Why the largest study of planned home births won’t sway ACOG
The internet is abuzz about a new study out of the Netherlands comparing the outcomes of planned home birth with those of planned hospital births in low-risk women. With over half a million women involved in the study, it is the largest of its kind. Its findings provide the best evidence to date that perinatal mortality (death of the baby during or soon after labor and birth) and morbidity (measured by likelihood of NICU admission) are no more common in planned home births than in comparable populations of planned hospital births.
The American College of Obstetricians and Gynecologists (ACOG) came out against home birth in 2006. They argued that unexpected complications can occur in labor and birth, so the hospital is the safest bet. Despite the existence of a good sized body of literature on home birth, ACOG emphasized the lack of evidence that home birth is safe, concluding that, by default, a policy of universal hospitalization is the optimal way to organize maternity care. ACOG’s statement reads:
Studies comparing the safety and outcome of U.S. births in the hospital with those occurring in other settings are limited and have not been scientifically rigorous. The development of well-designed research studies of sufficient size, prepared in consultation with obstetric departments and approved by institutional review boards, might clarify the comparative safety of births in different settings. Until the results of such studies are convincing, ACOG strongly opposes out-of-hospital births. (Out-of-hospital births in the United States, ACOG 2006)
OK, so now we have an enormous study with the statistical power to detect important differences in perinatal mortality. Will ACOG change their tune?
Some obstetricians may (and to be sure, there are a good number of OBs who already support home birth and home birth midwives), but ACOG as a professional body will most certainly stick to their guns. A closer look at their statement reveals their bias. ACOG pledges to oppose planned home birth unless and until there are large, well-designed studies on the safety and outcomes a) of U.S. births, b) prepared in consultation with obstetric departments, and c) approved by institutional review boards. This is a carefully constructed catch-22.
Planned home birth accounts for less than 1% of all births in the United States. In order to construct a U.S. study the size of the new Dutch study, every single woman planning a home birth in the United States would have to be enrolled in that study for the next eight years. In addition, we would need reliable databases collecting data about perinatal death based on where a woman planned to give birth, something that the Netherlands has but the U.S. lacks. Even if these hurdles were overcome, obstetric departments and institutional review boards present another barrier. If the dominant view in our maternity care system is that home birth is unsafe, obstetric departments and IRBs would be unlikely to willingly participate in research on hundreds of thousands of babies being born at home.
ACOG will say that a study in the Netherlands does not apply to U.S.-style maternity care, a claim that is based in truth. Because conventional obstetric management holds sway in the U.S., out-of-hospital midwifery is seen as a fringe alternative and poorly integrated into our system here. Contrast that with the Netherlands, where all healthy women are cared for by midwives, and about a third of babies are born at home. Midwives are not just integrated in the system, they run the system. Home birth is certain to be less safe in a system that marginalizes women who choose to give birth at home and the professionals who attend them.
A couple of generations ago, obstetricians led a charge in the U.S. to move birth into the hospital without any a priori evidence that hospital birth was any safer. Now that home birth is all but extinct, the “lack of evidence” on planned home birth in the U.S. serves to bolster ACOG’s position. The U.S. is not fertile ground for home birth research because a professional organization looking out for the power and financial interest of its members has run home birth underground and failed to provide the complementary specialist services that ensure continuity of care and safety when complications arise.
I love this quote from a British policy-maker, shared by Eugene Declercq in his 1998 article, ‘Changing Childbirth’ in the United Kingdom: Lessons for U.S. Health Policy:
To consider it safer, or even to have a consensus view, is not the same as having evidence . . . are you not saying that you have made a policy on the basis of safety which was not justified on the statistics when they did exist, and now you say there is not any possibility of getting statistics? Is that not putting women into a trap?” (House of Commons Health Committee 1991b: 210–211).
We need more and better research on home birth. We can use data from the Netherlands to determine the safety of home birth in systems that support and integrate home birth midwifery. After all, it is the only place left with a maternity care system that lends itself to home birth safety research, and national registers to conduct that research soundly. In the U.S., we must study how we can reform our maternity care system to provide access to midwife-led care in all settings, and best practices for caring for the women who rightly and inevitably will continue to desire birth at home.