Home Birth in the United States: Action and Reaction

Abstract

Less than 2 percent of babies are born at home in the United States. So, why do home births continue to raise such a red flag for medical organizations? Why do they continue to spend such energy and resources on opposition efforts? Most recently the American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association (AMA) joined forces in a sharp new offensive. Following ACOG’s statement reiterating its long-standing position against home births in 2007 (1), the organization introduced a resolution before the AMA House of Delegates in June 2008, asking them to join in and support development of legislation in opposition to home birth. The AMA statement resolves “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 post-partum period is in the hospital or a birthing center within a hospital complex….or freestanding birth center” that meets specific professional organization standards. The resolution, which also called for regulatory oversight of midwifery practice and licensing of midwives, provided no science-based evidence in support of its anti-home birth or anti-midwife stance. In addition, strangely, the AMA’s original resolution on home birth specifically singled out former television host Ricki Lake and her recent popular film, “The Business of Being Born,” which features home birth, including her own. Although the statement about Ms. Lake was later removed from the amended version of the resolution, it hit the headlines and caused an outcry from women’s and childbirth advocacy groups. “It’s scary that both (the ACOG and AMA) have sort of targeted me,” said Ricki Lake. “I’m all about choice. This is not unlike the abortion issue. I am pro-choice when it comes to childbirth and choices in birth. Home birth was around long before hospitals were taking over and I just think women need to know (the information) so that they can make the best choice for them”(2). Why do professional medical groups in the United States feel that they have to regulate and legislate on this issue of the mother’s choice about where to give birth to her baby and which professional should attend? Most other countries don’t. They recognize a woman’s autonomy and right to make choices about her birth setting and birth attendant. For example, the Society of Obstetricians and Gynaecologists of Canada (SOGC) does not take a position for or against home births, but sensibly states “The SOGC recognizes and stresses the importance of choice for women and their families in the birthing process. The SOGC recognizes that women will continue to choose the setting in which they will give birth. All women should receive information about the risks and benefits of their chosen place for giving birth…”(3) That’s the key….all women should be informed about the risks and benefits of their chosen place of birth. Members of the Maternity Care Discussion Group (MCDG, an online Canadian listserve group of health professionals and advocates) have weighed in on the current fray. Dr. Michael Klein, a pediatrician and family physician in Vancouver, British Columbia, says, “In any case, why should one professional organization have a position on the activities of another? I wonder how medical organizations would feel if organized midwifery had an official position on the practices of medical organizations” (M. Klein, MCDG Listserve, June 19, 2008). Dr. Andrew Kotaska, an obstetrician in Yellowknife, Northwest Territories, wrote a pungent comment (A. Kotaska, MCDG Listserve, June 18, 2008): I would invite ACOG to join the rest of us in the 21st century. Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficence, whether such recommendations are founded on sound scientific evidence or the prehistoric musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not “offering” VBAC, vaginal breech birth, or home birth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, randomized controlled trial. Science supports home birth as a reasonably safe option. Even if it didn’t, it still would be a woman’s choice. ACOG and the AMA are, by nature, conservative organizations; and they are entitled to their opinion about the safety of birth at home. As scientific evidence supporting its safety mounts, however (to which British Columbia’s prospective data is a compelling addition), they will be forced to accede or get left behind. The concerning part of this proposed AMA resolution is the support of “legislation.” If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of home birth, then their actions are a frontal assault on women’s autonomy and patient-centered care. Hopefully the public and lawmakers realize the primacy of informed choice enough to justify (list member’s) Deborah Simone’s words: “We don’t need to be angry or even react to these overtly hostile actions from the medical community. We just need to keep doing what we do best; the proof is always in the pudding.” It is sad to see the obstetrical community still trying to earn itself a wooden club as well as the wooden spoon; if the resolution passes, it is sad to see the politico-medical community helping them. A recently established group, The Big Push for Midwives Campaign, has issued a strong statement about the controversy (4). It is a nationally coordinated campaign organized to advocate for regulation and licensure of certified professional midwives in all 50 states, the District of Columbia, and Puerto Rico and for the autonomous practice of both certified professional midwives and certified nurse-midwives, and to resist the AMA’s attempts to deny American families access to safe and legal midwifery care. Steff Hedenkamp, Communications Coordinator, is quoted as follows (4): Maternity care is a multi-billion dollar industry in the United States, so it’s no surprise to see the AMA join the American College of Obstetricians and Gynecologists in its ongoing fight to corner the market and ensure that the only midwives able to practice legally are hospital-based midwives forced to practice under physician control. I will say, though, that I’m shocked to learn that the AMA is taking this turf battle to the next level by setting the stage for outlawing home birth itself—a direct attack on those families who choose home birth, who could be subject to criminal prosecution if the AMA has its way. Other organizations also disagree with the ACOG and AMA, and emphatically support the availability of home birth as a choice for women and families. They include, in the United States, the American College of Nurse-Midwives (ACNM), American Public Health Association, Midwives of North America, Citizens for Midwifery, Coalition for Improving Maternity Services, Our Bodies Ourselves, and many other national and state advocacy groups. The ACNM has issued a letter of opposition with multiple supporting documents to the AMA, stating that “We strongly oppose efforts to legislate site-of-birth choices for women and their families,” and “strongly reject(s) Resolution 204’s call for greater physician and regulatory oversight of midwifery practice”(5). Individual physicians, such as Philadelphia obstetrician and ACOG member Lauren Plante, also express support for home birth, pointing out it “remains a viable option in several developed nations where birth outcomes for both mothers and babies are excellent” (Plante L. Letter to ACOG re its statement on home birth, March 19, 2008). Great Britain is one of those nations, where the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have recently taken a firm stand and issued a lengthy joint statement, citing 43 references, in support of home births (6). The latest actions taken by the ACOG and AMA, however, go further than simply defensive saber rattling. It is true that currently “There is no law in any state that requires a woman to give birth in a hospital,” according to leading authority on legal rights George Annas (7, p 185). But the concern voiced by Susan Jenkins, legal counsel to the Big Push for Midwives 2008 Campaign, and others is that the AMA resolution calls for enacting some type of legislative prohibition of home birth at the state or federal level, of penalties, or of a law restricting a woman’s right to decide where she wants to give birth. “It’s unclear what penalties the AMA will seek to impose on women who choose to give birth at home, either for religious, cultural or financial reasons—or just because they didn’t make it to the hospital in time,” said Susan Jenkins. “What we do know, however, is that any state that enacts such a law will immediately find itself in court, since a law dictating where a woman must give birth would be a clear violation of fundamental rights to privacy and other freedoms currently protected by the U.S. Constitution”(4). As I asked earlier, why do medical organization spend so much energy and resources on opposing home birth in the U.S. …especially when other maternity-related health problems in that nation need much more attention and improvement? Preterm and low-birthweight rates have been climbing for decades, unnecessary cesarean deliveries in healthy women are soaring, ethnic and racial disparities in care and outcomes are disturbing, women wanting a vaginal birth after a previous cesarean are denied it, maternal mortality rates are increasing, and other issues of quality and safety in facilities and services raise serious concerns. In the wake of the current efforts to outlaw home birth and regulate midwifery practice, I hope that the ACOG and AMA reexamine their priorities and use their resources and expertise to work on more relevant and pressing maternity matters.