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Obstetricians Claim Homebirth is Unsafe…Again. Where’s The Evidence?

November 29th, 2012 by avatar

by Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research

Today, midwife and researcher, Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research, takes a look at the recent article in the American Journal of Obstetrics and Gynecology that shared the authors’ view of the appropriate professional response from obstetricians when counseling and discussing home birth with patients.  Was this article based on good science?  Accurate and accepted studies? Did the authors selectively choose their sources and ignore other research that may have supported a different viewpoint?  Wendy shares information and research that invites consideration and discussion of the validity of the authors’ opinion. – Sharon Muza, Community Manager.

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Recently, an article in the American Journal of Obstetrics & Gynecology pled with obstetricians to not support planned home birth in any way, and even suggested that those who do “should be subject to peer review and justifiably incur professional liability and sanction from state medical boards” (1).  In their strongly worded opinion, the authors (the first two of whom are, curiously, members of the journal’s Advisory Board, and four of whom are also board members of the International Society of Fetus as a Patient) make their case that physicians should provide evidence-based information to women that planned home birth is not safe, that reports of patient satisfaction are overrated, that it’s actually not cost-effective, and that a pregnant woman has a moral duty to her fetus to give up her autonomy to her doctor’s judgment on this issue.  Let’s take a look at the basis for these recommendations.

Although there are many high-quality studies of home birth on which Chervenak et al. could have based their opinions, they led with the ACOG statement (2) that rests on the findings of the Wax et al. meta-analysis (3), which relied heavily on a study that included unplanned home births in its findings of neonatal mortality rates (4).  Many strong critiques of the Wax analysis have been published (5-11), including an unbiased look from someone who has no stake in the home birth debate.  The authors cited several more poor-quality studies, as well as 52 citations of commentaries, opinions and anecdotes (some even pulled from the popular media) to build their “evidence” basis. They conveniently ignored the large and growing body of literature that continues to show that planned home birth with qualified and experienced midwives holds no greater risk of perinatal mortality than birth in the hospital, and in fact results in far fewer interventions and lower risk of maternal and perinatal morbidity.

Here are some of the high-quality studies that Chervenak et al. did not cite in developing their opinion of the “professional responsibility response”:

  • two systematic reviews (12-13) and a meta-analysis (14) of home and birth center safety studies that all show that there is no greater perinatal risk for planned, attended home births than for hospital births, and significantly fewer interventions;
  • the only large-scale, high-quality study of Certified Professional Midwives (CPMs) in the U.S. that described intrapartum and neonatal death rates as similar to other studies of low-risk home and hospital births (15);
  •  other high-quality U.S. studies that show no difference in perinatal mortality between planned home and hospital births (16-18);
  • several high-quality Canadian studies confirming no difference in the rates of perinatal death between planned home and hospital birth with much lower rates of both interventions and adverse outcomes (19-21);
  •  a huge Dutch study of over half a million births that shows no difference in perinatal mortality rates or NICU admissions between planned home and hospital births (22);
  • another Dutch study that shows no difference in perinatal mortality and lower risk of interventions and other adverse outcomes, particularly for multips (23);
  • large, high-quality U.K. studies that show no difference in perinatal mortality rates and lower risk of both interventions and adverse outcomes (24-25); and
  • a German study that shows no difference in rates of perinatal mortality and lower risk of interventions and adverse outcomes (26).

The authors then go on to discount the evidence of higher satisfaction among women choosing to deliver at home, as well as the cost-effectiveness of doing so, while presenting absolutely no evidence to the contrary.  The authors reference a study in the Netherlands where the transport rate from home to hospital is over twice that in the U.S. (and where Chervenak et al. took great liberties in interpreting the results on patient satisfaction) and a U.K. study where the costs of home and hospital birth are virtually equivalent.  While consistent, this approach to selectively reviewing the evidence and generalizing the findings to the U.S. maternity care system is disingenuous and deliberately misleading to American obstetricians and their patients.  A Washington State study of Medicaid patients planning a home birth with Licensed Midwives showed a savings of nearly $3 million, including the increased cost of those who transferred care and/or site of delivery (27).  This analysis did not attempt to account for the vast cost reductions of potentially avoided interventions, including cesareans and their complications, which would make the case for the cost-effectiveness of midwifery-led care in Washington State even stronger.  It is puzzling that Chervenak et al. did not cite this study, which is recent, took place in the U.S., was conducted by unbiased health-economics consultants, and directly addresses one of their four concerns.

The authors’ main argument against the proven cost-effectiveness of planned home birth is that “the lifetime costs of supporting the neurologically disabled children who will result from planned home birth” have not been factored in, nor have the supposedly increased rates of death.  If one accepts the conclusions of the enormous body of literature that finds no difference in perinatal mortality rates or other adverse outcomes between planned, midwife-attended home births and hospital births, then the pursuit of this line of reasoning is a non-starter.

The U.S. continues to lag behind many other high- and low-resource countries in accepting the evidence of the vast benefits of midwifery care.  The U.K.’s National Health Service has encouraged women to plan home births with midwives for several years; the Netherlands has always acknowledged midwives as the primary care provider in the childbearing year; New Zealand’s system similarly places midwives at the forefront of maternity and newborn care; Japan has a long tradition of midwifery-led care.  Most recently, British Columbia Health Minister MacDiarmid, accepting the evidence of safety, patient satisfaction and cost-effectiveness, has announced government support for women with low-risk pregnancies to plan a home birth, including support for physicians to become appropriately trained to attend home births (28).  But the medical associations of the U.S. continue to erect barriers to the type of interprofessional collaboration that has resulted in the excellent outcomes of these other countries.  The Chervenak et al. article is clearly intended to be yet another of those barriers.

In the centerpiece of the AJOG article, Chervenak cites himself an astounding 15 times in justifying why the rights of a pregnant woman to make autonomous decisions for herself and her baby should be relegated to her doctor’s judgment of what’s right for the “fetus as a patient,” grounded firmly, of course, in the aforementioned “evidence.”  In an astonishing disregard for shared decision-making and informed choice, Chervenak et al. state that “in a professional relationship, the physician’s integrity justifiably limits the woman’s rights by limiting the scope of clinically reasonable alternatives.”  The authors’ repeated and unusual use of the word “recrudescence” when referring to home birth, which reveals their perception of the choice as a disease or disorder, and their stubborn contempt for high-quality evidence if it disproves their opinion, exposes their intent and certainly calls into question their “integrity.”

“Professional responsibility” demands that we dare to examine the evidence that does not agree with our personal beliefs.  It requires that we allow the volumes of high-quality evidence to seep into our analysis of reality and into our presentation of true informed choice to our patients.  “Professional responsibility” demands that we examine and disclose our own personal, religious or anecdotal beliefs that may bias our interpretation and presentation of the research.  And it requires that we refuse to cloak those personal beliefs as “evidence” and “integrity” and by so doing avoid an abuse of power in relationship with our patients.

