Parsing the ACOG Statement Against "Cause Célèbre," Home Birth
Refuse to be a womb pod - What do I think about ACOG's homebirth statement?
The True Face of Birth - 10 responses to ACOG's statement on home birthContributing editor Amy Gates also blogs about attachment parenting, activism, green living and photography at Crunchy Domestic Goddess.
Submitted by Amy Gates (view blog) on Tue, 02/12/2008 - 12:10pm
IT IS NO LONGER SAFE FOR A HEALTHY PREGNANT WOMAN TO GIVE BIRTH IN ANY HOSPITAL IN THE UNITED STATES!
Dangers of Hospital Birth --
Why Birthing in a Hospital Causes More Problems Than It Solves for Normal Birthby Ronnie Falcão, LM MS
There's a saying that birth is as safe as life gets. Sometimes birth can become dangerous for the baby or, very rarely, for the mother. This is when hospital-based maternity care really shines, and we're able to save mothers and babies who might have died a hundred years ago. Thank goodness that there are skilled surgeons who can come to the rescue when truly necessary.
There's also a saying that when you've got a hammer in your hand, everything looks like a nail. So it is that for hospital-based birth attendants, it is easy to become accustomed to treating every birth as a disaster waiting to happen. Many obstetricians have lost touch with the possibility of normal birth, so much so that even a pitocin induction with an epidural, fetal scalp electrode and vacuum extraction is called a "natural birth". Some hospital staff seem offended by the idea of minimizing interventions, as if preferring not to have a needle the size of a house nail inserted near your spine is the same as declining to have a second piece of Aunt Sally's Fruit Cake. Sadly, some of today’s younger doctors may never even have seen a truly physiological labor and birth—a birth completely without medical intervention.
This is how the saving grace of the hospital can become the scourging disgrace of maternity care. In their rush to prevent problems that aren't happening, hospital personnel may aggressively push procedures and drugs that can actually cause problems. Pitocin can cause uterine contractions that are so strong that they stress the baby and cause fetal distress. [1] IV narcotic drugs affect the baby so strongly that the baby may not breathe at birth [2] ; there is even a specific drug that is used to counteract the narcotics to help these drugged babies to breathe . [3] There is considerable debate as to how epidurals affect the progress of labor, but they certainly affect a woman's ability to get into a squat, which opens the pelvic plane by 20-30%; anyone can understand that this could affect the possibility of the baby's fitting through the pelvis. Epidurals can lower the mother's blood pressure so that the baby isn't getting enough oxygen through the placenta; this can cause fetal distress and the need for an emergency c-section to rescue the baby . [4]
In addition to the specific dangers of individual obstetric interventions, hospital births suffer the effects of any form of institutionalized care. Perhaps the best-known risk of hospital birth is hospital-acquired infections. Those most susceptible to hospital-acquired infections are those with compromised immune systems, such as newborns. In particular, babies are born with sterile skin and gut that are supposed to be colonized by direct contact with the mother's skin flora. If antibiotic-resistant hospital germs colonize the baby's skin and gut instead, the baby is at high risk of becoming very sick from infections that are very difficult to treat. The overall infection rate for babies born in the hospital is four times that of babies born at home [5], and these infections are more likely to be antibiotic-resistant.
More people die every year from hospital-acquired infections (90,000) [6] than from all accidental deaths (70,000), including motor vehicle crashes, fires, burns, falls, drownings, and poisonings. An additional 98,000 people die each year from general medical error . [7]
Another obvious risk of institutionalized care arises from the piecemeal nature of the care. Because there are so many different kinds of personnel performing so many different procedures, there is a lot of potential for miscommunication about critical matters. In an astoundingly progressive admission of institutional shortcomings, Beth Israel Hospital published a paper [8] about a tragic miscommunication that resulted in a baby's death. To their great credit, instead of covering up this horrible mistake, they used it as a wake-up call to revise their protocols, in an attempt to reduce miscommunication and increase safety. Unfortunately, other hospitals are slow to adopt the reforms of Beth Israel Hospital.
One of the most dangerous aspects of hospital care is that those providing most of the direct care (i.e. the nurses) are hierarchically subservient to those managing the care from a distance (i.e. the doctors). This kind of a power structure can prevent knowledgeable nurses from mitigating the potentially dangerous actions of the doctors.
