November 29, 2006
Douglas W. Laube, MD
President, ACOG
409 12 th Street, SW
Washington, DC 20024-2188
Dear Dr. Laube:
This month, the American College of Obstetricians and Gynecologists (ACOG) released a policy statement to its members strongly opposing out-of-hospital birth. Such a policy has the potential to severely restrict childbearing families’ access to care in out-of-hospital settings, including homes and birth centers. Lamaze International believes that birth can safely take place in hospitals, birth centers and homes1 and points to a growing body of evidence that supports the safety of out-of-hospital birth for low-risk women. Lamaze International also expresses concern about the routine and inappropriate use of interventions without supporting evidence that increasingly typifies hospital-based maternity care in the United States.
ACOG’s assertion that there is a lack of evidence to support the safety of out-of-hospital birth is not based in current research. Early studies that compared home and hospital births had flaws in both method and design that drew the researchers’ conclusions into question. These include combining planned and unplanned home birth and home births with qualified and unqualified attendants, and failing to select appropriate cohorts of hospital births for comparison. The only study comparing home and hospital births that has been published in the last decade in ACOG’s professional journal2 Obstetrics & Gynecology suffers from these and other flaws, rendering the findings invalid.3
More recent studies that are methodologically superior have found no differences in perinatal mortality between home and hospital birth and significantly lower rates of cesarean surgery, instrumental vaginal delivery, episiotomy and other adverse maternal outcomes.4-6 The largest study to date of planned home births in North America 5 found rates of medical interventions in intended home births significantly lower than averages reported in comparable studies in hospital-based births. Studies of care in freestanding birth centers have yielded similar results.7-9
Lamaze International believes that the emphasis in out-of-hospital settings on care practices that support normal, physiologic birth results in these favorable outcomes for low-risk mothers and their infants, as well as high levels of client satisfaction.
Hospitals in the United States are not safe havens for low-risk women. A recent national survey of childbearing women10 supported in part by Lamaze International revealed high rates of interventions in hospitals, including many for which there is a preponderance of evidence of harm, such as episiotomy, elective induction of labor, continuous electronic fetal monitoring, and staff-directed pushing. Only 2% of respondents reported receiving all of the care practices that support normal birth.11
Lamaze International joins with the American College of Obstetricians and Gynecologists (ACOG) in supporting “conditions that will improve the birthing experience for women and their families without compromising safety.” Lamaze International believes that the best way to do this is to provide care practices that are supported by the evidence, such as freedom of movement in labor, access to continuous labor support, and non-separation of mothers and babies after birth, and to avoid the routine use of interventions that put mothers and babies at risk. ACOG is in the unique position to further enhance maternal and fetal safety by endorsing models of collaboration that ensure swift access to hospital care when transfer from the out-of-hospital setting is necessary.
Sincerely,
Jeannette Crenshaw, MSN, RN, IBCLC, LCCE, FACCE
President, Lamaze International
1. Lamaze Philosophy of Birth. Available at http://www.lamaze.org.
2. Pang JW, Heffelfinger JD, Huang GJ, et al. (2002) Outcomes of planned home births in Washington State: 1989-1996. Obstetrics & Gynecology;100(2):253-9.
3. Goer, H. (2005). When Research is Flawed: The Safety of Home Birth. Lamaze Institute for Normal Birth. Available at: http://www.lamaze.org.
4. Janssen PA, Lee SK, Ryan EM, et al. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ;166(3):315-23.
5. Johnson KC, Daviss BA. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ ;330(7505):1416.
6. Olsen O. (1997) Meta-analysis of the safety of home birth. Birth;24(1):4-13; discussion 4-6.
7. Fullerton JT, Severino R. (1992). In-hospital care for low-risk childbirth. Comparison with results from the National Birth Center Study. Journal of Nurse-Midwifery;37(5):331-40.
8. Jackson DJ, Lang JM, Swartz WH, et al. (2003). Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care. American Journal of Public Health;93(6):999-1006.
9. Walsh D, Downe SM. (2004). Outcomes of free-standing, midwife-led birth centers: a structured review. Birth;31(3):222-9.
10. Declercq ER, Sakala C, Corry MP, Applebaum S. (2006). Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection.
11. Lamaze International Education Council (2003). Position paper: protecting, promoting and supporting normal birth. Washington: Lamaze International. Available at http://www.lamaze.org.