ACOG is asking its members to report failed home births. Maybe I am biased but what good is this registry if there is no registry on successes?
Reporting of Unsuccessful Attempts at Home Delivery with or without Adverse Consequences
In 2006 there were 24,970 home deliveries reported in the United States[1]. Obstetrician-gynecologists and other members of the medical community may be faced with the presentation of an obstetrical patient who has attempted home delivery unsuccessfully. The need exists to quantitate the frequency and information of these events. The goal of this registry is to attempt to quantitate when home delivery is unsuccessful and what the outcomes are. To be HIPPA-compliant, no identifying information will be requested. Data points include the state of occurrence, as well as the month and year of delivery, maternal and gestation age, gravidity and parity and obstetric or neonatal complications. An attempt to identify the home attendant type if known will also be useful data.
ACOG appreciates your recognition of this issue and your utilization of this registry to assist us in data collection.
"All that is necessary for the triumph of evil is for good men to do nothing" Edmund Burke, 18th century Philospher.
"A long habit of not thinking a thing wrong gives it a superficial appearance of it being right." Thomas Paine
"The welfare of humanity is always the alibi of tyrants." Albert Camus
"Choice is the essence of ethics: if there were no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose." Margaret Thatcher, March 14, 1977
"A long habit of not thinking a thing wrong gives it a superficial appearance of it being right." Thomas Paine
"The welfare of humanity is always the alibi of tyrants." Albert Camus
"Choice is the essence of ethics: if there were no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose." Margaret Thatcher, March 14, 1977
“It is difficult to get a man to understand something, when his salary depends on his not understanding it.” ― Upton Sinclair
Explaining the Cause
I am a practicing obstetrician who is a strong supporter of patients rights to informed consent and refusal. I believe a patient has the right to choose her own path given true and not skewed informed consent. Following that tenet, just as a woman should be able to choose to have an elective c/section she should be able to choose not to have one, as well. The American system of hospital based obstetric practice has been eroding those choices for women for quite some time. Due to concerns of economics, expediency and fears of litigation women are being coerced to make choices that may not be in their best interest.
I have had a long relationship collaborating with midwives and find the midwifery model of care to be evidenced based and successful. I was well trained at Cedars-Sinai Medical Center in the mid 80's to perform breech deliveries, twin deliveries, operative vaginal deliveries and VBACs, and despite evidence supporting their continued value, hospitals are "banning" these options. Organized medicine is also doing its best to restrict the availability of access to midwives.
Home birthing is not for everyone but informed choice is. Medical ethics dictates that doctors have a responsibility and a fiduciary duty to their patients to provide true, not skewed, informed consent and to respect patient autonomy in decision making. Countries with the best outcomes in birthing have collaboration between doctors and midwives. This is not what has been happening in the hospitals of America. Its time for a change and the return of common sense.
The midwifery model of care supports pregnancy as a normal function of the female body and gives a legitimate and reasonable alternative to the over-medicalized model of birth that dominates our culture. Through this blog I hope to do my part to illuminate what is wrong with our maternity care system and what is right with it. I do not expect all to agree and that is OK. We must all understand that given honest data it is not always reasonable to expect two people to come to the same conclusion. Our differences should be respected.
I have had a long relationship collaborating with midwives and find the midwifery model of care to be evidenced based and successful. I was well trained at Cedars-Sinai Medical Center in the mid 80's to perform breech deliveries, twin deliveries, operative vaginal deliveries and VBACs, and despite evidence supporting their continued value, hospitals are "banning" these options. Organized medicine is also doing its best to restrict the availability of access to midwives.
Home birthing is not for everyone but informed choice is. Medical ethics dictates that doctors have a responsibility and a fiduciary duty to their patients to provide true, not skewed, informed consent and to respect patient autonomy in decision making. Countries with the best outcomes in birthing have collaboration between doctors and midwives. This is not what has been happening in the hospitals of America. Its time for a change and the return of common sense.
The midwifery model of care supports pregnancy as a normal function of the female body and gives a legitimate and reasonable alternative to the over-medicalized model of birth that dominates our culture. Through this blog I hope to do my part to illuminate what is wrong with our maternity care system and what is right with it. I do not expect all to agree and that is OK. We must all understand that given honest data it is not always reasonable to expect two people to come to the same conclusion. Our differences should be respected.
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It would only make sense if all homebirths were reported but there is a contingency of women who will do this unassisted. Many of these women feel like the system failed them, they can't afford the care and or they don't trust the caregivers. Some states have not legalized midwifery, isn't this true? There cannot be accurate counts of homebirths if people are doing it "illegally".
ReplyDeleteArtemis,
ReplyDeletehttp://mana.org/statechart.html lists information about this. There are indeed several states where midwifery is prohibited. A woman delivering at home is not yet prohibited, but the limits and prohibitions against midwives lends to the concern that it's only a step away in these states for homebirthing to be illegal altogether, and gives heavy concern to it being not even a baby step away that homebirth could be considered child endangerment, and thus cause for CPS/DCF to step in and take away the baby.