Many people feel that the hospital must be the safest place to birth because of all the equipment they have. Well, the equipment is only as good as the people using it. In many hospitals, there are not enough Registered Nurses to cover all the patients, so they use Medical Technicians, who are trained to perform procedures but not necessarily trained to interpret fetal heart tracings. Most labors start at night, and women birthing second or subsequent babies often birth during the night. This is the time when the senior staff are home sleeping in their beds, because their seniority allows them to opt for the more desirable daytime shifts. A recent study confirmed that outcomes at births are worse during the night, because even the most sophisticated equipment is useless in the wrong hands . [9]
(For the record, many homebirth midwives now carry equipment that is as sophisticated as that in most hospital birth rooms. This includes continuous electronic fetal monitors and equipment for performing neonatal resuscitation if necessary.)
Institutionalized care also suffers from the economic pressures of running an efficient organization, regardless of how this might interfere with the normal process of labor and birth.
Sometimes doctors recommend pitocin without true medical necessity, simply to hasten the birth. This may be due to a need to free up a birth room to make room for other patients, or because the doctor has other responsibilities elsewhere. Stimulating labor artificially overrides the baby's ability to space out the contractions if the labor is too stressful. This increases the risk of fetal distress.
Hospital staff have a strong bias towards confining the laboring woman to the bed and requiring her to push in a reclining position. This often puts the baby's weight on the placenta or umbilical cord, possibly restricting the baby's supply of oxygenated blood from the placenta. In contrast, upright positions put the baby's weight downward, towards the open cervix and away from the placenta and umbilical cord, reducing or eliminating fetal distress caused by cord compression.
A rush to clamp and cut the umbilical cord within seconds after birth is one of the most dangerous hospital practices. This premature severance of the umbilical cord cuts the flow of oxygenated blood to the baby before the baby has established the lungs as the source of oxygen. Premature cord clamping also deprives the baby of the blood that would naturally fill the pulmonary vasculature as it expands in the minutes immediately after the birth. This practice is documented to increase the risks of neonatal hypoxia, hypovolemia, and anemia, thus increasing the need for blood transfusions. [10]
There is some very new research showing that placental tissue itself may be a rich source of pluripotent stem cells, in addition to the blood stem cells in blood drawn from the umbilical cord. [11] We do not yet know whether premature cutting of the umbilical cord halts the migration of pluripotent stem cells from the placental tissue into the baby's body to repair damage from even minor birth trauma.
Perhaps the most egregious and unnecessary interference with the normal birth sequence is the separation of mother and baby immediately after birth. Even a ten-minute separation is too long during this critical first hour after birth - it prevents the natural nipple stimulation that increases the mother's oxytocin to contract the uterus and prevent a postpartum hemorrhage.[12] Instead of baby-provided nipple stimulation, hospitals are now routinely using synthetic oxytocin by IV or injection after the birth to control bleeding.
Similarly, early cuddling of mother and baby stimulates oxytocin production in the newborn, thus raising the baby's body temperature to help with the adaptation to the extrauterine environment. The mother's body is the best warmer for the newborn. [13]
Because different personnel are involved in providing piecemeal care for mothers and babies, providers do not always see how their actions in one area may cause problems in another area. For example, because obstetricians are not involved in breastfeeding issues, they may not realize that cutting an episiotomy hampers a woman's ability to sit comfortably in order to nurse her baby. Likewise, the pediatricians also are not involved in breastfeeding, so they may not realize that separating the mother and baby right after the birth in order to do a routine newborn exam also interferes with breastfeeding. Nursery nurses often do not seem to appreciate the importance of minimizing the separation of mother and baby and thus also unwittingly interfere with breastfeeding. They tend to ignore the World Health Organization's recommendations to delay initial bathing of the baby until at least six hours after the birth, even though bathing causes the baby's temperature to drop so dangerously low that they do not return the baby to the mother for an hour or more. [14] [15]
I emphasize the hazards to the breastfeeding relationship because breastfeeding is so vital to a newborn's well-being, reducing infant mortality by 20%. [16] This is a huge health benefit, and hospitals should be taking the lead in tailoring their routines to support breastfeeding. But because the functions of caring for mother and baby are separated into the roles of maternity nurses (who care for the mothers) and nursery nurses (who care for the babies), sometimes the mother and baby are also physically separated. Most of the time, there are no lactation consultants in the hospital - they are often only available during weekday business hours. But babies need to be fed around the clock, and if a Lactation Consultant isn't available to help a struggling mother/baby pair, it might become necessary to feed the baby artificial breastmilk with a bottle, which further interferes with successful breastfeeding.
