The Out-of-hospital birth debate continues

A few weeks ago, the American College of Obstetricians and Gynecologists released the following policy on out-of-hospital birth:

Out of Hospital Births in the United States

Labor and delivery is a physiologic process that most women experience without complications. Ongoing surveillance of the mother and fetus is essential because serious intrapartum complications may arise with little or no warning, even in low risk pregnancies. In some of these instances, the availability of expertise and interventions on an urgent or emergent basis may be life-saving for the mother, the fetus or the newborn and may reduce the likelihood of an adverse outcome. For these reasons, the American College of Obstetricians and Gynecologists (ACOG) believes that the hospital, including a birthing center within a hospital complex, that conforms to the standards outlined by American Academy of Pediatrics and ACOG,1 is the safest setting for labor, delivery, and the immediate postpartum period. ACOG also strongly supports providing conditions that will improve the birthing experience for women and their families without compromising safety.

Studies comparing the safety and outcome of U.S. births in the hospital with those occurring in other settings are limited and have not been scientifically rigorous. The development of well-designed research studies of sufficient size, prepared in consultation with obstetric departments and approved by institutional review boards, might clarify the comparative safety of births in different settings. Until the results of such studies are convincing, ACOG strongly opposes out-of-hospital births. Although ACOG acknowledges a woman’s right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births.

1 American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 5th Edition. Elk Grove Village, IL, AAP/ACOG, 2002.

Approved by the Executive Board October 2006

“…ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births.” In other words, homebirth CNMs/CMs and CPMs? And what about last year’s large, peer-reviewed, prospective cohort study in the BMJ? That study certainly didn’t strike me as particularly “limited” and “not…scientifically rigorous.”

In response, the ACNM recently released the following statement, which was also signed and supported by eight other organizations, including the American Nurses Association, the Midwives Alliance of North America, Citizens for Midwifery, Lamaze International, the Coalition for Improving Maternity Services, the White Ribbon Alliance for Safe Motherhood, the American Association of Birth Centers and Birth Network National:

November 20, 2006
Douglas W. Laube, MD
President, ACOG
409 12th Street,
SW Washington, DC 20024-2188

Dear Dr. Laube,

Some families, after thoughtful consideration, choose home birth or birth in an out-of-hospital birth center. On behalf of those families, we are writing to express our concern about the recent ACOG Policy Statement, Out-of-Hospital Birth in the United States . The troubling nature of this statement places in jeopardy access to a valid, evidence-based system of care. Providers who support evidence-based care have an ethical responsibility to offer access to care at all levels and in all settings for these families.

The safety of birth in any setting is of utmost priority. Unfortunately, studies which have not differentiated between planned and unplanned home birth or attendance by qualified versus unqualified attendants, and/or that do not clearly define appropriate inclusion criteria, have been used to discredit all out of hospital birth.

The implication that there is insufficient evidence to support the safety of planned out-of-hospital birth is unsubstantiated. After a review of the evidence, ACNM published a position statement in 2005 in support of planned home birth under specific conditions. That statement is reflective of similar interpretations of the evidence by national and international panels. Furthermore, we are not aware of evidence supporting the assertion that the hospital is the safest setting for labor, birth and the immediate postpartum period for low risk women.

Across health care disciplines, it is well documented that safety can be best assured when health care professionals and institutions collaborate to ensure that women have access to qualified providers. Indeed, many health care institutions and obstetrician-gynecologists support the right of women to choose out-of-hospital birth by actively working to maintain respectful collaborative relationships, provide expert consultation, and facilitate transfer of care.

In contrast, the ACOG statement discourages collaborative practice and support for out-of-hospital birth providers. This position could potentially harm the culture of safety around birth, for patients and providers.

We agree that there is much to be learned from further studies. Research that focuses on the characteristics and management of normal birth, the impact of various care processes on morbidity, and variables that affect client satisfaction and experience as related to birth site are all necessary.

In order to ensure the provision of safe and appropriate care, research should be focused on the ways in which all health care providers and institutions can establish seamless systems of care when transfer is needed from the home or birth center to the hospital. The data needed for such research can only be provided if we continue to offer safe, comprehensive and appropriate care in all settings.

Finally, we are distressed that this statement is published at a time when the public health system is preparing for pandemic influenza. The National Pandemic Flu Plan calls for hospitals to develop ‘surge capacity’ plans to maximize their capability to care for seriously ill patients, and create alternative care sites for routine care. Specifically, the plan calls for health systems to explore ways of “increasing the role of home care, and developing off-site care facilities.” It seems likely that in an influenza pandemic, a hospital bed – in short supply and in close proximity to those ill with a virulent virus – may not be the safest place for healthy women to give birth.