References

1. Chervenak F. A., McCullough L. B., Brent R. L., Levene M. I., & Arabin B. (2012) Planned home birth: the professional responsibility response. Am J Obstet Gynecol, Nov 13. doi:10.1016/j.ajog.2012.10.002. [Epub ahead of print].

2. American College of Obstetricians and Gynecologists. (2011). Committee Opinion no. 476. Committee on Obstetric Practice. Planned home birth. Obstet Gynecol, 117(2, part 1), 425-8.

3. Wax J. R., Lucas F. L., Lamont M., Pinette M. G., Cartin A., & Blackstone J. (2010).  Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. Am J Obstet Gynecol, 203(3):243.e1–243.e8. doi:10.1016/j.ajog.2010.05.028

4. Pang J. W., Heffelfinger J. D., Huang G. J., Benedetti T. J., & Weiss N. S. (2002). Outcomes of planned home births in Washington state: 1989-1996. Obstet Gynecol, 100(2):253-9. http://dx.doi.org/10.1016/S0029-7844(02)02074-4

5. Carl M. A., Janssen P. A., Vedam S., Hutton E. K., & de Jonge A. (2011). Planned home vs hospital birth: A meta-analysis gone wrong. Medscape Ob/Gyn & Wom Health. Retrieved from http://www2.cfpc.ca/local/user/files/%7B1E683014-14EB-489F-99CE-B5A2185A6FC5%7D/Medscape%20%20Wax%20Critique%20-%20Michal,%20Janssen,%20Vedam,%20Hutton,%20de%20Jonge.pdf

6. Gyte G., Newburn M., & Macfarlane A. (2010). Critique of a meta-analysis by Wax and colleagues which has claimed that there is a three-times greater risk of neonatal death among babies without congenital anomalies planned to be born at home. National Childbirth Trust. Retrieved from http://www.scribd.com/doc/34065092/Critique-of-a-metaanalysis-by-Wax

7. Keirse M. J. (2010). Home birth: Gone away, gone astray, and here to stay. Birth, 37(4):341-46.

8. Hayden E. C. (2011). Home birth study investigated. Nature [Epub]. doi:10.1038/news.2011.162.

9. American College of Nurse Midwives. (2010). ACNM expresses concerns regarding recent AJOG publication on home birth. [Epub]. Retrieved from http://www.midwife.org/documents/ACNMstatementonAJOG2010.pdf.

10. Romano A. (2010). Meta-analysis: the wrong tool (wielded improperly). Retrieved from http://www.scienceandsensibility.org/?p=1349.

11. Dekker R. & Lee K. S. (2012). The Wax home birth meta-analysis: an outsider’s critique. Retrieved from http://www.scienceandsensibility.org/?p=5628.

12. Olsen O. & Clausen J. A. (2012). Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD000352. doi: 10.1002/14651858.CD000352.pub2.

13. Leslie M. S. & Romano A. (2007). Appendix: Birth can safely take place at home and in birthing centers. J Perinat Educ, 16(Suppl 1):81S-88S. doi:10.1624/105812407X173236

14. Olsen O. (1997). Meta-analysis of the safety of home birth. Birth, 24(1):4-13; discussion 14-6.

15. Johnson K. C. & Daviss B-A. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ, 330:1416. doi: http://dx.doi.org/10.1136/bmj.330.7505.1416

16. Cawthon L. (1996). Planned home births: outcomes among Medicaid women in Washington State. Olympia,WA: Washington Department of Social and Health Services. Retrieved from http://www.dshs.wa.gov/pdf/ms/rda/research/7/93.pdf.

17. Murphy P. A. & Fullerton J. (1998). Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol, 92(3):461-70.

18. Anderson R. E. & Murphy P.A. (1995). Outcomes of 11,788 planned home births attended by certified nurse-midwives: A retrospective descriptive study. J Nurse Midwifery, 40(6):483-92.

19. Janssen P. A., Saxell L., Page L. A., Klein M. C., Liston R. M. & Lee S.K. (2009). Outcomes of planned home births with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(6):377-83.

20. Hutton E. K., Reitsma A.H. & Kaufman K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. Birth, 36(3):180-89.

21. Janssen P. A., Lee S. K., Ryan E. M., Etches D. J., Farquharson D. F., Peacock D. & Klein M. C. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ, 166(3):315-23.

22. de Jonge A., van der Goes B. Y., Ravelli A. C., Amelink-Verburg M. P., Mol B. W., Nijhuis J. G., Bennebroek Gravenhorst J. & Buitendijk S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG, 116(9):1177-84. DOI: 10.1111/j.1471-0528.2009.02175.x.

23. Wiegers T. A., Keirse M. J., van der Zee J. & Berghs G. A. (1996). Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ, 313(7068):1309-13

24. Chamberlain G., Wraight A. & Crowley P. (eds.). (1997). Home births – The report of the 1994 confidential enquiry by the National Birthday Trust Fund. Cranforth, UK: Parthenon Publishing.

25. Northern Region Perinatal Mortality Survey Coordinating Group. (1996). Collaborative survey of perinatal loss in planned and unplanned home births. BMJ, 313(7068):1306-09. doi: http://dx.doi.org/10.1136/bmj.313.7068.1306.

26. Ackermann-Liebrich U., Voegeli T., Gunter-Witt K., Kunz I., Zullig M., Schindler C., Maurer M. & Zurich Study Team. (1996). Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ, 313(7068):1313-18. doi: http://dx.doi.org/10.1136/bmj.313.7068.1313.

27. Health Management Associates. (2007). Midwifery licensure and discipline program in Washington State: economic costs and benefits. Retrieved from http://www.washingtonmidwives.org/documents/Midwifery_Cost_Study_10-31-07.pdf.

28. Dedyna K. (2012, Nov 3). B.C. minister among first to support home births. Times Colonist. Retrieved from http://www.canada.com/minister+among+first+support+home+births/7494815/story.html.

About Wendy Gordon

Wendy Gordon, LM, CPM, MPH is a midwife, mother and educator in the Seattle area.  She helped to build a busy, blended homebirth practice of nurse-midwives and direct-entry midwives in Portland, Oregon for eight years before recently transitioning to Seattle.  She is a Coordinating Council member of the Midwives Alliance Division of Research, a board member of the Association of Midwifery Educators, and teaches at the Bastyr University Department of Midwifery.

 

Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Maternal Mortality, Maternal Mortality Rate, Maternity Care, Medical Interventions, Midwifery, New Research, Research , , , , , , , , , , ,

  1. avatar
    Amanda
    November 29th, 2012 at 05:41 | #1

    Wendy, thank you for supporting a women’s right to automony and informed consent. Empowerment is a key determinant of health.  The evidence you have provided gives women the information the need in order to make the choice that is right for them. Home birth is safe, hospital birth is safe. It is about choice.
    Also, thanks to Sharon for posting this article.

  2. avatar
    Mishka Brownley
    November 29th, 2012 at 05:46 | #2

    Thank you for this great, informative article.