Because the entire model of hospital birth is based on the birth as a medical procedure, hospital staff seem to miss the fact that they are interfering in a delicate time in a new baby's life. Perinatal psychologists describe the first hour after birth as the "critical period", during which the baby will learn how to learn and whether or not it is safe to relax and to trust the outer world. This has tremendous implications for mental health and stress-related disorders. [17]
There was a time when cesareans were acknowledged to be a risky surgery reserved to save the life of the mother or baby. Now even cesarean surgery has become almost routine. Some obstetricians and hospital administrators are advocating for a 100% cesarean rate as a solution to liability and scheduling problems that are inherent in providing maternity care. [18] Unfortunately, cesarean surgeries increase risks for the mother and for this baby. They also increase the risk for subsequent pregnancies, with higher rates of placenta previa and placenta accreta, and small but non-zero risk that a pre-labor uterine rupture could result in the baby's or even the mother's death.
When someone needs to be in the hospital and needs to be receiving medical treatment for a life-threatening condition, the risk-benefit tradeoff comes in heavily on the side of benefit.
But for women who are hoping to have a drug-free birth, it makes no sense to expose themselves to the infection risks associated with simply being in the hospital. Most people know that it is unwise to take a newborn baby out and about in public because of the risk of exposing the baby even to ordinary germs. It is even a worse idea to expose the baby to the antibiotic-resistant strains of germs commonly found in hospitals.
When a woman planning a homebirth needs medical care and care is transferred to a hospital-based provider, the phrase "failed homebirth" is often written in her chart, even if she goes on to have an outcome that is better than if she had started out in the hospital. I would like to propose the concept of a “failed hospital birth” as any birth where hospital procedures specifically cause more problems than they solve. When you consider hospital infection rates, surgical complications, and the damage to the breastfeeding relationship caused by routine separation of mother and baby, we might find that close to 95% of planned hospital births are failed hospital births. They failed to support the mother in an empowering birth experience to better prepare her for motherhood, and they failed to satisfy the baby's overwhelming need and desire to enter and adapt to the outside world as nature intended.
Our society has an obligation to improve maternity care services as much as possible. Consider that the countries with the safest maternity care rely on midwives as the guardians of normal birth, reserving risky medical procedures for cases of true need. "In The five European countries with the lowest infant mortality rates, midwives preside at more than 70 percent of all births. More than half of all Dutch babies are born at home with midwives in attendance, and Holland's maternal and infant mortality rates are far lower than in the United States..." [19] The United States needs to return to a model of midwives as the default maternity care providers, reserving the surgical specialists for the highest-risk patients. We need to educate pregnant women so that they understand that the choices they make about drugs during labor affect their baby, just like the choices they make about drugs during pregnancy. We need to offer women realistic pain relief alternatives to dangerous pharmaceuticals; warm water immersion during labor provides risk-free pain relief that many women find as satisfactory as an epidural. (Mothers who are uncomfortable with the idea of waterbirth can easily leave the tub to give birth "on land", while still deriving tremendous comfort and safety benefits of laboring in water.) Hospitals need to develop new routines that protect mother-baby bonding and the breastfeeding relationship as if they are a matter of life and death, because they are.
Obstetricians would do well to practice according to the wisdom contained in the phrase, "If it ain't broke, don't fix it." This means supporting healthy women with normal pregnancies in birthing at home if they choose and encouraging women planning hospital births to work with them to minimize interventions that turn normal births into risky medical procedures.
[For references, see gentlebirth.org/original or e-mail midwife@gentlebirth.org]
_______________________________
Ronnie Falcao, LM MS, is a homebirth midwife in Mountain View, California. 650-961-9728
1) Oxytocin for labor induction.
Stubbs TM.
Clin Obstet Gynecol. 2000 Sep;43(3):489-94.
