Although the American College of Obstetricians and Gynecologists (ACOG) reiterated its opposition to home birth in early 2008, its stance on the matter has not shifted since 1979.50 In a news release describing that position, ACOG acknowledged “a woman’s right to make informed decisions regarding her delivery and to have a choice in choosing her health-care provider,” but made it clear that ACOG “does not support programs that advocate for, or individuals who provide, home births.”3
It emphasized its opposition pointedly, saying: “Choosing to deliver a baby at home…is to place the process of giving birth over the goal of having a healthy baby.”3
AMA resolution includes the reasoning behind the opposition
The American Medical Association (AMA) listed several variables that underscore the need for a clear-cut policy on home birth:
- the fact that 21 states “currently license midwives to attend home births, all using the certified professional midwife credential (CPM or ‘lay’ midwives), not the certified midwives (CM) credential which both the American College of Obstetricians and Gynecologists and American College of Nurse Midwives recognize”
- considerable media attention to celebrities who have given birth at home
- the fact that “an apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia, or other obstetric emergencies.”1
Both ACOG and the AMA consider the following to fall within the category of “hospital”:
- a birthing center situated “within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics and ACOG”
- “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.”3
Another variable overlooked in most studies is the speed of transfer and the outcomes of pregnancies in which the women intended to deliver at home but ended up requiring urgent transfer. One study that did examine this scenario found that “women who had booked for a home birth, but later needed to transfer their care for a hospital birth, appeared to have the highest risk of intrapartum-related perinatal mortality.”24
There is also some controversy regarding the delivery of women who are pregnant with twins, who have a fetus in breech presentation, or who have a history of cesarean delivery. One study examined outcomes for intended home delivery of 57 women who had a prior abdominal delivery.25 Fifty of these women delivered vaginally in the home, and seven (12.3%) delivered in the hospital. One hospital transfer was urgent for fetal distress. One baby was stillborn, delivered at home.
Many policy makers decry the high prevalence of cesarean delivery in the United States and argue that providers who don’t perform this procedure offer a low-cost alternative for obstetric care.36 Some proponents of elective primary cesarean argue that it protects the perineum, but this issue is largely absent from the debate on home birth. Nor have I seen any study that addresses long-term outcomes in women who deliver at home, as most data collection ends after the delivery.
This oversight concerns me when I see interviews of midwives who doubt the existence of fetopelvic disproportion, who make statements such as, “You can get a baby through a knothole” and “I’ve never seen [a pelvis] that isn’t large enough.”37
If patients are encouraged to have a prolonged second stage of labor, does it have a harmful effect on their pelvic floor in later years? This important question merits further discussion.—ERIN E. TRACY, MD, MPH
EDITOR’S NOTE: See the related item, “ Award-winning video urges women to avoid cesarean delivery.”
A 10-year prospective study of vaginal birth after cesarean (VBAC) in birth centers found that more than 50% of uterine ruptures and 57% of perinatal deaths involved the 10% of women who had more than one prior cesarean delivery or who had reached a gestational age of more than 42 weeks.26
Skill of the caregiver is important
The training and qualifications of the obstetric care provider are incredibly important. One study evaluated 4,361 home births attended by “apprentice-trained midwives from 1970 to 1985 and 4,107 home births attended by family physicians from 1969 to 1981.”27 The perinatal mortality rate for the midwife-attended births was 14 for every 1,000 births, in contrast to the rate of 5 for every 1,000 physician-attended births.
Three types of midwife are credentialed in this country: