"Doctors who in any way support planned home birth should be subject to peer review and justifiably incur professional liability and sanctions from the Medical Board".
http://www.ajog.org/article/S0002-9378(12)01074-5/fulltext
I'm spitting FIRE right now!!! FIRE!!!
This could have HUGE national implications for homebirth.
clinical@acog.org
EMAIL THEM!!!!!!!! We need to let them know we WILL NOT stand for this medical ABUSE! How dare they! Using that JUNK science trying to FORCE us to deliver with them.
They are in DIRECT conflict of interest here. How can they recommend that we be FORCED to use their services?
If you have ever had or ever want to have a homebirth in the U.S. You should be writing a letter!!!
The ACOG is a doctor's union. Its entirely within their interest to tell members to discourage patients from using alternatives to their care. It shrinks the union's potential customer base and therefore the potential earning power of its members. A union's basic function is to protect the job security and wages of its members, kinda hard to do that if the members actively send potential work/revenue away.
Mind, I still disagree, and will write them a LONG letter. A doctor should give advice in the interest of the health of the patient, not the interest of their paycheck. And its much safer for me to labor at home with my obsetric history, for way too many reasons to list here. No one at the hospital had to say this out loud, granted, but several did.
DOG BITES MAN!!!!!!!!!!!!!!!!!!!!!!!!!
What you have posted is an article in a journal that is opinion not policy. It is an article from American Journal of Obstetrics and Gynecology. That isn't the same thing as ACOG. Even Dr. Amy felt the article was poor.
Regarding ACOG being a "trade union" ... well, if it is then certainly MANA is as well. MANA refuses to release the statistics they keep on perinatal mortality in homebirth. It is hard to imagine they would refuse to release them if they were good. "MANA has a vested interest in attracting women to homebirth to line the pockets of midwives". I am just using the same logic to apply to both groups.
My personal opinion is women have a right to give birth at home. Health care providers have an obligation to be educated about risks and share this information with parents. Parents have a right to true informed consent. No doctor or midwife has a responsibility to attend homebirths. Hospitals, thus doctors who work with or for them, have a responsibility to provide emergency care to everyone, including homebirth transfers.
The American Journal of Obstetrics and Gynecology is published by Elsevier. There is a journal published by ACOG but this is not where the article appeared.
just for this one. i must have read ajog and thought acog. Dang abbreviations!I was just playing with that CDC wonder thing and I don't get lower out of hospital birth so far what you got. I tried making all moms as low risk as the program allows because and making infant deaths up to 28 days. It still isn't perinatal mortality because it does not include stillbirths. I get sick of seeing infant mortality, up to one year, as having something to do with birth when data is collected on perinatal mortality which is a reflection of maternity care. It is really cool to play with that thanks for the link. Thanks!
the program doesn't allow you to adjust for low risk. which is kind of irrelevant, because all of the MWs I know take traditionally high risk patients. I think the impact of high risk is much lower then what anti-homebirth groups seem to believe. Many of the things that would force a hospital CNM to turn her client over to an OB, an out of hospital MW will take on. multiples, breech, GD, previous fetal demise, multiple losses, VBAC. Those women are all being serviced in the homebirth community.
Still birth is also not the most important data. Almost all of still births are due to genetic deformity. If we remove them from the data of 24 hours post birth there isnt enough data to look at. Looking at 1-28 days would be misleading here as well then. A woman in a hospital having a more medicalized birth would be more likely to abort a baby because she would have access to that information in advance of delivery. Homebirth moms often forego that type of testing and even if they do know, are less likely to abort. One would need to adjust for that. There is also the concern that things done in the hospital, during delivery, drugs given, etc. DO contribute to long term health problems that could caused delayed mortality. So, just using the data from infants who died in the first month wouldn't include children whose immune systems were compromised at a young age due to things done at the hospital (administration of vaccines, antibiotics, etc.)
If you look at highly viable infants (34-41 weeks gestation) the rates for a MD in hospital for mortality through the first year: 3.0
ALL midwives out of hospital, including lay MWs: 2.88
Just CNMs: 2.41
CNM in hospital would show a true collection of solely low risk women, so wouldn't be comparable to out of hospital CNMs who often take on high risk clients.(1.91)
And of course, we are forgetting to include maternal mortality, which is obviously much higher in the hospital and which an increase can be majorly attributed to medical error Its a shame our government doesn't track that data and instead allow hospitals to have closed datas on their maternal mortality rates.
