September 2, 2009

ACOG’s Home Birth Survey

Earlier this week, the American College of Obstetricians and Gynecologists posted a survey, Complications Related to Home Delivery, at its website. The survey, designed for OB/GYNs, has raised the hackles of home birth and midwifery advocates, who question the intent of the survey and limitations inherent in the design.

In the introduction to the survey, ACOG explains:

The American College of Obstetricians and Gynecologists is concerned that recent increases in elective home delivery will result in an increased complication and morbidity rate. Recent reports to the office indicate our members are being called in to handle these emergencies and in some instances have been named in legal proceedings. To attempt to determine the extent of the problem, a registry of these cases will be maintained at ACOG on a year-by-year basis.

The intro language strongly suggests that the organization is looking for bad examples (an “increased complication and morbidity rate”) to use in defending its stance against home birth. While OB/GYNs were asked to complete the survey “even if there was no adverse outcome,”  I wonder how many would bother to fill out the form when the stated purpose is to “determine the extent of the problem.”

In addition, I have concerns about the type of information collected by the survey. The survey was initially viewable and completable by the public – a cached version is available, and makes apparent that it included no identifying data that could be used to follow-up with the person reporting the cases or to confirm that the person completing the survey is actually an OB/GYN. There was (and is) no way to confirm or examine the details of any case, unlike real registries of patient data and outcomes.

The survey is still available, but is now behind password protection to limit it to ACOG members. Of course, even behind password protection, this is not a random sample of OB/GYNs capable of determining how often these providers encounter home birth transfers – it now excludes OB/GYNs who are not members, and would include information only from those providers who were motivated enough to respond.

Such a survey can produce anecdotes about provider experiences, but is unlikely to add much to the knowledge base about home birth and transfers in the absence of more comprehensive data collection – it’s simply not a well-executed scientific survey. As a Big Push for Midwives press release [PDF] notes, some suspect that the submitted stories – likely to represent the worst outcomes of home birth – are intended to be used by ACOG “to support its ongoing state and federal lobbying campaigns aimed at denying women access to out-of-hospital maternity care and Certified Professional Midwives.”

In response, home birth advocates – acting via Facebook, blogs, Twitter, and the like – encouraged the submission of positive home birth stories to the site before it was password-protected. Jill at the Unnecesarean provides an example of one of the calls that was going around, which includes the express intent to force the survey into the members-only area of the site.

On a related note, am I the only one who thought of pizza given the repeated “home delivery” language ACOG used? Think that tells us anything about the organizational perspective on birth?


28 Responses to “ACOG’s Home Birth Survey”

  1. Nicole Deggins Says:

    HA! I still remember hearing “Home Delivery is for Pizza” for the first time while watching the Today Show. It was the first time I was enraged/motivated enough to actually go to a television show’s website and write a rebutal. I am very angry about the tactics ACOG is using to undermine women and this “survey” of sorts really seems to be unethical. It will hold no REAL weight as a research study yet we can be sure they will use the responses to formulate policies and create opinon statements that continue to scare women into the “what if” category. In light of the new study released from Canada its even more shameful. They are not even looking at the research yet call themselves a profession medical organization. They are operating more like a Birth Cartel if you ask me.

  2. Amy Tuteur, MD Says:

    The problem is not that ACOG is seeking examples of homebirth disasters; the problem is that there are too many homebirth disasters.

    It is well known that planned homebirth with an American homebirth midwife dramatically increases the risk of neonatal death. According to the Linked Birth Infant Death data collected by the CDC from 2003-2005, homebirth with a direct entry midwife (as opposed to a certified nurse midwife) nearly triples the risk of neonatal death compared to low risk hospital birth. Planned homebirth with an American homebirth midwives has triple the neonatal mortality rate compared to planned homebirth in Canada or the Netherlands.