2) Neonatal Resuscitation Textbook from the American Heart Association and the American Academy of Pediatrics, p. 7-3, "Narcotics given to the mother to relieve pain associated with labor commonly inhibit respiratory drive and activity in the newborn."
3) Neonatal Resuscitation Textbook from the American Heart Association and the American Academy of Pediatrics, p. 7-3, "In such cases, administration of naloxone (a narcotic antagonist) to the newborn will reverse the effect of narcotics on the baby."
4) A comparison of the hemodynamic effects of paracervical block and epidural anesthesia for labor analgesia.
Manninen T, Aantaa R, Salonen M, Pirhonen J, Palo P.
Acta Anaesthesiol Scand. 2000 Apr;44(4):441-5.
5) Outcome of elective home births: A series of 1146 cases.
Mehl–Madrona, L. E., Peterson, G., et al.
J. Reproductive Med., 1977 (5), 281–290.
6) http://www.cdc.gov/ncidod/dhqp/healthDis.html
7) http://www.cdc.gov/washington/overview/patntsaf.htm
8) A 38-year-old woman with fetal loss and hysterectomy.
Sachs BP.
JAMA. 2005 Aug 17;294(7):833-40. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=AbstractPlus&list_uids=16106009&query_hl=112&itool=pubmed_docsum
Articles at:
http://www.boston.com/business/healthcare/articles/2005/08/17/a_babys_death_prompts_reforms_in_care/
http://www.medpagetoday.com/OBGYN/Pregnancy/tb/1559
http://www.rmf.harvard.edu/risklibrary/cases/r_dec2001news-C-TeamworkFlaws-incP.asp
9) Time of birth and the risk of neonatal death.
Gould JB, Qin C, Chavez G.
Obstet Gynecol. 2005 Aug;106(2):352-8.
10) Neonatal transitional physiology: a new paradigm.
Mercer JS, Skovgaard RL.
J Perinat Neonatal Nurs 2002 Mar;15(4):56-7
11) Stem Cell Characteristics of Amniotic Epithelial Cells.
Miki T, Lehmann T, Cai H, Stolz DB, Strom SC.
Stem Cells. 2005 Aug 9
12) MISSING
13) Randomised study of skin-to-skin versus incubator care for rewarming low-risk hypothermic neonates.
Christensson K, Bhat GJ, Amadi BC, Eriksson B, Hojer B.
Lancet. 1998 Oct 3;352(9134):1115.
14) THERMAL PROTECTION OF THE NEWBORN: A SUMMARY GUIDE from the WHO
15) The effect of bather and location of first bath on maintaining thermal stability in newborns.
Medves JM, O'Brien B.
J Obstet Gynecol Neonatal Nurs. 2004 Mar-Apr;33(2):175-82.
16) Breastfeeding and the risk of postneonatal death in the United States.
Chen A, Rogan WJ.
Pediatrics. 2004 May;113(5):e435-9.
There's a newish book, "Impact of Birthing Practices on Breastfeeding" by Mary Kroeger
17) This statement is a summary of a number of different books, papers, etc. The two key books for someone interested in this topic are:
"The Magical Child" by Joseph Chilton Pierce
"The Scientification of Love" by Michel Odent, MD
There's a group of psychiatrists dedicated to the topic:
Association for Pre- & Perinatal Psychology and Health
http://www.birthpsychology.com/
Summary of key points:
http://www.birthpsychology.com/violence/odent1.html
http://www.birthpsychology.com/primalhealth/primal6.html
This last article contains numerous additional research references.
18) Who is responsible for the rising caesarean section rate?
Usha Kiran TS, Jayawickrama NS.
J Obstet Gynaecol. 2002 Jul;22(4):363-5.
http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.0006/0219.html
Phelan, J. P. (1996, Nov.). Rendering unto Caesar cesarean decisions. OBG Management.
Cesareans: Are they really a safe option? by Henci Goer
Bruce Flamm: "I have heard some doctors say that all women should have babies by C-section, that vaginal births are archaic. " from Are Women Having Too Many C-sections?
19) Midwives Still Hassled by Medical Establishment," Caroline Hall Otis, Utne Reader, Nov./Dec. 1990, pp. 32-34