Jul 17, 2008

AMA and ACOG fight home births

Have you heard the news?? According to ABC news (7/11/2008), the American Medical Association (AMA) recently agreed to support proposed legislation that could make having a planned home birth difficult if not impossible.

The AMA agreed to back resolution 205, in which it agreed with a recent ACOG (American College of Obstetricians and Gynecologists) position that home births are not as safe as hospital births. Both the AMA resolution and the ACOG statement on home births (2/6/2008) have come in response to the publicity surrounding the new film, the Business of Being Born. The fact that ACOG feels threatened by the film's open advocacy of home births---when home births only account for under 1% of all births nationwide in the US (the official figure, actual figures may be closer to 2%)----suggests how paranoid ACOG has become of midwives and their support of home births.

Like many of ACOG's practice guidelines or seemingly innocuous educational reports, their "statement on home births" is a highly politicized document, which bears little relationship with evidence-based medicine. Their attack on Lake and Epstein's film is hardly disguised when they say, "childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause celebre."

As if women are choosing home births because they are trendy.  It may be because home births are now safer than a hospital birth for the first time, given the current trends towards unecessary interventions, many of which are not evidence-based.  

ACOG might also have noted that childbirth decisions should NOT be influenced by legal issues. Indeed, the epidemic of inductions (up to 60%) and cesareans (30%) within low risk hospital births in the US, may be due to obstetric fears of malpractice than concern for maternal or fetal or neonatal well-being.

ACOG might have noted that childbirth decisions should NOT be influenced by economic issues. They might have noted that hospitals are trying to save money when they use electronic fetal monitoring (EFM, now used in over 90% of all hospital births in America) rather than the intermittent auscultation with a hand-held doppler still used in Europe and the developing world that offers improved neonatal and maternal outcomes over EFM in many low risk births. Click here for the NEJM article on electronic fetal pulse oximetery (which was hoped to be an improvement over EFM but the trial was cancelled when it became clear it was no improvement over a technological method already deemed questionable). Interestingly, Michael Greene's scathing rebuke of EFM in the New England Journal of Medicine (vol 355 Nov 23, 2006) that was picked up by news wires around the country during Thanksgiving week that year, is only available to NEJM subscribers, but you can see the abstract here. 
But they ignored the practices prevalent across the US that have contributed to a profound crisis in hospital based obstetrics that the film Business of Being Born so ably unpacks. There are no clear answers to our dilemma, but a fear mongering against the very groups that are trying to improve the birthing outcomes for women is not one.

As for the AMA decision, it is one thing to reject a phenomenon that has been studied, but quite another to reject a phenomenon they have shown almost no interest in. The most recent study of home births in its flagship journal, JAMA, dates to 1980. In other words, for 28 years nobody on the JAMA editorial board has felt the need to address the evidence on home births. Perhaps it is too difficult to study home births or there simply aren't studies out there worth reviewing? Actually there are great studies, but from Canadian or European journals, which DO show an interest in the evidence comparing home and hospital births. One of the more recent and largest studies---from the British Medical Journal (18 June 2005)---found far lower rates of intervention for home births, but comparable intrapartum and neonatal mortality rates (1.7 per 1000) than the average low-risk hospital birth.