In Out-of-Hospital Birth

The American College of Obstetricians & Gynecologists (ACOG) has published a revised and updated Committee Opinion on “Planned Home Birth.” If you read the media reports on it, you would think the new Opinion is “same-old, same-old,” but there are some extraordinary differences. Let’s do a “compare & contrast” between the 2011 and 2016 versions and see what they are.

To begin with, while both versions assert that hospitals and birth centers are the safest for birth—no surprises there—the new version adds “accredited” as a qualifier for birth centers. This is a subtle distinction that takes ACOG even further than the 2011 version in the direction of acknowledging both the role of regulation in establishing safety for out-of-hospital birth and that professional bodies associated with out-of-hospital birth can be responsible agencies for regulating quality of maternity care.

The next revision is along the same lines but breaks entirely new ground. Both Opinions list factors that impact home birth outcomes (more in a minute about those), one of which is care provider qualifications. As one would expect, both include obstetricians, although, doubtless, these would be few and far between. However, while the 2011 version admits only midwives certified by the American Midwifery Certification Board, which would be Certified Nurse-Midwives (CNMs) or Certified Midwives (CMs), the latter being non-nurse midwives trained through the nurse-midwifery system, the 2016 version adds midwives “whose education and licensure meet International Confederation of Midwives’ [ICM] Global Standards for Midwifery Education.” This opens the door to a growing number of Certified Professional Midwives (CPMs), direct-entry midwives who have been certified by the North American Registry of Midwives (NARM). This is because in 2013, the Midwifery Education Accreditation Council (MEAC) revised its standards to align them with ICM’s, which means that MEAC-accredited midwifery schools must meet ICM standards. Furthermore, NARM is in the process of instigating a bridge program to bring its certified midwives in line with ICM standards as well. Considering ACOG’s long-standing opposition to CPMs, their addition to the roster of acceptable home birth providers is nothing short of revolutionary, so much so that one has to wonder whether the authors of the new Opinion realized what they were doing when they changed the language.

Less obvious in the media reports, the 2016 version also shifts ACOG’s stance on home birth risk. The 2011 version unequivocally states that home birth increases the risk of newborn death, although that risk is mitigated by the appropriate selection of candidates, the qualifications of the care provider, and practice within an integrated care system, which is defined as “ready access to consultation and access to safe and timely transport to nearby hospitals.” The 2016 version, by contrast, states that “comparable” perinatal mortality rates can be achieved when these criteria are met. In other words, under the right circumstances, planned home birth doesn’t confer excess risk of death. Furthermore, while neither version acknowledges any obligation to provide an integrated system in the furtherance of safety, the new version admonishes: “When antepartum, intrapartum, or postpartum transfer of a woman from home to hospital occurs, the receiving health care provider should maintain a nonjudgmental demeanor with regard to the woman and those individuals accompanying her to the hospital.”

Still, both versions cite the same flawed research, only now, of course, there is more of it. (For example, you can find deconstructions of some of the prominent studies here and here.) This means that the excess risks of home birth for the baby may not be what ACOG says it is, although no one disputes that risk increases when women have health or obstetric complications; the home birth attendant isn’t qualified; or the system doesn’t allow home birth midwives to consult or collaborate with physicians or transfer care efficiently.

Both versions specifically list prior cesarean as a contraindication to home birth (along with malpresentation, which is usually breech, and multiple pregnancy in the case of the new version) on the grounds that VBAC requires a facility with the ability to perform immediate cesareans. The 2011 version leaves it at that, but the 2016 version enjoins health care providers and insurers to “refer patients to facilities with available resources” and to “do all they can to facilitate transfer of care or comanagement in support of a desired [VBAC],” and that “such plans should be initiated early in the course of antenatal care.” This elides over the responsibility of obstetricians to offer VBAC, seeing as many hospitals can’t handle emergencies 24/7 yet have no problem admitting women with other complications that may result in requiring an urgent cesarean—not to mention administering treatments such as induction and epidurals that occasionally do the same—and it doesn’t address the dilemma of women carrying breech babies or twins who don’t want an automatic trip to the operating room. Nevertheless, it’s a step in the right direction.

On the other side of the ledger, both versions acknowledge that women are less likely to undergo medical intervention and experience less morbidity with planned home birth, but the addition of new research raises the stakes with regard to cesareans. The 2011 version reported a 5% rate with planned home birth vs. 9% with planned hospital birth. The 2016 version reports the same 5% for planned home birth vs. 24% with planned hospital birth. The 2016 version theorizes that this discrepancy may be because of factors such as that women planning home births are less likely to be 1st-time mothers, but while this is true, studies confining the comparison to 1st-time mothers still find an excess (Romano 2012). Moreover, neither version includes the increased mortality in the babies of future pregnancies consequent to the excess number of cesareans in women planning hospital births in the calculation of comparative risk.

All in all, congratulations to ACOG for making it even clearer that the U.S. obstetricians professional organization understands that all home births are not alike and should not be dumped into one basket. However, the job isn’t done. For one thing, ACOG members have to walk the walk, and for another, the recognition that factors within obstetrician control increase safety, namely, working with home birth practitioners to integrate care and offering planned vaginal birth to all women desiring it so they aren’t forced out of the hospital, creates an obligation to provide those elements of care.

Also, considering ACOG’s continuing opposition to home birth, the new Opinion doesn’t go far enough. It didn’t consider why women reject hospital birth, which could then lead to a discussion of: “What can we do about it?” Gene Declercq has a presentation on home birth trends that answers the first question. U.S. women who had recently given birth in the hospital were asked: “For any future births, how open would you be to giving birth at home?” Thirty percent of women planning future pregnancies “definitely wanted” or “would consider” a home birth. In other words, a substantial percentage of women are so dissatisfied with their care that they would consider something as radical as opting out of the hospital next time. Dissatisfaction was particularly acute in black women. Among women who would consider home birth next time, 25% of non-Hispanic black women definitely wanted home birth vs. 10% of non-Hispanic white women, 5% of Hispanic women, and 10% of all other women. If ACOG obstetricians don’t want women leaving the hospital feeling like they don’t want to come back with their next baby, then they and hospitals need to improve their product. As for how to do this, abundant research shows that obstetricians and hospitals need to make physiologic care the default, ensure that all laboring women are treated with dignity and kindness, individualize care according to women’s values and preferences, assist women in making informed decisions, and respect and accommodate their choices. What’s more, not only would that reduce the number of women seeking out-of-hospital birth, it would improve the care of the 99% of women who don’t. It’s a win-win.

Romano A. The place of birth: home births. In: Goer H., Romano A., eds. Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing; 2012.

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