Pregnancy & Birth

Choices in Childbirth: A Statement by Physicians, Midwives and Women's Health Advocates who Support Safe Choices in Childbirth

(If you would like to support this statement, you can fill out the form at the bottom of this page.) 

We are physicians, midwives, women’s health advocates, and educators concerned about preserving safe choices in childbirth that respect the diversity of women’s needs. As this country moves forward with various proposals for national health care reform, we urge the following:

1.  That communities preserve the option of vaginal births after cesarean (so-called “VBACs”).

Substantial evidence points to the safety of this choice for most women. The current American College of Obstetricians and Gynecologists (ACOG) recommendation (based only on “expert opinion,” rather than on the best available published evidence) is that VBACs be offered only when an anesthesiologist and surgeon are in the hospital throughout labor, a requirement that is not feasible for most community hospitals. This position has served to eliminate VBAC as an option in many hospitals across the country (where anesthesiologists and surgeons are minutes away even if not “in house”). We urge ACOG to revise this position so that it reflects the best available evidence.

The American Academy of Family Practice recommends "a management plan for uterine rupture and other potential emergencies requiring rapid cesarean section," and the Society of Obstetricians and Gynaecologists of Canada recommends that women give birth in a hospital where a “timely” cesarean section is available. This approach allows mothers and their providers to make a choice regarding a VBAC based on each woman’s specific situation. External constraints on VBACs based on inadequate data have no place in maternity care. It should also be noted that the current ACOG guideline, which says that the standard of care is to counsel nearly all women with a previous cesarean and offer VBAC as a choice, is widely ignored.

2.  That options for hospital-based midwifery care (utilizing Certified Nurse Midwives and Certified Midwives) be made available in all communities across the country.

Every country in the world that has maternity outcomes superior to ours uses midwives for a greater percentage of their births than we do. The track record of hospital-based midwives in the U.S. has been outstanding. Women who have access to such midwifery care evaluate it in the very highest terms, yet many institutions have paid little attention to either establishing or expanding midwifery services. In the past few years, the demand for midwifery services has increased and the proportion of hospital births attended by midwives has also increased in many areas. Government policies that support midwifery education and recognize midwives as a more central element in the perinatal workforce will be essential as we look ahead to establishing an adequate number of well-trained maternity caregivers in this country.   

3.  That Certified Professional Midwives (CPMs) be licensed and regulated in order to make the option of homebirth as safe as possible.

Only a small minority of women (about 0.6%) in the United States chooses homebirth, and this figure has remained fairly constant for 20 years. Evidence from the U.S. and abroad illustrates that with a trained birth attendant and appropriate support this is a safe choice for uncomplicated pregnancies. There are advantages and disadvantages for low-risk women attached to each potential setting for childbirth, whether it is the hospital, free-standing birth center, or home. Women who want to give birth at home or in free-standing birth centers will be best served by a system that offers oversight to the skills and protocols followed by out of hospital caregivers. One means of making the homebirth option safer is to establish licensure for CPMs, whose certification specifically requires skills and experience in out-of-hospital births. In addition, states and third-party insurers that now impose financial or regulatory limitations on Certified Nurse-Midwives or Certified Midwives who wish to practice in either free-standing birth centers or the home setting – or the physicians who collaborate with them – should reverse such policies. Equitable payment by Medicare, Medicaid, and other insurers for services provided by midwives is also essential.

The popular media like to examine childbirth choices. Recently, discussion has been frequently limited to the choice of a medically elective cesarean. This option is often presented in positive terms, sometimes quoting an obstetrician who supports the principle of a woman’s right to choose this procedure to birth her child. Rarely has there been recognition of the principle of a woman’s right to choose a VBAC or out-of-hospital birth. Little is said about the ethics of forcing women to undergo major abdominal surgery when they are not able to find a hospital where they have the opportunity to attempt a VBAC. Liability concerns are often cited as a major reason for diminishing VBAC options, but little is said about the increasing risks of surgical childbirth to a woman, her baby, and her subsequent babies.
 