  3. November 29th, 2012 at 07:44 | #3

    Wendy ~ Thanks for this piece! I especially appreciate the in-depth look at the research on homebirth safety. When we look at the full body of research on homebirth, it is clear that it is time to change the debate. A large body of credible research tells us that homebirth is safe *and* has fewer interventions for mother and baby. Let’s start at looking at what homebirth providers are doing right and see how we can transfer those benefits to other settings.

  4. avatar
    Willa Powell
    November 29th, 2012 at 08:21 | #4

    Thank you for reminding us that professional ethical conduct requires that a doctor disclose his/her personal bias. In light of the influence editorial papers like this have on the obstetric community, the first question women should be asking when selecting an OB is, what evidence is there that the OB will put his own agenda ahead of mine?

    I too was struck by the use such an arcane word, but quickly realized how perfectly matched the word was to the author’s attitude:

    Recrudescence (v) (of disease, trouble, etc.) to break out or appear again after a period of dormancy; recur [latin: recrudescere, to become raw again, to grow worse; crudus, bloody, raw]

    A century ago, this newly emerging profession bemoaned the loss of “teaching material” for clinical training because woman were served at home by midwives. They launched a campaign against midwives, calling them “hopelessly dirty, ignorant and incompetent”, at the same time that doctors were losing whole wards of women to puerperal sepsis. Their campaign eventually succeeded but not until after doctors changed their ways and started applying real science, including hand washing and the sterilization of instruments between use. The pre-science attitude is very present in everything these authors have written, yet they would eliminate all alternatives without changing any of the harmful habits of today’s obstetricians…

    Shameful.

    Willa Powell

  5. avatar
    Susan Hodges
    November 29th, 2012 at 08:37 | #5

    Thank you for a well-written, thorough and much needed critique of ACOG’s latest slap at home birth.

    You wrote: In an astonishing disregard for shared decision-making and informed choice, Chervenak et al. state that “in a professional relationship, the physician’s integrity justifiably limits the woman’s rights by limiting the scope of clinically reasonable alternatives.” This attitude and position expressed by Chervenak et al is outrageous and completely unacceptable, and violates many rulings by the US Supreme Court which found that adult persons may not be compelled even to donate blood to save the life of their child, let alone undergo surgery or any other intervention.

    Thank you again — I hope your critique gets a lot of attention!

  6. avatar
    Nasima Pfaffl
    November 29th, 2012 at 08:42 | #6

    Wendy thank you for your thoughtful article. I love your review of the research which illustrates the safety and reduction of intervention in homebirths. Its time the maternity system started looking at what homebirth providers are doing right and transfer some of those benefits to the system as a whole.

  7. avatar
    Ellen Harris-Braun
    November 29th, 2012 at 09:04 | #7

    It’s great to see a detailed assessment of this recent article. Thanks! When authors pick and choose, ignore, or misuse the evidence, we need to be calling them on it (whichever “side” of the issue they are supporting).

    There’s one part of the Chervenak article I can fully agree with, though: They say, “Much can and should be done to create a home-like, psychologically, and socially supportive hospital birth to support the legitimate expectations of women for a humane, safe, and undisrupted labor experience with full back-up immediately available.” How about we focus as a healthcare culture on those “can” and “should” to-do items?

    One thing I’d like Science & Sensibility to shed some light on: what does it mean that the Chervenak article was published in the “Clinical Opinion” section of the journal? Is that any kind of meta-information from the journal about the article itself?

  8. November 29th, 2012 at 09:44 | #8

    Thank you so much for this informative blog article. I find it curious and annoying that some obstetricians, and obstetrical societies, continue to insist that home birth is unsafe despite the availability of high quality research that supports its safety and efficacy, as described here. It is time to reframe the conversation. Home birth is safe with a skilled birth attendant. The next step is how to thoughtfully discuss and take action to ensure that all women have access to the safest system possible to support their choices in childbirth. It is time to utilize the consensus statements developed at the Home Birth Summit (Fall 2011) by a multidisciplinary team representing a cross-section of the maternity care system, including obstetricians, pediatricians and family practice physicians. These common ground statements address issues such as: an integrated healthcare team for women choosing home birth; shared decision-making between clients and providers; data collection and research on key processes and outcomes across all birth settings; addressing disparities in access to high quality services and perinatal outcomes; licensure of midwives based on a national certification; deficits of the current liability system; and effective communication across all disciplines, especially when transfers from home to hospital are necessary. If you are interested in reframing this conversation to a more practical and useful level for consumers, providers, and other valuable stakeholders check out the work being done to address these issues on the Homebirth Summit website at http://www.homebirthsummit.org/. Geradine Simkins, CNM, MSN, Executive Director, Midwives Alliance of North America

  9. avatar
    Kelly Olmstead
    November 29th, 2012 at 09:49 | #9

    Thank you,Wendy Gordon, for this clear, well-researched, and thoughtful rebuttal of ACOG’s recent article about homebirth. When I first read it, I was shocked and eventually almost came to think it was an Onion piece of satire, so backwards were the comments regarding a woman’s need to give up her autonomy to the physician and that he need only present what he felt were reasonable choices. Knowing that a couple of the authors are part of a group for “Fetus as Patient” makes it make more sense. The fact of the matter is that, while the fetus’ safety is of course critically important (to the mother as well!), it does not supersede a woman’s sovereignty over her own body, nor her primacy in the decision making.

  10. avatar
    Becky Banks
    November 29th, 2012 at 10:40 | #10

    @Jeanette McCulloch
    I would also say, “and what they *are* doing right in a medical setting” and use it more in a home setting.

  11. avatar
    Ida Darragh
    November 29th, 2012 at 10:56 | #11

    This is an excellent rebuttal to the AJOG article. Their article, which was just a restatement of the same approach they have taken about home birth for a decade, has now been debunked by many sources. Wendy’s article is one of the best responses written to date. Kudos, Wendy, on such an articulate, well researched response!

  12. avatar
    Mari Patkelly
    November 29th, 2012 at 11:20 | #12

    Wendy and ALL,

    This is so amazing and so wonderful to read! THANKS!

    Knowing that this information is being seen in the public realm now in such an important and unified way – so that “the truth” can be known by many – is a great gift to me, both personally and politically!

    I have been holding – “sort of alone” for 34 years – an experience I had at The University of New Hampshire’s “New England Center” in the mid 1970′s – before Corporate Health Care even existed – at a Childbirth Conference with many types of birth practitioners in attendance.

    At this time I was teaching CEA childbirth classes in Rochester, NH and studying for my BSN in nursing at UNH so I could become a home birth midwife while slowly reading a book by Barker Benfield – which Robbie Davis Floyd, blessedly and recently reviewed on Amazon.