    The Midwives Alliance of North America, the trade union for homebirth midwives has been collecting safety data as well, encompassing the years 2001-2008. That data has been offered publicly to those who can prove they will use it for the “advancement” of midwifery and who sign a confidentiality agreement legally prohibiting them from sharing the information with anyone else. It does not take a rocket scientist to suspect that MANA is hiding its own safety data because it shows that homebirth with a homebirth midwife increases the risk of neonatal death.

    It is important to understand that American homebirth midwives are grossly undereducated and undertrained. They have far less education and training than certified nurse midwives, Canadian midwives, Dutch midwives, Australian midwives, or any other midwives in the industrialized world. The lack of education and training is reflected in their dismal mortality statistics.

  3. MomTFH Says:

    Surprise, surprise, no one’s favorite home birth basher is here.

    Amy, the limited evidence on direct entry home birth is mixed and mostly favorable. There are plenty of other iatrogenic causes of perinatal morbidity and mortality that you could spend your time on.

  4. Heather Hall Says:

    (hopefully I’m not just preaching to the choir here)

    I’m really unhappy with the negative language used. And I see no mention of Certified Professional Midwives vs. Direct Entry Midwives, although many DEMs are quite qualified and very very experienced in normal birth. I am in the middle of my midwifery training using the CPM model of apprenticeship training. I have witnessed 50 births myself, as well as my own and know many many women who have also birthed at home with a midwife – all three types listed above. Granted my pool of known cases is small, but I have only known of a few questionable cases, and only one death due to negligence. All these cases were peer reviewed and appropriate measures were taken to prevent further problems. The other deaths I know of would not have been resolvable in a hospital setting, based on autopsy review. These cases were also peer reviewed. Midwives do rely on emergency services when medical help is needed, this is what doctors are for, medical help! In the case of normal birth with normal healthy women, there is no need for a medical care provider. In either situation, careful records are kept of prenatal care; often home birth and birth center midwives do much more thorough prenatal care than hospital based care providers due to the importance of catching problems preemptively so they may be resolved or referred to a medical care provider before an emergency occurs. This includes requesting basic labs and prenatal testing for women who choose it, nutritional education, measurements, palpation of the uterus, and normal birth education. Almost all of the births I have attended went beautifully and the mothers and babies had uneventful post partum experiences. All had thorough newborn exams and successful breastfeeding. A few needed some extra breastfeeding support. In about 10 cases women needed to transport at some point during their labor, birth or immediately after. These are where the real horror stories begin. Again and again, I have heard of women being abused when seeking medical assistance. I am one of these women. I had a hematoma along a minor tear after the birth of my daughter. I went to the hospital and my pulse was tachycardic when I got there, although it had been fine when we decided to go to the hospital. The triage nurse was wonderful. She copied all my records from my midwife and asked her some questions before they were able to take me back to a room. On the way there, a doctor wanted to check my pulse again. He had on latex gloves, which were not fresh to my case. My mother, my midwife, and the nurse were all screaming at him not to touch me with latex. He waved them off and took my pulse. My arm immediately swelled to twice the size. They took me to the room, put in an IV. We had to wait 45 minutes for a cart of non latex supplies to arrive. In the meantime, my mother and midwife were forced into the waiting room, so I was alone without any advocate or support. I was given demerol and pitocin without any notice or consent. Demerol doesn’t work with my body and I would have told them that if they would simply have told me they wanted to give me pain medication. Instead, I found myself unable to communicate and still in great pain. The OB/GYN who came to the ER insisted on mashing the heck out of my uterus despite being informed I had lost less than 2 cups of blood for my entire birth and post partum period, and I immediately involuted at a normal rate once I delivered my placenta naturally at about 25 minutes, as well as nursing twice successfully which produces natural oxytocin in the body. I would have refused this ‘treatment’ if I had an effective voice. Instead I was repeatedly harassed with questions about my birth and my baby, who was home with her dad and grandmother, quite safe and healthy. When they finally got around to inspecting my injuries, I had lost my voice screaming ‘I’m here for my vagina not my uterus’ incoherently. I was taken to the OR and repaired, and released 9 hours later with no care or acknowledgment of my latex reaction, my lack of consent informed or otherwise, or the horrible treatment at the hands of the doctor. My vagina isn’t even well repaired, I have ruggae hanging out one side. The tear was a minor simple second degree that would have healed fine at home if not for the hematoma. I might be more satisfied if I had been treated like any other emergency patient – with a shred of dignity and respect.
    The previous poster calls to Europe for examples of good birth outcomes at home, they have a totally different arrangement of care. If only our medical providers would work in concert with our home birth midwives, they would see the good care we offer, and be less frantic when a transport needs to occur because they would have had the opportunity to meet the mother and review her case. People would be less hesitant to transport because the horror stories would be far fewer. It’s a win win situation, why is it such a turmoil for this to happen?