If we really wanted to show the trust cost of hospital births we could throw morbidity into the mix, we would definitely see rates shoot up in the hospital for both mothers and babies. Unfortunately, that data is also not available.
So, while many of the deaths at home MAY have been prevented if the mother had delivered in a hospital, there are more deaths in a hospital that relate to poor medical treatment, that could have been avoided had those women had their babies outside of the hospital.
Its more than just dead babies at 28 days in a "low risk" group. It's much more complicated than that.
'the program doesn't allow you to adjust for low risk. which is kind of irrelevant, because all of the MWs I know take traditionally high risk patients."
When I had a homebirth the midwives did careful risk screening and I think it increased the safety. I know of midwives like you describe. My homebirth was so long ago maybe midwives were more careful as a whole then, I also had CNMs. Adjusting for risk would only help homebirth statistics I would guess.
" I think the impact of high risk is much lower then what anti-homebirth groups seem to believe. Many of the things that would force a hospital CNM to turn her client over to an OB, an out of hospital MW will take on. multiples, breech, GD, previous fetal demise, multiple losses, VBAC. Those women are all being serviced in the homebirth community."
I see this reflected online. I find it very scary. Hospital CNMs I have worked with do care for most of these women but an OB would be also involved in their care.
"Still birth is also not the most important data"
True but it is important data.
. " Almost all of still births are due to genetic deformity."
This isn't true. A signficant number of very normal appearing babies die in term and postterm stillbirths. From what I read online there are a fair amount of intrapartum deaths at home as well. This is exceedingly rare in the hospital. Stillbirth rates need to be included if women are to have good information from which to make a choice.
" If we remove them from the data of 24 hours post birth there isnt enough data to look at"
I am not sure what you mean here.
. " Looking at 1-28 days would be misleading here as well then. A woman in a hospital having a more medicalized birth would be more likely to abort a baby because she would have access to that information in advance of delivery. Homebirth moms often forego that type of testing and even if they do know, are less likely to abort. One would need to adjust for that."
In my personal experience I have cared for many mothers in the hospital that chose not to abort babies with lethal anomalies. I think you are generalizing stereotypes that are not accurate. As well I have known of, I choose not to be involved in terminations, mothers who planned homebirth who did have genetic testing and did terminate. It would be a horrible decision and I am not judging this. I know that you can't assume that homebirth moms do x and hospital birth moms do y in this regard.
" There is also the concern that things done in the hospital, during delivery, drugs given, etc. DO contribute to long term health problems that could caused delayed mortality. So, just using the data from infants who died in the first month wouldn't include children whose immune systems were compromised at a young age due to things done at the hospital (administration of vaccines, antibiotics, etc.)"
I don't think these are valid concerns. I still think up to 28 days is the best cut-off.
"If you look at highly viable infants (34-41 weeks gestation) the rates for a MD in hospital for mortality through the first year: 3.0
ALL midwives out of hospital, including lay MWs: 2.88
Just CNMs: 2.41
CNM in hospital would show a true collection of solely low risk women, so wouldn't be comparable to out of hospital CNMs who often take on high risk clients.(1.91)"
Again I don't think up until the first year is valid. There are too many other causes of death unrelated to maternity care in the first year. I think in hospital CNMs would be the best comparison and as I said they are often the birth attendants at some of the high risk births you listed.
"And of course, we are forgetting to include maternal mortality, which is obviously much higher in the hospital and which an increase can be majorly attributed to medical error Its a shame our government doesn't track that data and instead allow hospitals to have closed datas on their maternal mortality rates."
Is it much higher among women with the same risk factors? I doubt it. I haven't searched for the data recently but I know it is available. Sometime in the last decade death certificate redefined what is counted as maternal mortality, and that year many people exploited it as if maternal deaths had suddenly jumped. I am sorry I don't remember the year.
"If we really wanted to show the trust cost of hospital births we could throw morbidity into the mix, we would definitely see rates shoot up in the hospital for both mothers and babies. Unfortunately, that data is also not available."
Some studies have shown higher morbidity in hospitals. That is probably true. But major neonatal morbidity has been higher in some homebirth groups.
"So, while many of the deaths at home MAY have been prevented if the mother had delivered in a hospital, there are more deaths in a hospital that relate to poor medical treatment, that could have been avoided had those women had their babies outside of the hospital. "
I don't buy that. In Colorado midwives attending home birth have three times the perinatal death rate that all hospital birth ( including high risk, all gestational ages) has. The data is easy to find.
