The "Authorities" Resolve Against Home Birth

The ‘‘Authorities’’ Resolve Against Home Birth

Nancy K. Lowe
Editor

This editorial has been gathering momentum in
my mind since I heard about a resolution introduced
by the American College of Obstetricians
and Gynecologists (ACOG) to the House of Delegates
of the American Medical Association’s (AMA)
annual meeting in June 2008. American College of
Obstetricians and Gynecologists’s resolution #205
was adopted by the AMA and is titled ‘‘Home
Deliveries.’’ So that I cannot be accused of misquoting
the AMA or ACOG, you will ¢nd the text
of the adopted resolution at the end of this editorial.
In his ‘‘College News’’ column of ACOGToday (September
2008), ACOG Executive Vice President
Ralph W. Hale reported on his attendance at the
AMA Annual Meeting and wrote, ‘‘Also, there
was model legislation related to home deliveries
supporting the ACOG position against home
births.’’ The point of this resolution is to lobby
against home birth as an option for women and
against providers of home birth services. This type
of resolution by ‘‘authoritative’’ bodies such as
ACOG and AMA will certainly in£uence decisions
made by third-party payers when women request
home birth services and by liability insurance carriers
when providers seek coverage for home birth
services.
Rumor has it, as stated in the Los Angeles Times
on July 9, 2008, that in the original ACOG
resolution, there was another ‘‘whereas’’ that was
deleted before adoption. It read, ‘‘Whereas, there
has been much attention in the media by celebrities
having home deliveries, with recent ‘Today
Show’ headings such as ‘Ricki Lake takes on baby
birthing industry.’’’ You may not be aware that in
2007 producer Ricki Lake and director Abby Epstein
released a documentary ¢lmThe Business of Being
Born. The ¢lm asked the question ‘‘Should most
births be viewed as a natural life process, or should
every delivery be treated as a potentially catastrophic
medical emergency?’’ If you have not seen
this ¢lm, I encourage you to do so and to view it with
an openmind, an open intellect, and an open heart.
The DVD can be purchased for a modest price at
http://www.thebusinessofbeingborn.com/
Evidently, ACOG felt it necessary to highlight
Ms. Lake’s coverage of this issue as a potential
threat to the safety of mothers and babies. It is
beyond the scope of an editorial to review the international
and national data about maternal
and infant outcomes and the relationship of these
outcomes to location of birth. However, one instructive
example is a prospective cohort study
of maternal and infant outcomes in British Columbia
during the ¢rst 2 years after women were
given the choice to plan a home birth with regulated
midwives (Janssen et al., 2002). After controlling
for appropriate confounding variables, the data
showed no increased maternal or neonatal risk
for the 862 planned home births compared
with 1,314 planned hospital births.The overall transfer
rate to hospital care was 21.7% in the home
birth group with 16.5% transferred during labor.
The multivariate analysis showed that the
women who planned to have home births were
signi¢cantly less likely to undergo induced or
augmented labor, epidural analgesia, episiotomy,
or cesarean delivery.
I was born in the United States and I am very proud
to be an American, but I am embarrassed that our
country founded on the ideals of individual liberty
and freedom, can also support ‘‘authoritative’’ initiatives
such as these by the ACOG and AMA,
initiatives that are founded on neither science nor
an understanding of the physiologic and psychosocial
needs of mothers and babies. What is most
risky about home birth in the United States is that
for most women who desire it there is a scarcity of
quali¢ed providers of home birth services. There is
no system of care that provides the needed
safety net if transfer to a di¡erent type of care is required
during labor. Rather, women who desire to
birth at home sometimes chose providers unwisely,
and those who require transfer are often treated
with disdain and disregard as though their decision
to give birth outside the hospital system is irresponsible,
reckless, and perhaps immoral. There is
nothing more inhumane or uninformed than this attitude
toward women who desire to birth at home

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and the quali¢ed providers who are willing to attend
them.