  5. Rachel Says:

    Speaking for myself only, I’ve never been a fan of the “but somebody else is doing it, too” defense. Whatever MANA is or isn’t doing with its data (a separate issue) does not negate the concerns of those who believe ACOG will use its collected stories to lobby against women’s home birth, midwifery, etc. choices, nor does it negate criticisms of ACOG’s methods. I somehow doubt that the organization plans to use its “problem” stories to advocate for better/more training for the non-CNM midwives who currently attend home births at the request of women, or for bureaucratic/insurance changes that would make it easier for other types of providers (for those who raise an education/training concern about CPMs, which is a separate debate) to attend those home births.

  6. Amy Tuteur, MD Says:

    Rachel,

    Isn’t the issue whether homebirth is safe?

    The fact is that planned homebirth with an American direct entry midwife is the most dangerous form of planned birth in the US. The neonatal mortality rate is triple that of low risk birth in the hospital, and triple that of homebirth in Canada and the Netherlands.

    It is strange to focus on what ACOG is or is not doing to highlight the problem and ignore the problem itself.

    Aren’t American women entitled to know about the dangers of homebirth with a direct entry midwife?

  7. Rachel Says:

    I simply wasn’t coming at it from the perspective (and maybe this is just me) that critiquing ACOG’s approach and noting people’s concerns about it says anything about the overall safety of home birth or what women are entitled to know – although neither was the subject of this specific post, folks are free to debate those matters and any other of the multiple separate issues raised.

  8. Jen Says:

    “The problem is not that ACOG is seeking examples of homebirth disasters; the problem is that there are too many homebirth disasters.”

    If it’s so well-documented, why bother seeking anecdotes? Do they know Amy Tuteur has it all figured out? Why don’t they just talk to Amy Tuteur?

    That comment is spam. See it here on the Huffington Post. http://bit.ly/W5wPK

    “Isn’t the issue whether homebirth is safe?”

    Did you read the post, Amy? That wasn’t the point, but it was a nice segue into your spam.

  9. Wendy CPM Says:

    I find it particularly hypocritical of ACOG to claim in their Statement on Home Births that “studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous,” and then throw up a completely anonymous, unverifiable, highly-biased questionnaire on their website for use in collecting anecdotes. Astonishing.

    And Dr. Amy, for you to defend ACOG flies in the face of everything you claim to be in terms of “teaching” your followers how to critically evaluate research. Your duplicity is showing…

  10. Amy Tuteur, MD Says:

    “I find it particularly hypocritical of ACOG to claim in their Statement on Home Births that “studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous,” and then throw up a completely anonymous, unverifiable, highly-biased questionnaire on their website for use in collecting anecdotes. Astonishing.”

    Really? And how hypocritical do you find it that MANA (the Midwives Alliance of North America) has collected safety data from 2001-2008, has offered it publicly to people who will use it for the “advancement” of midwifery and hides it from the general public?

    MANA’s own data almost certainly shows that homebirth with a CPM increases the risk of neonatal death and they are struggling mightily to prevent the public from finding out the truth. That’s not merely hypocritical; that’s unethical.