    This important book called Horrors of the Half Known Life – The Rise of Gynecology in America – is a “must read” for all gentle birth activists NOW! AND STILL!!! And, it is very, very hard stuff to take in…and so I am aware of very few people who have read it. It took me many times of taking it out – reading and “taking in” some of it – and then bringing it back again to the UNH Library before I finally finished it…

    My lonely experience at the New England Center that day occurred on several levels in several of the smaller workshops as well but the climax was in a large session scheduled for all participants when an OB “honored speaker” used the same study and/or another similar one to debunk the safety of home birth.

    I knew, having seen this “study” myself recently, that it included ALL out of hospital births and few – if any – planned home births with trained attendants!!!

    So energized, I raised my hand immediately to question him about his knowledge regarding the particulars of this study and he would not recognize me. Furious at his false representation of the facts, I simply stood up as he spoke and said “Excuse me sir, and I need to know if you are aware that this study includes all births that happen outside of hospitals – at home “by mistake,” on the street in slums, on the way to the hospital, in the parking lot of the hospital etc. etc. etc.?

    He lowered his head for a moment of silence and continued his presentation having made no response to me at all!

    I sat down…having had yet another lonely experience of being ignored by an OB, similar and also different from those I had already experienced when I was ignored and abused and then “only” ignored while trying to give birth naturally to my two children Gus in 1969 and Lonya 1970 – in hospitals. Still fuming and clear that I had done the right thing, I sat down shaking with emotion as he went droning on …

    When he finished and we rose to leave, I was approached and praised for my “courage” by several women… and as I type this NOW I wonder where those dear brave women – who supported me – are now…

    Are they still working as so many of us have done and are doing with birth in the USA and if not… I wonder about why they disappeared from our ranks…

  13. avatar
    Kimberly Radtke
    November 29th, 2012 at 11:23 | #13

    Excellent response to the ACOG article. Not sure how they can write what they did given the abundant research about the safety of home birth. The views of Chervenak re: women’s inability to make an informed decision is appalling. I appreciate the reminder that professional ethical conduct requires that a doctor disclose his/her personal bias. In addition, the summary you provided about the safety of home birth was very helpful and valuable. Thank you for taking the time to write an excellent response. Let’s hope that ACOG pays closer attention to the research on this topic as well as others.

  14. November 29th, 2012 at 13:18 | #14

    As everyone has said this is an excellent rebuttal, Wendy, I agree with everyone’s comments thus far. What no one has mentioned is the great political and financial powers at work here. Hospitals and OBs have much to gain, both financially and politically, for birth to remain in hospitals. Maternity departments bring in a large percentage of a hospital’s overall income. It is extremely unfortunate that political and financial gain entices some people who work in the medical field to actively speak against professional midwifery and a homebirth movement that in contrast has the well-being of families and the rights and choices of women as its first priority.

  15. November 29th, 2012 at 20:16 | #15

    Wendy – thank you for such a thorough, clear and informative article!
    Agreed: Women should be able to receive all the pertinent and unbiased information to make their own choices, to be truly able to give informed consent. All care providers should assume the professional responsability owed to their patients, and not present their personal beliefs as evidence.

  16. avatar
    Jana Studelska
    November 29th, 2012 at 21:55 | #16

    It’s interesting to note that these ACOG authors would not only deny autonomy to birthing mothers, but are also seemingly willing to extend their brand of brow-beating autocracy to their own members. Those who dare not dance to the party tune are threatened with “peer review” and “professional liability and sanction from state medical boards.” That kind of heavy-handed leadership breeds contempt. We all know physicians who are willing to walk away from the abusive professional relationship ACOG insists on imposing. Send those docs a little lovin’ today. Additionally, I applaud you Wendy, for writing a response with annotations and references. That you were able to accomplish that in your busy day makes your words even more powerful. ACOG might take a lesson from your book and do some homework.

  17. avatar
    Liz
    November 30th, 2012 at 06:53 | #17

    ““Professional responsibility” demands that we dare to examine the evidence that does not agree with our personal beliefs. It requires that we allow the volumes of high-quality evidence to seep into our analysis of reality and into our presentation of true informed choice to our patients. “Professional responsibility” demands that we examine and disclose our own personal, religious or anecdotal beliefs that may bias our interpretation and presentation of the research. And it requires that we refuse to cloak those personal beliefs as “evidence” and “integrity” and by so doing avoid an abuse of power in relationship with our patients.”

    The final paragraph of this article is incredibly powerful – and one with which I wholeheartedly agree. Professional responsibility should guide all groups of care providers – not just physician groups – in creating standards and practice guidelines. It is an essential step toward assuring accountability, credibility and safety.

    It is my fervent hope that midwives in the US (NACPM, MANA) will “dare to examine the evidence that does not agree with our personal beliefs” and and take a good, hard, critical look the “personal, religious and anecdotal beliefs” that currently exist among professional midwives and that are not supported by any evidence. (Evidence for safety of breech birth at home? Evidence for safety of twin birth at home? Evidence for safety of herbal methods of managing postpartum hemorrhage? Evidence for safety of refusing GDM/GBS screening in pregnancy? Evidence for safety of OOH VBAC? Evidence for supporting the refusal routine vaccinations? Evidence for expectant management of PROM at home?) Wendy Gordon’s statement should be a call to action not just for physicians, but for all midwives. We should not be afraid to adhere to the professional standards of responsibility that we expect of others.

    It’s high time. The women and families who choose professional midwifery care deserve this.

  18. November 30th, 2012 at 07:30 | #18

    Thank you for this piece. Critical examination is a wonderful practice in academia and Wendy you did an extraordinary job here. Brilliant. The comments reflect something different, and a sticking point with me in birth community. It is very easy to demonize. And even when it is accurate, we only close doors to change by agreeing with each other to merely demonize. For change to occur, we need to do more ON OUR SIDE than just preach to the choir. We need to take wonderful articles like this and reach out to the very community we address–professionals in OB/GYN, and invite them into the conversation. Personal stories and anecdotes are valuable and poignant, but advocates must move it beyond put-downs and dualistic good vs. evil thinking. We must grow up and into a new maturity that establishes our role as global advocates—not just advocates for what we believe in and against what we don’t. We have to advocate for the entire community, including the OB/GYNs. They are not happy either. Nor are labor and delivery nurses. Nor are charge nurses in NICU, nor are neonatologists, nor are pediatricians. And we don’t even bother to ask about the mental health professionals and social workers who pick up the pieces of a maternal care system gone awry. No one is perfectly happy with maternal care. And the US has it good compared to the rest of the world. And the wealthy parts of the US have it good compared to the poor parts.

    So yes, ACOG is screwed up in some areas. They know it too! But the answer is to build relationships not only blast the system from afar and pat each other on the back for it.

  19. November 30th, 2012 at 09:53 | #19

     Congratulations and thank you Wendy for publishing a brilliantly researched and written response to this latest attacks on home birth. I have read all of the comments and whole heartedly agree with everyone including the commenter that reasoned that the ridiculousness of the article made her wonder if she was in fact reading an Onion satire piece and not a article published in a scholarly journal. 
    I am left with this thought.The obstetrical  profession is scared. ACOG has read the studies, they cannot ignore the fact that home birth babies and mothers do as well as hospital birthed babies and mothers with far greater satisfaction and far fewer interventions and cesarean sections. This latest article and the Wax study are just the latest examples of ACOG grasping at anything they can to discredit the fine care midwives provide in the home setting.