In other disaster situations, access to care based on technology may not be available even in a hospital. Preserving our competencies in providing perinatal care in low resource settings is critical to adequate preparedness in the United States and our continued support of midwifery education and safe motherhood in the developing world.

Since potential necessity and strong patient desire by a small percentage of women assure that birth outside the hospital setting will likely persist, we encourage ACOG to partner with other health care providers to enhance the safety of birth in out-of-hospital settings by promoting an agenda for continued research, developing policies to ensure seamless coordination of care across settings, and encouraging collaborative management across disciplines. ACNM proposes the development of a joint task force to develop guidelines for out of hospital birth and to establish a research agenda to explore issues of safety across birth settings.

We look forward to our continuing dialogue and the opportunity to work collaboratively on this issue.

Sincerely,

Katherine Camacho Carr, CNM, PhD, FACNM
President, ACNM

Finally, the American Association of Birth Centers also released the following statement:

November 16, 2006
Douglas Laube, MD, MEd, President
American College of Obstetricians & Gynecologists
409 12th Street SW, PO Box 96920
Washington, DC 20090-6920
Fax: 202-863-4981

Dear Dr. Douglas Laube:

We are hereby responding to the recent ACOG Executive Committee Statement regarding out-of-hospital birth which we direct to each member of the Committee personally.

The statement does not appear to be evidence-based, and AABC has been unable to find a factual basis to support this sweeping pronouncement. To the contrary, the evidence demonstrates that birth center outcomes are at least equivalent to those in hospitals for low-risk women. Please refer to the attached reference list for examples of these studies from the U.S. and Europe. Your statement could have serious consequences for women choosing licensed birth centers, of which there are over 180 in number, particularly in areas where access to maternity and women’s health services is limited. As I’m sure your organization realizes, there is a growing crisis of access to obstetric care for women in rural and other medically underserved areas, and this is an unfortunate time to artificially further limit access to care by marginalizing fully licensed birth facilities.

Women choose out-of-hospital birth for a variety of reasons including desire to avoid intervention of hospital routines, previous unsatisfactory or untoward hospital experiences, desire for family participation, concern about possible exposure to hospital infections for healthy women and infants, and preference for midwifery care. Birth center providers, their consulting specialists and affiliated acute care services work very hard to prepare for any eventuality including a need for hospitalization and cesarean section, so that women can be assured of safe and satisfying outcomes. In many hospitals around the country in-house twenty-four hour availability of anesthesia or surgery to perform emergency cesareans does not exist. These services are available on call. Licensed birth centers operate by agreement with transfer facilities in the same way, and consultants are on call and immediately available when needed.

The fact that birth can become complicated is the reason the birth center was developed (and demonstrated first in 1975), as a point of entry to a continuum of care based on the medical, psychological, social and economic needs of the childbearing woman and her family. It is why AABC, as an organization, has worked very hard to develop a team approach to the care of women in childbirth – a team which includes obstetrical specialist consultation, acute care medical and nursing services, close follow-up of mother and baby, pediatric services, and the host of other social and community services that may be indicated for individual women and their families. It is why we have developed national standards and sought the assistance of the American Public Health Association to promulgate recommendations for licensure. It is why we have established a Commission for Accreditation of Birth Centers to provide assistance and oversight to birth center operations.

Childbirth is more than a physiological event, important as that is to the whole spectrum of care of the mother, baby and family. Surely your members are aware of the growing evidence to support not only the physiological, but also the psychological, social and emotional impact of the care afforded during the childbearing year and the impact on the mother, the infant and the family. Granted, these all need further study, as evidenced in the Institute of Medicine report entitled “Research Issues in Birth Settings”. That report spelled out the need for research in all birth settings. In the interim, we do need to allow low-risk normal birth to occur when possible in the family-centered, comfortable environment of the birth center, when that is the choice of the mother and her family.

We urge you to reconsider your statement on out-of -hospital birth. Although we strongly disagree with your position on the quality of existing studies, we do agree that more study is needed, and will continue to support study of all issues surrounding the preservation of access to normal birth. We suggest that the birth center model operating within an established network of consultation and referral can be an important factor in improving outcomes in this country.

Sincerely,

Jill Alliman, MSN, CNM
President, American Association of Birth Centers
American Association of Birth Centers

So, in a rather sweeping statement, ACOG is trying to say that the only safe births are those that happen in hospitals, and out-of-hospital birth is not something ACOG obstetricians should support. If you’re interested in signing the ACNM’s letter in response to ACOG’s new policy, you can visit the ACNM website and add your name to the open letter.