There can not be accurate counts of homebirths with ACOG won't even accept successful homebirths in their surveying, when they're only collecting information on the small number where intervention ended up being needed, while ignoring the much higher number of births where things went completely normal and were successful
Dr. F,
http://www.acog.org/survey/hdComplications.cfm
now forwards to
https://access.acog.org/eweb/DynamicPage.aspx?WebCode=LoginRequired&Site=ACOG&urlReq=/survey/hdComplications.cfm
The survey questions are no longer reachable without an ACOG ID and password. This angers me. The options for outcome were only listed as, "emergency room, operating room or labor and delivery suite." Convenient that not only is there no option for an out-of-hospital birth being successful, but not having the option will enable them to honestly say that no successful midwife/home/birth center births were reported, and only the small number of people who saw this survey before it went behind lock and key will ever know about the censorship that makes up this incomplete and inaccurate survey. If ACOG was so confident that a survey would show them right, then they need to be willing to accept ALL data. By censoring out a valid option, they're showing something to be afraid of.
As a mother of a child who died after an unsuccessful homebirth, I would like to be able to view the statistics of outcomes from homebirth on both "sides".
ReplyDeleteHere is a partial copy of the survey from ACOG:
ReplyDeleteComplications Related to Home Delivery
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.
If you have been called to attend, whether in the emergency room, operating room or labor and delivery suite, a patient who came to your hospital after an unsuccessful attempt at elective home delivery, please complete the following survey even if there was no adverse outcome. Include only current events after June 15, 2009.
State: Select Month / Year of Delivery: Select Select Year2009
Gravida: 1 2 3 4 or more
Para: 1 2 3 4 or more
Maternal Age: Less than 20 20-25 25-30 30-40
Greater than 40
Gestational Age: Less than 30 weeks 30-36 weeks 36-40 weeks
Greater than 40 weeks
Problem: Cord Prolapse
Obstructed Labor
Malpresentation
Maternal Death
Maternal Injury
Multiple Pregnancy
Postpartum Hemorrhage
VBAC Rupture
Previa/Abruptio
Infection
IUGR
Preterm Labor
Prolonged Rupture of Membranes
Other: (please list)
Fetal Outcome: Fetal/Infant Death
Fetal/Infant Major Injury
Successful Delivery
Pre-Arrival Length of Labor: Select Length of LaborLess than 6 hours6-12 hoursGreater than 12 hours
Home Attendant: Select Home AttendantDoctor (MD)Certified Nurse Midwife (CNM)Certified Professional Midwife (CPM)UntrainedOther
This survey IS NOT collecting any identifying information from the respondents. To help detect accidental duplicate submissions, please select the numeric value of your birthday month + day. (optional) For example: April (4) + 19 = 23. Select
Are the results viewable by the public? Is this survey still active?
ReplyDeleteWhat are your thoughts about unsuccessful homebirth turned emergency and infant death as a result. (sorry that is a loaded question)
I doubt the raw data will ever be viewable to the public. I also will be suspicious of any data that arises from this survey as it is unscientific and ACOG has already has a position statement on home birth that they are committed to.
ReplyDeleteAs to your second question, I will attempt a short answer. There will always be bad outcomes in pregnancy as in life despite well trained personnel and no negligence. Getting pregnant carries with it some risks that are inevitable and must be accepted. There are no guarantees. In general, delivering a baby is designed by nature and is safe. Where it takes place does not matter as much as organized medicine would like you to think. If hospitals were the be all end all then how does one explain the occurance of emergencies and infant death there at similar rates to home birth for low risk labors? There will always be tragic outcomes. What I and my colleagues support is education of patients and the freedom to choose their own path. This is true whether we are talking home birth, VBAC, breech, induction or even elective c/section. In my experience home birth patients and families are much more involved in their birth plans and willing to accept responsibility for their choices than are hospital based patients.
Dr. F... love your last answer there. I have long loved a statement made by Dr. Marsden Wagner:
ReplyDelete"Doctors are human; birthing women are human. To err is human. Women have the right to have any errors committed during their birthing be their own and not someone else's."
What annoys me (and yes I am late to the party, sorry) is that most drs ignore those times that having an attended home birth is safer than the alternative. In my own case with a history of precipitous labors, I determined through my own statistical regression (yes, sorry, I have taken upper level stats and calc), that it was safer to have a 10 -15 min labor at home with a midwife, than have my baby delivered while racing to the hospital (17 mi away) and delivering said baby in the car. In fact, it is safer than being induced early in order to avoid the precipitous labor, which was the main suggestion of local personnel.
ReplyDeleteSo yes, women really should have the right to choose their own errors. As thinking human beings, we can read and reason through the data as needed.