When will we remember that pregnancy, childbirth,
and lactation are normal healthy physiological processes
that are a continuum and do not require
medical intervention unless there is a medical problem?
A woman’s body and the physiology of
pregnancy, labor, birth, and lactation are designed
to promote the well-being of the fetus and newborn.
When will we establish optimal outcomes as the
goal of health care during the childbearing cycle,
rather than attempting to reduce by small increments
the incidence of morbidity and mortality that
is compounded by the very interventions we use to
attempt to avoid such problems? We all know that
in our current health care milieu for childbearing
women, the protection of normal is not valued or
supported, except in a very few locales. Those who
support normalcy are usually swimming upstream
against a system that treats every laboring woman
as a surgical case. The idea that a normal spontaneous
birth is by design the best outcome for a
healthy woman and her infant is neither believed
nor entertained as a basic concept. Most U.S.-
trained physicians and sadly most U.S.-trained
nurses have minimal experience with normal labor
and birth.Without fetal monitors, intravenous lines,
infusion pumps, epidurals, pitocin, endless charting,
and rules theses individuals are helpless and
unskilled to provide the kind of informed human
support and wise guidance that a laboring woman
needs while the normal process of labor and birth
unfolds.
In fact, knowledgeable women often must ¢ght to
defend the normalcy of the process and their desire
to labor and birth spontaneously without medical
technology or intervention. In many ways it is reminiscent
of the 1960s when many of us who were
young women at the time fought for our right to natural
childbirth without general anesthesia and to
have our husbands accompany us into the delivery
room. Breastfeeding was not the norm and was not
supported by hospital care. During my 5-day postpartum
stay after a vaginal delivery in 1969, I had to
repeatedly insist that my newborn son be brought
to me during the night for breastfeeding because
as I was told by the nurses, ‘‘Dr. X’s patients are to
sleep at night.’’ How audacious authority can be.
Amazingly, a few years later a headline in the science
section of the Chicago Tribune declared,
‘‘Science ¢nds Breast is Best.’’ Since that time the
accumulation of scienti¢c evidence has overwhelmingly
validated that physiologically obvious
statement, and the system, including its ‘‘authorities,’’
¢nally caught up to actively support
breastfeeding.Will it take a similar declaration: ‘‘Science
¢nds spontaneous labor and normal vaginal
birth is best’’ to change the course that we are currently
on and to change the rhetoric of the
authorities?
Why do 1% to 2% of U.S. women even want
to birth at home? For most it is simply because
they sincerely believe that the process is normal
and healthy and does not require the environment
of an ‘‘illness’’ system to support it. For these
women, birth has a unique, earthy, and frequently
spiritual component that they want to experience
fully under their own terms. They want to
actively labor and birth, rather than to have labor
happen to them, give over control to a system
and people with their own rules, and be delivered
of their babies. Some desire home birth because of
the subculture of their religious communities,
while others are overtly afraid of what may happen
to them in the hospital. They may be ‘‘on the
edge’’ of the allopathic medical system and be very
resistant to interventions that the system thinks
are in their best interest. Does this make them
wrong? No, it simply means that the system is not
meeting their needs for holistic care that supports
normalcy.
The point is that we have no system of maternity
care in the United States that provides a healthy woman
the choice of giving birth at home and if she
needs to transfer to a di¡erent type of care during
labor, the transfer is easy.We do not have a system
in which this woman is treated with respect
and kindness, and her provider either maintains responsibility
for her care or professionally and
respectfully is able to transfer responsibility to another
provider. Interestingly, while ACOG and AMA
have declared that hospital grounds are the only
safe place to give birth in the United States, the
National Perinatal Association (NPA) adopted a
position paper in July 2008 titled, ‘‘Choice of Birth
Setting.’’ The paper supports a woman’s right to
home birth services and concludes that, ‘‘The National
Perinatal Association (NPA) believes that
planned home birth should be attended by a quali-
¢ed practitioner within a system that provides a
smooth and rapid transition to hospital if necessary.