"Its more than just dead babies at 28 days in a "low risk" group. It's much more complicated than that."
I agree it is very complicated and hard to study. I believe that even if it were proven, to them, that home birth has a higher neonatal mortality that many women who choose it now would still choose it. Lots of things cannot be measured. Despite my opinions about safety I think women should have a right to birth at home if that is their choice.
I can't jump into this conversation right now but I wanted to give a little encouragement and say thanks to both of you for a thoughtful discussion! As best as I can recall from my research for my last birth, I had concluded that homebirth was slightly more risky for mother and child (not including morbitity for mom) than hospital birth. That transfer care was a big factor. I also concluded that the biggest risk for the baby was in postnatal care. I still planned a HB because I felt the increased risk was low enough for me to take and the benefits of homebirth for both mom and baby (and family) were huge. We were extra cautious in the days following the birth and chose to see a pediatrician earlier than we may have if I weren't concerned about postnatal care as a result of my research.
I'd love the link for maternal mortality. And for Colorado homebirth vs hospital IMR.
I used a CNM as well. but none are practicing in my state now. so i will be forced to use a cpm for this pregnancy. i cannot go to a hospital. as a vbac im at too high a risk of being mistreated by them and ending up with a unnecessary section.
i think one day a hospitals advatages will outweigh the risks, but today i dont think they do. its easy for a hospital to sweep mistakes under the rug or just refuse to believe they contributed if the victims never sue. so the real rates of medical mistakes leading to both neonatal and maternal morbidity and mortality are probably much higher.
if you look at The Farm statistics they are much better than any hospital.
I just found links for all of it and erased it by accident. It is somewhat hard to find the original data instead of people quoting it but I did find it. Google Colorado perinatal mortality direct entry midwife. There are all sorts of articles. Finding the one with the source info was hard but I eventually found it at the end of a PDF.
Maternal mortality was recalculated in two different years and represents a big part of the rise. Again I had to look a long time for original data versus quotes. I found it all and used this page to look for something else and lost the links. If you are interested I know you can find it too. I think it is important to look at original data versus just what someone says the data shows.
Regarding the Farm study they used a clearly skewed comparison group. You can research that as well.
Obviously, OP personally distrusts hospitals so much you would be utterly terrified. I happened to know that wasn't ACOG and got all caught up in this again by posting that!
I think IdentityCrisisMama's discussion of how she made her choices reflects what I would hope most moms would do, look at data, even what you don't like, and choose what applies to your situation. I am just concerned that women have access to accurate information. I have to say I wish MANA had the same concern!
me too. i think all obs and mws should publish their personal numbers.
Yes. The part toward the end has a copy of the actual data. The beginning is inflammatory I realize but she obviously had sent away for the actual statistics and posted a copy.
I'd love the link for maternal mortality.
Maybe I found links for maternal mortality from WHO? I don't recall. I know there's so much to consider when looking at this stuff, which all of you have touched on. For neonatal -- there is a big issue of when this period is in terms of stats - it's different for different studies/regions, as I recall. I think WHO may have a good chart on maternal mortality.
What rarely gets discussed right in with the rest is morbidity. I think c-section is a morbidity and we all know the chances of that. I also think infant treatment in the hospital is a (I admit often very, very mild) morbidity.
So those are factors as well.
I believe C/S is a sort of morbidity as well. Not just because it is a surgery and a recovery, but because of the later obstetric risk for subsequent births of rupture or placenta previa or accreta. Again, everyone has to make a choice bases on their values and situation. I don't know of any research that doesn't report a decrease in cesarean section rates with planned homebirth. I have looked at a site advocating maternal request cesarean birth. The women there don't want to risk the morbidity of a vaginal birth. I personally would not choose a cesarean but I can understand valuing a complete intact non stretched pelvic floor. I still think ethics wise that patients have a right to refuse anything but they don't have a right to demand a non indicated surgery. I am glad I am not an OB because I would have a very hard time refusing an elective C/S to a mother who had researched it all and requested a C/S. The baby has to be born and there are risks to vaginal birth as well. It would be a really hard one to say "you have to take these risks" just because it is "natural". It isn't exactly comparable to for example, requesting an appendectomy even though you don't need one.
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