    What’s the difference between MANA withholding their safety data and Big Pharma withholding safety data on new drugs? Not much. In both cases a special interest group is trying to hide the truth from the public in order to make more money for themselves.

  11. MomTFH Says:

    Big Pharma’s drug research is usually a scientific study registered with and approved by the FDA. If it is done on a drug that is available in the population and reflects on its effectiveness or risks and contradicts earlier research, there is a definite ethical pressure to release these results.

    MANA is collecting information on the practice it is an advocacy group for, from members it has a good relationship with for its own purposes, which in normal and ethically valid, as long as they don’t try to use extend the validity to homebirth in general, since it is not a scientific collection.

    It is unethical for someone who doesn’t even have access to this unscientifically collected information to make conjectures about it, and try to use it to spam every post on the internet that mentions homebirth, regardless of the original intent of the post. Especially someone who loves to put the MD after her name as if she is an expert on evidence based medicine.

    ACOG said it was planning on using to “determine the extent of the problem”. Not only was their technique of soliciting stories on the internet from ob/gyns unscientific, but there is inherent bias in their call for submissions.

    Science fail.

  12. Elizabeth Says:

    I’ve only attended one homebirth so far this year as a doula. Everything went well. Mom and baby are doing great!
    The family is very happy they chose to give birth at home.
    It is interesting that ACOG will not review the current research on homebirth. We all know their methods of gathering and reviewing data is flawed.
    Also interesting that they use the term ‘elective homebirth’. Homebirth, in which they are so much against is no where near as risky as elective cesarean yet the cesareans benefit the members of ACOG and that is an acceptable risk for them.

  13. Amy Tuteur, MD Says:

    “MANA is collecting information on the practice it is an advocacy group for … for its own purposes, which in normal and ethically valid, as long as they don’t try to use extend the validity to homebirth in general, since it is not a scientific collection.”

    That’s not what MANA says. According to the NARM (North American Registry of Midwives) Summer 2006 Bulletin:

    “The data made available from the Midwives Alliance Statistics Project can be very useful for lobbying or regulatory purposes. It puts the control of the data in the hands of the midwives. Having state level data can be useful when trying to get a bill passed, but it can also be useful to show that midwives are involved in self-assessment and accountability. In other words, it shows your numbers but also that you are on top of things and will be in the future. It is much stronger than just a flash of numbers at bill-passing time, and might boost your chances of avoiding your regulatory board feeling the need to monitor you in some other way …”

    So MANA intends that the data be used specifically to show that homebirth is safe, and to prevent states from instituting regulatory measures, yet the public cannot see the data. That’s unethical.

  14. Jen Says:

    “…a special interest group is trying to hide the truth from the public in order to make more money for themselves.”

    AMY WINS! She brings it full circle by describing ACOG and summarizing the point of the post.

    Great job!

    See, when you know ACOG’s goal and that’s your context, you will assume that every other organization operates as such. MANA is all about the big bucks, you know. That “natural birth industry” is all about the revenue, monopolizing and annihilating any competition and– oh wait, that’s ACOG.

  15. Jen Says:

    And seriously, if Amy has it all figured out and analyzed, why is no one hailing her as a hero or listening to her? Wouldn’t ACOG be loving her one-woman crusade to prove her personal, emotion-based bias that all American home birth midwives are idiots and quacks?

  16. MomTFH Says:

    Whether or not that is unethical, which I disagree with you strongly about, is irrelevant. By those standards, ACOG’s information is even MORE unethical. They are not even gathering information on their own practitioners, but on transfers from other practitioners, with a definite bias in the collection by announcing they are anticipating negative accounts.

    This is not a professional organization gathering information from its own members about their own practices to be more infomed on their own area of advocacy, which I would think was incredibly common. This is a professional organization gathering information unscientifically about ANOTHER group that they have a position statement against already, and want to shut down. If ACOG was collecting info from its own members on how their own patients’ deliveries were going for its own advocacy, I don’t think anyone would be complaining.