Safety for all births must be evaluated through an
objective risk assessment, especially for non-hospital
births. NPA supports and respects families’
right to an informed choice of their birth setting’’
(available at http://nationalperinatal.org/). Further,
in Canada following the model of British Columbia,
2 JOGNN, 38, 1-3; 2009. DOI: 10.1111/j.1552-6909.2008.00300.x http://jognn.awhonn.org
E D I T O R I A L Editorial
the province of Alberta has recently expanded its
health care system to include women’s access to
midwifery services ‘‘in a variety of locations including
hospitals, community birthing centers, or in their
homes’’ (http://www.health.alberta.ca/regions/mid
wifery.html).
Some of you who are reading this know me personally,
most do not. I am a nurse-midwife committed
to the midwifery philosophy of care, however, I have
never attended a home birth. I gave birth to my
own children in hospital, and my daughter is a
board certi¢ed obstetrician-gynecologist. I am part
of the U.S. system.Yet the very core of my being, my
scienti¢cally trained brain, and four decades experience
in the business of mothers and babies tell me
it is our system that is not serving mothers and babies
well. There is not some inherent danger lurking
for healthy American women who desire to give
birth at home. The primary danger is that the ‘‘system’’
does not support this choice. To pretend that
a normal healthy woman cannot give birth safely
without the trappings of a U.S. hospital is not only
audacious but also uninformed. Perhaps it is time
for a new woman’s movement, one that embraces
the normalcy of childbirth and puts mothers and
babies back on the center stage rather than the
system’s need to defend the interventionist subculture
it has developed and that it must ¢nancially
support. This system has not improved outcomes
for mothers or babies while the cost of care has
continued to escalate keeping pace with unnecessary
intervention. The recent initiatives of our
medical colleagues, the ‘‘authorities,’’ simply highlight
the painful reality that the ‘‘Emperor has no
clothes!’’
205. HOME DELIVERIES
Introduced by American College of Obstetricians and Gynecologists
HOUSE ACTION: ADOPTED AS FOLLOWS
RESOLVED,That our American Medical Association support
the recent American College of Obstetricians and
Gynecologists (ACOG) statement that ‘‘the safest setting
for labor delivery, and the immediate postpartum period
is in the hospital, or a birthing center within a hospital
complex, that meets standards jointly outlined by the
American Academy of Pediatrics (AAP) and ACOG,The
Joint Commission or the American Association of Birth
Centers’’; and be it further
RESOLVED,That our AMA support state legislation that
helps ensure safe deliveries and healthy babies by
acknowledging that the safest setting for labor, delivery,
and the immediate postpartum period is in the hospital
or a birthing center within a hospital complex, that
meets standards jointly outlined by the AAP and ACOG,
or in a freestanding birthing center that meets the standards
of the Accreditation Association for Ambulatory
Health Care,The Joint Commission, or the American
Association of Birth Centers.
REFERENCES
American Medical Association (AMA). (2008). Resolutions. Retrieved
November 1, 2008, from http://www.ama-assn.org/ama1/pub/up
load/mm/38/a08resolutions.pdf
Block, J. (2008, July 9). Big medicine’s blowback on home births. Los
Angeles Times. Retrieved October 29, 2008, from http://www.la
times.com/news/opinion/commentary/la-oe-block9-2008
jul09,0,3357453.story
Hale, R. A. (2008, September). ACOG’s positions advocated at AMA meeting.
ACOG Today, p. 2.
Janssen, P. A., Lee, S. K., Ryan, E. M., Etches, D. J., Farqukarson, D. F., Peacock,
D., et al. (2002). Outcomes of planned home births versus
planned hospital birth after regulation of midwifery in British Columbia.
Canadian Medical Association Journal, 166, 315-323.
National Perinatal Association (NPA). (2008). Position paper: Choice of
birth setting. Retrieved October 16, 2008, from http://nationalperi
natal.org/
JOGNN 2009; Vol. 38, Issue 1 3
Nancy K. Lowe E D I T O R I A L