  20. avatar
    RS
    November 30th, 2012 at 10:10 | #20

    To be absolutely clear about this: the critiqued original article was not published in ACOG’s journal (that is called Obstetrics & Gynecology, aka “The Green Journal”). This article was in the American Journal of Obstetrics and Gynecology, which does not represent ACOG and it is NOT an ACOG opinion (although the opinion might be shared by some of that organization’s members). The critiqued article actually calls out ACOG for being *too* respectful of women’s rights.

  21. November 30th, 2012 at 12:23 | #21

    @Emme Corbeil
    Case in point to my comment.

  22. avatar
    Marijke van Roojen, LM, CPM
    November 30th, 2012 at 14:02 | #22

    Thanks Wendy for doing the research and for your clear and substantive response. Well done. I so appreciate your work and advocacy on behalf of women and their clear right to authentic informed choice.

  23. avatar
    Becky
    November 30th, 2012 at 19:48 | #23

    Wait, did you seriously just cite this year’s Cochrane review as saying that there was no difference in perinatal mortality?? And no one has pointed out that this review included ONE study with ELEVEN (yes, eleven!!!) women, and concluded that further research is needed, not at all what you reported as its conclusion. If you’re going to so misrepresent this review, how can we trust your assessment of the rest of the data?

    http://summaries.cochrane.org/CD000352/benefits-and-harms-of-planned-hospital-birth-compared-with-planned-home-birth-for-low-risk-pregnant-women

    You cite the studies from the Netherlands, without noting that the country has received criticism for their relatively high perinatal mortality rate, and that there’s evidence that while women attended by midwives have the same mortality at home and in the hospital, high risk women who delivery with OBs actually have a lower perinatal mortality rate. “Low risk” women cared for by midwives had a perinatal mortality rate over 3x the rate for women cared for by OBs. http://www.bmj.com/content/341/bmj.c5639

    You also don’t note that while the UK’s Birthplace study found no difference for multiparous women, it found that for nulliparous women with no complications at the start of labor, the risk of adverse outcomes was 2.8 times greater at home. In the appendix published online, it was noted that when only the highest quality data was used, the difference in adverse outcome for nulliparous women at home or in a freestanding birth center compared to a hospital increased.

    You cite the Johnson and Daviss study of CPMs, without noting that the study included no controlled comparison hospital groups, and that while the CPM mortality data and the hospital intervention data were from 2000, the study didn’t calculate hospital mortality rates at all, instead citing several studies dating back up to thirty years prior.

    You don’t note that the Janssen study from Canada is underpowered to detect differences in perinatal mortality, and itself admits that this is the case. Several of the other studies listed are also underpowered to detect differences in mortality.

    There is evidence that shows higher risks with home birth. Besides the Pang study, which in fact did attempt to control for planned place of birth, although it could not do so perfectly with the available data,
    http://www.ncbi.nlm.nih.gov/pubmed/21380991
    Found increased risk of neonatal seizure and mortality in home births.
    http://www.ncbi.nlm.nih.gov/pubmed/20182433
    Show higher neonatal mortality for home births with Certified Nurse Midwives and “other” midwives, when compared to Nurse Midwives in hospital.
    There is also research out of Australia showing increased mortality in home births.
    http://www.bmj.com/content/317/7155/384
    http://www.ncbi.nlm.nih.gov/pubmed/2246989
    http://www.sciencedirect.com/science/article/pii/0266613894900426

    Are there problems with these data? Absolutely. There are problems with *all* the research on home birth. Finding an equivalent comparison group is nearly impossible, because home birthing women are self selected. We are dealing with relatively rare outcomes; the risk of perinatal mortality at term for low risk women is often reported to be about 1 in 1000. Even a doubling or tripling of the mortality rate would need a very large study size to show as statistically significant. The population wide studies from the United States and Australia do tend to show increased mortality, but it is harder to ensure that only planned homebirths are included, and that the groups being compared are equivalent. Yet smaller better controlled studies are likely to be underpowered to detect differences.

    In any case, this evidence only applies to low risk women, well trained midwives, strict standards of care and smooth transfer procedures, which unfortunately is too often not the actual case in the United States. I don’t care for this editorial, which is not an official statement from the ACOG, but I do have definite concerns about the safety of homebirth as it is in most places in the United States. I especially have concerns about the way women are being told that home birth is “as safe or safER” than hospital, without qualifications being put on that statement.

  24. December 1st, 2012 at 00:49 | #24

    Thank you, Wendy Gordon! Outstanding work.

  25. avatar
    Willa Powell
    December 1st, 2012 at 09:17 | #25

    RS (above) argues that AJOG is not the official journal of ACOG (saying the “green journal” Obstetrics and Gynocology is). This is splitting hairs. The primary author of this article is the Ethics Officer for ACOG, therefore, it is his responsibility to limit his pronouncements on ethical matters to positions ACOG supports. If he “gets out ahead of” ACOG, then ACOG should sanction him by removing him from the position he holds within ACOG. Anything less is condoning that position.

  26. avatar
    Willa Powell
    December 1st, 2012 at 10:31 | #26

    @Liz
    Liz, you realize all the items you listed are subject to informed consent? If you are suggesting that midwives should present what evidence there is in support of these actions/interventions (vaccines, GBS screening) or against a patients wishes (home breech, VBAC), that’s all well and good, but the are the mother’s decisions. If no midwives are willing/available for home VBAC, then a significant number of women are going to take an even riskier approach of going it alone. Which is the more ethical response: refusing to be party to a home VBAC, or reducing a woman’s overall risk by providing professional support? Granted, it’s safer, professionally, for a midwife to just say no, but it is neither ethical nor compassionate to do so.

  27. December 1st, 2012 at 11:19 | #27
  28. December 1st, 2012 at 11:31 | #28

    No one has discussed any culture but the medical one. Ironic, isn’t it? And…we talk for women so easily. We construct words and concepts, memes of safety and choice that take us off onto tangents of internalized patriarchy. It isn’t our fault. It is our training as women grown and trained in patriarchy. We speak for women and end up telling them, and each other, what is best for them. All of the time. Then, we turn on each other and God help an advocate coming up against the status quo of advocacy. Can’t anyone see this cycle perpetuated over and over again in our “birth worlds”?

    I appreciate this perspective @Becky brings. “I especially have concerns about the way women are being told that home birth is “as safe or safER” than hospital, without qualifications being put on that statement.”

    And it begs the consideration of class in US birth scene. This grand concept of informed “choice” of home vs hospital is predominantly concept for the privileged. I would offer that this topic needs to be addressed in the context of race and class as well. No one has discussed any culture but the medical one. Ironic, isn’t it? Now rather than get our culturally inappropriate rebozas in a twist, can’t we back up and see what HAVEN’T considered in this discussion?