A number of states now seek to license and regulate Certified Professional Midwives. Almost half of all states currently license or otherwise recognize direct entry midwives in some fashion, and no state has yet reversed its decision to do so. This has apparently alarmed some in the medical profession, as evidenced by the June 18, 2008 resolution of the American Medical Association (written by ACOG), which appears to have the intent of making homebirth illegal. As a result, there has been increasing antagonism between those who support the choice of homebirth and those who do not.

The media attention given to the homebirth controversy often eclipses other, more pressing concerns about obstetric care and outcomes. For example, both preterm and low birthweight births are increasing every year in the U.S., in part because of increases in inductions and pre-scheduled cesarean deliveries. Medical organizations such as the AMA and ACOG should refocus efforts to place greater priority on the preterm and low birthweight problem, especially iatrogenic prematurity caused by inductions and planned cesarean section.

We urge the promotion of public policies that draw from the best available evidence in the maternity care field. Best practices in maternity care are well-described in an excellent new report issued by the Childbirth Connection, the Milbank Memorial Fund, and the Reforming States Group – Evidence-Based Maternity Care: What It Is and What It Can Achieve. Policy makers should also turn to model projects like the extraordinary example of the DC Birth Center in one of the poorest areas of Washington, DC, where prematurity has been halved utilizing the Certified Nurse-Midwife in a coordinated system of care with collaborating obstetrical specialists. (View the recent feature about its founder, Ruth Lubic.) We need to create more choices in childbirth that produce optimal outcomes along with safe and satisfying birthing experiences.

We look forward to a more productive dialogue on these issues. We encourage the American College of Obstetricians and Gynecologists and the American Medical Association to strike those resolutions that deny childbearing women the autonomy and rights that medical professionals, educators, and women’s health advocates have historically endorsed.  We believe, for example, that the joint homebirth statement of the Royal College of Obstetricians and Gynecologists and the Royal College of Midwives offers a more balanced presentation of the issues involved than the resolution recently passed by the AMA (see page 15, resolution 205). Canadian physicians and midwives have issued a similar collaborative document. 

We recognize the central importance of health care reform proposals now under consideration and urge all maternity caregivers to become involved in debates surrounding these proposals. We support efforts to make maternity care safer by reducing the risk of systems errors that can harm patients and lead to litigation. It is time to create a system that allows women all reasonable choices in childbirth and to encourage practices that produce optimal outcomes for both mothers and babies.

SIGNATORIES

Leah Albers, CNM, DrPH, Professor, College of Nursing and Dept. Obstetrics & Gynecology, School of Medicine, University of New Mexico Health Sciences Center (Albuquerque, NM)

Elizabeth Allemann, MD. Medical Director, Columbia Community Birth Center, and Founder, Physicians for Missouri Midwives (Columbia, MO)

Jennifer Block, author and journalist (Brooklyn, NY)

Ida Darragh, CPM, Chair, North American Registry of Midwives (Little Rock, AR)

Eugene Declercq, PhD, Professor of Maternal and Child Health, Boston University School of Public Health (Boston, MA)

Neal F. Devitt, MD, Senior Physician, La Familia Medical Center (Santa Fe, NM)

Cynthia Flynn, CNM, PhD, Associate Professor, College of Nursing, Seattle University, and President, American Association of Birth Centers (Seattle, WA)

Daniel M. Fox, President Emeritus, Milbank Memorial Fund (New York, NY)

Marjorie  Greenfield, MD, Associate Professor, Case Western Reserve University School of Medicine (Cleveland, OH)

Daniel Grossman, MD, FACOG, Senior Associate, Ibis Reproductive Health; and Clinical Instructor, Department of Obstetrics, Gynecology and Reproductive Sciences, UCSF (San Francisco, CA)