    Unless she has an axe to grind.

    As you most clearly do.

  17. Sabbath Davies Says:

    I’m sorry, Amy can you explain to me the flaws you see in, say, the latest research proving homebirth’s safety? The one released by the CMAJ? What issues do you have with that study? (It didn’t go unnoticed to me that you specifically said American midwives, and not just midwives, so I am assuming that your party line has changed with the release of this study).

  18. maryann Says:

    Amy Tuteur, MD Says: homebirth with an American direct entry midwife is the most dangerous form of planned birth in the US.

    WRONG!
    planned repeat cesareans are the most dangerous form of planned birth in the US.
    If you really want to have an effect on infant mortality why waste your time looking at planned home birth. (pay no attention to the man behind the curtain) The fact is, the US is behind almost every other industrialized nation in infant mortality. This is in an industry that OBs have had an unprecedented monopoly and control over. And are desperately trying to side step responsibility for.I know if your motives were infant health you would be looking at the 98% of births taking place in hospitals that got us those shameful statistics.

  19. MomTFH Says:

    Oh, and Rachel, that is an excellent point about the terminology being used. They are subtly referring to the joke t shirts that were going around that said “Home delivery is for pizzas” or something along those lines I heard about. It is similar to how people who are opposed to the current health care reform call it “ObamaCare” in order to link it to negative feelings about Obama in general (who is not drafting the legislation), instead of evaluating it on its own merits.

  20. Amy Tuteur, MD Says:

    “can you explain to me the flaws you see in, say, the latest research proving homebirth’s safety? The one released by the CMAJ?”

    Sure. CMAJ has published my letter about the study. You can find it at http://www.cmaj.ca/cgi/eletters/cmaj.081869v1

  21. Amy Tuteur, MD Says:

    “planned repeat cesareans are the most dangerous form of planned birth in the US”

    Not even close. Planned repeat C-sections are extraordinarily safe. Check the scientific evidence.

  22. kori Says:

    Amy, I’d like to know your numbers for neonatal morbidity at home being “three times” as high as neonatal morbidity in the hospital for low-risk pregnancies. Is the difference *clinically* significant? For example, maternal morbidity from elective repeat c/s is twice as high as that from vaginal birth. 0.2% is twice as much as 0.1%. Those numbers are pretty darn small, but if I told someone their risk of dying was 200% greater with elective repeat cesarean, I’d be taking advantage of numbers to scare people in an unethical manner.

  23. Sabbath Davies Says:

    Okay. So, if information was released regarding the 7 documented deaths, and it was within your realm of reason, would you still have issue with the study?

    It has many things addressed that were raised with other studies –

    The same cohort of midwives that delivered in the hospital delivered those in the home setting, which by the way are Registered Midwives, and not just any lay or direct entry midwife. (I personally would like to see CPM’s in this country required to hold licensure for public safety, but still feel that they are the correct care provider for low-risk family’s that have determined that they would like an out of hospital birth.)

    It included only those women’s births who would have qualified for a homebirth if they choose based on the guidlines set forth by BC’s standards. (Which include VBAC’s at home, but not breech delivery or those augmented with pitocin, to name a few things).

    I guess, in as gently as a way I can say it as possible, what will be enough? I mean what amount/kind of evidence will you need to see to determine that homebirth, while it isn’t YOUR choice, is still a safe choice?

    Because really, even if it is slightly more dangerous to birth at home (which I don’t think it is, by the way), this is still about having a choice and an option. It is a dangerous line to walk, deciding what people should and should not do. I believe in licensure for a myriad of reason, namely so that there is a place that the public has an appropriate avenue for recourse, and that we can require midwives to prove a minimum competency. But I will never agree that one setting is right for everyone. That is, I believe, a very large mistake.

  24. Amy Tuteur, MD Says:

    “So, if information was released regarding the 7 documented deaths, and it was within your realm of reason, would you still have issue with the study?”