    Cultural factors impacting a choice of location, access to care
    Race–the racial gap in mortality rates wasn’t mentioned. That is not right, and it is on us to address it!
    Socioeconomics–
    Unplanned pregnancy
    mental health
    substance use
    domestic violence
    smoking
    alcohol use
    working wages
    childcare

    Did I mention mental health? First for the birthing woman. Then her partner. Then the care provider. 1 in 5 women. Urgh…

  29. December 1st, 2012 at 11:38 | #29

    @Walker Karraa
    Case in point is the new Lamaze Tool Kit. A missed opportunity.

  30. avatar
    Becky
    December 1st, 2012 at 16:48 | #30

    The primary author of this article is the Ethics Officer for ACOG, therefore, it is his responsibility to limit his pronouncements on ethical matters to positions ACOG supports.

    This would only be true if he were writing in his official capacity. A commentary published under his own name would not necessarily reflect the views of the ACOG, and in fact this paper criticized the stance of the ACOG.

  31. avatar
    Liz
    December 2nd, 2012 at 06:56 | #31

    @Willa Powell

    Would informed consent include that certain situations in pregnancy or childbirth increase the risk to the health and lives of the mother and baby in a homebirth? Or would informed consent include that the midwife is basing her care on her own “personal, religious and anecdotal beliefs” and not evidence-based protocols?

    Because I would support both of those methods of informed consent.

    Unfortunately, informed consent is often shrouded in “xxx is a variation of normal” and midwives are “experts in normal” and therefore “homebirth with a midwife is as safe or safer than hospital birth” without any shred of evidence to support that statement.

    For instance, do we know the answer to this question: Is breech birth at home with a midwife as safe, or safer, than any type of breech delivery in the hospital?

    I do not wish to derail the topic of discussion – but if midwives are going to demand that physicians abide by evidence-based practices, we should at the very least be doing the same. And to not hide behind the doctrine of “informed consent.”

    We should also stop kidding ourselves that midwives only attend healthy, low-risk women at home. That is an utter fallacy. I could be persuaded to believe that homebirth is a safe option for women with low-risk pregnancies. But knowing what risks are taken daily with women and their children in OOH situations with licensed, certified midwives, I’m dubious about these unequivocal claims that there is no increased risk.

    Please, show me the evidence.

  32. avatar
    Wendy Gordon, LM, CPM, MPH
    December 2nd, 2012 at 14:48 | #32

    @Becky, you are correct that there is no study that is perfect. Accepting this, it is necessary to evaluate the *quality* of the evidence along with the conclusions of the authors.

    YES, the RCT assessed in the latest Cochrane review is small; AND more than half of the review discusses the quality of the existing observational studies. The authors state that “Maternal and perinatal mortality are so low in low-risk pregnancies that these outcomes cannot be the primary outcome measures. Instead it is of interest to study any excess rates of interventions, complications and morbidity related to planned hospital birth in order to assess the price paid for a general policy based on the belief that planned hospital birth is always the safest.” Based on the body of evidence that exists, they conclude that “…all countries should consider establishing home birth services with collaborative medical back up and offer low-risk pregnant women information about the available evidence and the possible choices.”

    YES, the Netherlands has a higher overall rate of perinatal mortality than many other countries; AND it has been conclusively laid to rest that the higher rates cannot be attributed to homebirth. The study you linked had nothing to do with place of delivery.

    YES, the U.K.’s Birthplace Study found higher rates of “adverse outcomes” for the subset of nulliparous women; AND those rates were still so low that the authors concluded that all women with low-risk pregnancies should still be offered the autonomous choice of homebirth.

    YES, the Johnson & Daviss study corroborated their findings with the large body of literature that showed the same low rates of intrapartum and neonatal mortality; AND when the authors conducted an additional analysis to do exactly the type of hospital comparison you’re talking about, they still found absolutely no difference in the adjusted neonatal death rates between planned homebirths and a low-risk hospital cohort.

    YES, there are studies that conclude that there are higher rates of mortality in home birth; AND those studies typically included unplanned, accidental and/or unattended home births in the “planned” home birth group. Higher mortality and morbidity rates are well documented in unplanned homebirths. This is precisely why it is critical to assess the QUALITY of the evidence along with the findings. To specifically address the studies you listed:
    – The Pang study did not and could not adequately control for “planned” place of birth, because the birth certificate did not capture that information. Their analysis not only included unplanned & accidental home births in the “planned” category, but unattended preterm births as well, for which we can absolutely expect a higher rate of mortality & morbidity.
    – The Chang & Macones study from Missouri also included unplanned home births, both preterm and grossly postterm. It is also important to note that over the 17 years of data analyzed, there actually were no CPMs in practice in Missouri; in fact, it was a criminal offense for direct-entry midwives to attend home deliveries. The CPM credential was not accepted for licensure until 2008 — three years after the end of Chang’s study period.
    – The Malloy CNM study also did not distinguish between planned and unplanned homebirths. There was no distinction between “other midwives” and no attendant at all.
    – The first two Australian studies you cited (Bastian & Crotty) both included women with high-risk pregnancies in the home birth group; twins, breech, preterm and postterm deliveries have all been well documented as having higher rates of morbidity and mortality, no matter the location of birth.
    – The third Australian study you cited (Woodcock) actually found that there was no difference in perinatal mortality in the planned home birth cohort and had fewer interventions.

    While indeed no study is perfect, it is not acceptable to ignore the highest quality evidence because it does not agree with one’s personal opinions. It is not ethically acceptable for physicians to withhold information from women because they don’t personally like the idea of home birth. As the folks at Citizens for Midwifery have recently pointed out, by proposing that physicians deliberately stand in the way of full informed choice for pregnant women, Chervenak et al. rejects the ethic that autonomy is a fundamental human right.

  33. December 2nd, 2012 at 20:25 | #33

    @Liz I keep coming back to your comment, as I feel like you are not recognizing that it is not the responsibility of the HCP to “decide” what is the right answer for a mother (and her baby) but rather the responsibility of the HCP to provide all the evidence, share all the information, identify information that is his or her opinion, and state that as such and let each family decide what risk level (weighed against the benefits) each family is comfortable with. To quote a HCP from a listserve that I read, ” one person’s comfort with the the risk of rainfall is another person’s aversion to the possibility of a hurricane.” When a mother knows the risk of all her options, she makes a decision that she feels comfortable with. And we must respect and honor the wishes of those mothers even when decisions may be different then those we might make for ourselves.

  34. avatar
    Liz
    December 3rd, 2012 at 12:21 | #34

    I don’t think I said anything about a health care provider deciding for a patient. I do not believe a HCP – physician or midwife- should make decisions for a patient.

    Where we agree: all HCPs should be

    - providing *all* the evidence
    - sharing *all* the information
    - identifying their own prejudices,beliefs and superstitions – and presenting them as such.