Eleanor Hinton Hoytt, President and CEO, Black Women’s Health Imperative (Washington, DC) 

Susan Hodges, President, Citizens for Midwifery (Athens, Georgia)

Tanja Johnson, MSN, ARNP, CNM (Orlando Florida)

Tekoa King CNM, MPH, Associate Professor Dept of Obstetrics, Gynecology, University of California, San Francisco (San Francisco, CA)

Valerie King, MD, MPH, FAAFP, Associate Professor, Department of Family Medicine, Oregon Health & Science University (Portland, OR)

Michael C. Klein, MD, CCFP, FAAP (Neonatal-Perinatal), FCFP, ABFP, Emeritus Professor of Family Practice and Pediatrics, University of British Columbia & BC Children's & Women's Health Centre (Vancouver, Canada)

Mary Lawlor, CPM, LM, MA, President, National Association of Certified Professional Midwives (Putney, VT)

Lawrence Leeman, MD, MPH, Associate Professor Family and Community Medicine,
Associate Professor Obstetrics and Gynecology, University of New Mexico (Albuquerque, NM)

Michael C. Lu, MD, MPH, Associate Professor of Obstetrics, Gynecology and Public Health, UCLA (Los Angeles, CA)

Charles Mahan, MD, FACOG, Professor Emeritus, Department of Community and Family Health, College of Public Health, University of South Florida (Tampa, FL)

Shafia M. Monroe, CM, President, International Center for Traditional Childbearing (ICTC) (Portland, OR)

Sister Angela Murdaugh, CNM, MSN, FACNM  Past President of the American College of Nurse-Midwives and Consortium of Texas Certified Nurse-Midwives (Weslaco, Texas)

Judy Norsigian, Executive Director, Our Bodies Ourselves (Boston, MA)

Kristen Ostrem, CNM, MSN, Chapter Chair, on behalf of the members of the New Mexico Chapter of the American College of Nurse-Midwives (Albuquerque, NM)

Debra Pascali-Bonaro, women’s health advocate and filmmaker (River Vale, NJ)

Cynthia Pearson, Executive Director, National Women’s Health Network (Washington, DC)

Lauren Plante, MD, MPH, FACOG, Associate Professor, Obstetrics & Gynecology, Thomas Jefferson University (Philadelphia, PA)

Marcie Richardson, MD, FACOG, Harvard Vanguard Medical Associates, Beth Israel Deaconess Hospital (Boston, MA)

Gary A. Richwald, MD, MPH, Health Policy Analyst and Consultant, American Social Health Association (Los Angeles, CA) 

Judith Rooks, CNM, MS, MPH, midwife and epidemiologist (Portland, OR)
 
Kenneth Rosenberg, MD, MPH, Maternal and Child Health Epidemiologist (Portland, OR)

Sara G. Shields, M.D., M.S., FAAFP, Clinical Associate Professor of Family Medicine and Community Health, University of Massachusetts, Family Health Center of Worcester (Worcester, MA) 

Geradine Simkins, DEM, CNM, MSN, President, Midwives Alliance of North America (Maple City, MI)

Laura N. Sinai MD MSCE FAAP, North Carolina State Breastfeeding Coordinator for the American Academy of Pediatrics (Charlotte, NC)

Naomi Stotland, MD, FACOG, Assistant Professor, Dept. of Obstetrics, Gynecology, and Reproductive Sciences, UCSF Medical Director, Sage Femme Midwifery Services (San Francisco, CA)

Pam Udy, President, International Cesarean Awareness Network (Ogden, UT)

Cornelia Vanderziel, MD, FACOG, Harvard Vanguard Medical Associates (Cambridge, MA)

Abigail Wolf, MD, Assistant Professor, Clerkship Director, Obstetrics and Gynecology Thomas Jefferson Medical College (Philadelphia, PA)

Diony Young, Editor, Birth, and women's and newborns' health advocate (Geneseo, NY)

ADDITIONAL SIGNERS

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