    That’s a big if; the entire study hinges on the nature of those deaths.

    The lead author for this study is Patricia Janssen. Dr. Janssen published a similar study in 2002. That study was Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia (http://www.cmaj.ca/cgi/content/full/166/3/315). The original conclusion of the study claimed:

    “A comparison of adverse neonatal outcomes did not identify increased risk for babies born at home …”

    Yet 2 babies in the homebirth group died after the onset of labor compared to none in the hospital group and and Dr. Janssen was forced to publicly retract the conclusion that homebirth is safe.

    There is no question that Janssen is determined to publish a study that demonstrates that homebirth is safe. In 2002 she actually ignored the deaths in the homebirth group in order to arrive at the desired conclusions. This is a much better study, but again, the most crucial information is missing. Without it, we don’t really know whether homebirth in BC is as safe as hospital birth.

  25. Jill Says:

    From the aforementioned letter to the CMAJ:

    “Conflict of Interest:
    None declared”

    Seriously? None to declare?

    There was an interesting question above. If you’ve really got it all wrapped up in bag, why aren’t your analyses and recommendations being widely hailed by professional organizations and cited by fellow physicians? Or maybe they are and I just don’t know about it. I’ve always wondered that… you’ve worked so, so hard to get your stats publicized. Are you getting the feedback you want? Do you have any formal research planned for the future?

  26. Wendy CPM Says:

    Dr. Amy said:
    “CMAJ has published my letter about the study. You can find it at ”

    I wonder if you’re embarrassed by your letter, now that you realize that it wasn’t the authors who chose the definition of “perinatal death”, but rather the British Columbia Perinatal Database Registry. Maybe they will let you delete it from that online response system.

  27. HomebirthCNM Says:

    Here’s what I don’t get. Most OBs are miserable (and understandably so, to some degree). They are heavily burdened by enormous malpractice rates and risks, have bad hours, and from my 16 years in and out of ‘the system’ most don’t even like doing normal births one bit. OBs are specialists and should be treated so. God bless them for their OB and GYN surgeries, for high risk / medically complicated mothers, for difficult repairs, for skills like forceps and versions (though those are sadly hard to find these days). WHY do they want to do normal births? Can’t we all just get along? A more European system (where even pregnant OBs would only consider going to an OB if she were high risk) just makes so much more sense for everyone.

    I’m interested, Amy Tuteur, if you will go on record as stating that home birth with a CNM (and an effective transport system, etc) is safe?

  28. Amy Tuteur, MD Says:

    “I’m interested, Amy Tuteur, if you will go on record as stating that home birth with a CNM (and an effective transport system, etc) is safe?”

    That’s not what the data shows.

    Dr. Michael H. Malloy, at the University of Texas Medical Branch in Galveston, compared a range of adverse outcomes among infants by delivery attendant type and site of delivery occurring in the U.S. over a recent 5-year period.

    The present analysis was limited to term (37-to-42 weeks), singleton, vaginal deliveries.

    “However, while there were only 14 neonatal deaths occurring in association with a home-CNMW assisted delivery, the risk of death was more than two-fold higher for CNMW-home deliveries and four-fold higher for deliveries by other midwives versus CNMW-hospital deliveries.

    The prevalence Apgar scores of less than 4 was eight times higher for CNMW-home deliveries than for CNMW-hospital deliveries. What’s more, the risk of neonatal mortality and low Apgar scores was still increased for CNMW-home deliveries versus CNMW-hospital deliveries after adjusting for multiple potential confounders (including maternal age, race, education, parity, presence of one or more medical or labor complications, presence of an anomaly in infant, gestational age, and infant sex).

    “The increased risk of low Apgar scores among infants delivered at home suggests that the causal pathway to the increased risk of neonatal mortality may be through the occurrence of asphyxiating conditions at birth that are not easily handled by the home environment,” Dr. Malloy noted.

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