    I do believe groups of professionals have an ethical responsibility to adhere to practice standards that assure the greatest amount of safety to the greatest number of clients/patients served by members of the profession.

    Can someone tell me if riskier births attended by a CPM at home are as safe as hospital births? Let’s use breech as an example. Is breech birth at home with a CPM as safe as a breech delivery (vaginal or C/S) in the hospital?

    I do not know this answer. I hope someone does. (And I’m so glad no one is suggesting that CPMs aren’t attending breech births at home – because we all know they are).

    Wouldn’t/shouldn’t this information be presented as part of informed consent? How could a client make this decision without this crucial bit of information?

    I’m only using breech as an example – there are many conditions that are considered to be “higher-risk” in obstetrical circles, but mere “variations of normal” in homebirth midwifery circles. And I don’t know what the truth is.

    We are talking about evidence. I would like the evidence to support high-risk birth at home. Or at least a truthful discussion about the real risks one takes when choosing a risky homebirth. (Increased risk of neonatal mortality? Just a little? Twice as much? Four times as much? What is it?) But when the conversation turns to “we need to respect the mother’s wishes” it tells me that maybe the evidence doesn’t always matter.

  35. avatar
    RS
    December 3rd, 2012 at 16:33 | #35

    @Willa Powell
    @Willa, Where did you learn that the author is an Ethics Officer for ACOG? As far as I can tell, the only official opinions of ACOG on ethics matters are published that way– as official opinions. I would never want a professional society to stifle a person whose opinion differed from theirs, when not speaking in an official capacity! I would agree with you that it would be an aggressive thing for an “Ethics Officer” to do, but I have no idea where you’re getting that from. ACOG’s Ethics Committee Opinions are unauthored and I can’t find out who is on it or what their volunteer agreement says without hitting the login wall (I’m not a member, so no login). What if a member wanted to disagree and move the organization in further support of home birth? I suspect that you’d have no problem there. Demanding accuracy is not hairsplitting.

  36. avatar
    Willa Powell
    December 3rd, 2012 at 17:09 | #36

    Liz, I know your question is about evidence vs. anecdote, but let’s talk fact and truth for a moment. Just as we all know CPMs deliver breeches and take other “higher-risk” cases, I think we all know that OBs are not trained in how to deliver a vaginal breech safely, and many aren’t comfortable with VBAC.

    We also know that the occurance of cerebral palsey in babies identified as breech at birth has not decreased even though the vast majority of hospital breeches are born via c/s. The subjectivity of this line of questioning is this: when does pregnancy, labor and birth stop being a normal physiological process and become disease (setting aside both phrases “variation of normal” and “higher risk”)? If you ask a HCP, the answer is whenever you cross the line that marks their comfort zone. If an OB has never delivered a vaginal breech, he/she is out of his/her league and shouldn’t be catching yours. If a midwife has that experience, I trust her with mine.

    Most OBs are trained to view VBAC is higher-risk, even though the incidence of adverse outcomes is equal to that of a primip (… does that mean primip is a “higher-risk” condition?) But isn’t it true that a naturally conceived pregnancy and a vaginal delivery (after c/s) is still physiologically normal?

    As a consumer, if my HCP isn’t comfortable providing me what I, the laboring mother, am comfortable with pursuing, then that HCP has a moral obligation to find someone who has that expertise and refer me, not to cut off all my options and insist that I respond to his/her treatment of last resort: surgery.

  37. avatar
    Margaret Bean
    December 6th, 2012 at 08:51 | #37

    Dear Colleague, I sincerely hope you submitted this excellent critique to the ACOG Journal.

  38. avatar
    Amy Levi
    December 6th, 2012 at 11:07 | #38

    Hi –

    Please forward this to the Journal…it needs a wider audience than this blog! Nice work!

    Amy Levi

  39. December 14th, 2012 at 04:13 | #39

    This is a very nice critique of Chervenak’s new article. I agree with it on most every point.

    Chervenak is not an ‘ethics officer for ACOG’. He is, however, a very senior author in the view of academic OB/GYNs, who was written many many articles on medical ethics. He is considered a international expert on medical ethics. The problem, in my opinion, is that he has taken his bully pulpit to his own uses, going past a discussion of medical ethics into a declaration of his own views. An expert in medical ethics has authority in helping us define ethical questions in a way that we can best try to answer them. Such an expert, however, has no more right to declare the answers to these questions than anyone else. It is in this that Chervenak errs, in my opinion.

    I am not sure why Chervenak has chosen homebirth as a new topic to attack. He is a professional ethicist and has taken the position that the choice to homebirth is an unethical one. I disagreed with him after his first article in the Green Journal in press in a Letter to the Editor . While he tried to rebuke me in his response, I find this second article a near capitulation to my letter, in that he now addresses all the issues I claimed her ignored in the first.

    This article is much better written than the first, though his answers remain rather paternalistic and disrespectful of women’s rights and feelings. He claims that he can decide how women should feel about their place of birth, and if they do not agree, they are ignorant of some truth to which he is privy.

    And now I shall say something this crowd will not like.

    As for the data, I think that every person that claims that homebirth is every bit as safe as hospital birth lacks the experience of an obstetrician. Those that do have the experience of an obstetrician have seen numberous disasters that have resulted from homebirths gone wrong, in some cases leading to avoidable neonatal death or injury. These anecdotal experiences may fall out in the statistical wash of the larger studies, but they still drive opinion, and in many cases a total disbelief of the data. I personally have a hard time believing that the data captures truth, perhaps for the same anecdotal reasons. Bias? Perhaps, but its a bias I am comfortable following. I am an ardent supporter of womens’ rights to choose their place of birth, but not for a minute do I believe that the choice to deliver at home does not confer a relative danger to their infants.

    I hear the argument ‘but there are disasters in hospital birth too!’. Such arguments are never compelling to me. In ten years I have only seen only one really bad baby outcome in a hospital birth originating in a healthy low risk pregnancy with a healthy fetus. I have seen far more bad outcomes from bad homebirth transfers, even though the number of homebirths going on in our communities are orders of magnitude lower than the number of hospital births. What concerns me about the data is that most of the bad outcomes I have seen would never have been recorded in any of the analyses, as they did not result in neonatal death or perinatal death.

    Neonatal and perinatal deaths are the very end of a huge cascade of events. Our pediatric abilities are so strong that it would take a huge insult to lead to a neonatal death. That doesn’t mean that there aren’t babies that are injured who do not go on to die, and therefore fail to get measured in some of the larger studies.

    I see the critique that obstetrician’s are driven by anecdote, but I must also ask why ardent homebirth supporters are willing to pay attention to their own disasters? One does not have to look hard to find detailed documentation of cases where infants died or were injured in a situation where early maternal transfer was clearly indicated, but not done for various reasons. In many cases transfer is avoided at the counsel of the attending midwife, sometimes even in opposition to a patient’s expressed wishes. In other cases transfer is appropriate transfer is avoided because a mother is so strongly against it. Why are homebirth supporters so quiet about these cases? These are anecdotes, true, but why are they so ignored? It puzzles me.

    Chervenak discusses fiduciary duty of obstetricians. There is also a fiduciary duty of midwives – and that is to appropriately access hospital based birth services when there is any concern of a problem breweing, and to remain acutely aware of the limitations of their setting. If they do this, I think bad outcomes in homebirth will be limited. If they don’t, mixed in with large volume of beautiful wonderful homebirths will be the occasional disasters that will continue to color the view of obstetricians in this country.

  40. December 14th, 2012 at 04:16 | #40

    Apologies for the typos.

  41. avatar
    Louisa Wales, LM CPM
    December 14th, 2012 at 10:11 | #41

    Thanks Wendy for an excellent article. I also wanted to thank Dr Fogelson for his comment too. I want to point out that there are increasingly concerted efforts within the homebirth midwifery community towards concrete quality assessment and improvement within the profession. If you haven’t already seen the Midwives Association of Washington State Indications document (which you can find at http://www.washingtonmidwives.org) I urge you to do so. Documents like these which guide patient/client selection and support continuous risk assessment are invaluable tools for homebirth midwives. I have long been troubled though by the constant struggle that midwives face to transfer clients appropriately, even in states where Midwives are licensed and have in place documents and QA/QI processes. MAWS, in conjunction with the Washington State Perinatal Advisory Committee is piloting a home to hospital transfer project “Smooth Transitions” which will work toward the shared goal of optimizing maternal and neonatal outcomes. Both midwives and physicians agree upon the need for safe and seamless transfer, but I am constantly struck by the overwhelming silence from the physician camp when this is raised. In our state there are midwives working tirelessly at this both in their own communities and in general, but the reception and feedback from our hospital colleagues is consistently tepid. The onus cannot always and entirely be on the midwives alone to improve this. We dont work in the hospital so we can’t do it alone! We need physicians and nursing staff to meet us half way. It’s not enough to begrudgingly say “homebirth is appropriate for low risk women when seamless transfer of care is available when necessary” and then not work with us to make sure that happens. Part of what’s really amazing when midwives and physicians get together to do this is that we hold each other accountable. Midwives are asked to give and change, and physicians too. But more than that we get to sit around tables together under the shared umbrella of our commitment to excellent care of women and babies.

  42. December 16th, 2012 at 13:31 | #42

    I really appreciate this reply to their paper. My colleagues and I have had to deal with McCullough and Chervenak on another issue — prenatal dexamethasone for CAH, wherein they called us “unethical” for asking the feds to look into a first trimester fetal engineering attempt aimed at sex normalization, being pushed on pregnant women as “safe and effective” when there were no studies to show safety or even efficacy. The more I read about McCullough and Chervenak, the more I think their “pro fetus” political stance translates to pro-patriarchy and nothing more.

    Here’s a free paper showing what we found out about this fetal engineering attempt in spite of McCullough and Chervenak trying their best to shut us up: http://www.springerlink.com/content/m1523l7615744552/

    Thank you for fighting against people who think being pro-science means being anti-woman, or vice versa!

  43. December 28th, 2012 at 15:09 | #43

    Re: your article on dexamethasone for CAH.

    Wow. Really have to agree with Chervenak on this one.

    As you mention in your article, children born to mothers with CAH have a significant likelihood of being born with ambiguous genitalia, and in some cases are entirely virilized. This is a significant birth defect that can have substantial impact on future health that can be entirely prevented by treatment with dexamethasone, a steroid that to all available evidence causes no long term harm.

    While you do not come out and say this, the underlying premise of your paper is that congenital malformations of the reproductive tract should be grouped with homosexuality as a normal variant of human development, and therefore it is alarming to suggest that we should try to prevent it. These things are not equivalent. One is a sexual preference and/or sexual identity. The other is a physical malformation.

    You are concerned that someone at some time has suggested that the use of dexa will prevent lesbianism or ‘tomboyism’. These are of course the ideas of someone that has a problem with these things, but are not mainstream thought. In my education in medical school and ob/gyn residency, including extensive education in reproductive endocrinology, I have never even heard these ideas brought up.

    You present an argument that we do not have definitive proof that dexamethasone does not cause long term harm. This is not a good argument. We will never prove definitively that it causes no long term harm. That said, we have many many years of experience to suggest that it doesn’t cause any problems. More importantly, we also have very strong evidence that the use of dexa in CAH mothers prevents reproductive tract malformations. Given that, the risk/benefit is so strongly towards the use of Dexa that I have to agree with Dr Chervenak that to suggest that we should not use this drug is quite misguided.

    Your use of the term ‘fetal engineering’ suggests that you think that a baby born with malformed genitals was the way that baby was supposed to be, and one is harming that infant by preventing that problem. That is just nuts, and that is why Chervenak has a problem.

  44. avatar
    Jessie Valenzuela
    March 10th, 2013 at 23:40 | #44

    Thanks for the article! I trully beleive in homebirth and I agree with you that anyonethat thinks the other way around should responsably show the facts. I love that you illustrate the safety and reduction of intervention in homebirths. It is time for the maternity system to start looking at what homebirth providers are doing right not only for the medical system but for women itself.

    Jessie

  45. avatar
    Anon
    April 11th, 2013 at 18:21 | #45

    Judith Rooks, a CNM in Oregon was testified to evidence of the risks to Homebirth. I am curious if you don’t see this is evidence?
    https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585
    This evidence of a CNM worried about the 6-8 times risk of neonatal death, along with the Colorado and Arizona Homebirth statistics are damning to Homebirth credibility. Now that records are being kept, the real dangers of Homebirth are being realized.

  46. avatar
    Eyecatcher
    March 1st, 2014 at 03:27 | #46

    Melissa Cheyney herself has stated that she estimates that 96% of homebirths are planned. So that’s a pretty tiny percentage of unplanned homebirths that you’re claiming are skewing the Wax data so much. Seems to me whenever there’s a news article about a baby born in the car…the baby lives. Funny that.

    But anyway, to better address your claim, do you have any thoughts on the Cornell study? Since 2003 birth certificates are mandated to reference place of birth and be signed by the attendant. That pretty much rules out the “unplanned homebirth” argument. The recent Cornell study found a *minimum* of 4 times increased risk of death of the baby at homebirth as compared to hospital birth. It only went up from there for VBACs, breech, macrosomes, primips, etc.

    Not only that, but the CDC data would lump homebirth transfers – the “worst of the worst” into the hospital group. So the homebirth numbers are THAT bad, WITHOUT unplanned unattended births and WITHOUT transfers.

    Comments?

  1. December 3rd, 2012 at 08:43 | #1
  2. December 15th, 2012 at 14:30 | #2
  3. April 5th, 2013 at 22:55 | #3
  4. July 24th, 2013 at 23:09 | #4