Tuesday, December 05, 2006

ACOG's homebirth policy

Over on Giving Birth With Confidence, there is a post criticising ACOG's recently policy statement on homebirth. The gist of the policy statement is this:
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. Although ACOG acknowledges a woman's right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births.
Not suprisingly, the post from GBWC expresses profound disagreement. I submitted a comment and I look forward to seeing if it will be published. It would be ironic if it were not since they specifically condemn ACOG for being unwilling to engage in a public debate.
ACOG has made it clear, by burying the policy statement in the members-only section of the website, that they do not want dialogue on this issue. Big mistake!
Here's my comment:
There are too many factual errors here to address in one response, but I will start with the most significant.

"With one exception, we have numerous studies published over several decades all concluding that planned o-o-h births in healthy women with qualified attendants result in equally good or better outcomes with much less use of harmful interventions when compared with similar populations receiving conventional obstetric management."

While there are studies that CONCLUDE that homebirth is as safe as hospital birth, there is no study that actually SHOWS homebirth to be as safe as hospital birth. Virtually every study done to date shows that homebirth has an excess rate of preventable neonatal deaths in the range of 1-2/1000. The studies that are commonly cited in support of the safety of homebirth include the following:

1. Janssen's study in the CMAJ, Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. Patricia Janssen was actually compelled to acknowledge in a subsequent issue of the CMAJ that her study does NOT show homebirth to be as safe as hospital birth. Her response includes the following:

Although we tried to ensure that comparison groups met eligibility criteria for home birth, women who choose home birth differ from those who select hospital birth in both measurable and unmeasurable ways...


The purpose of our study was not to determine which method of care was better, home vs. hospital, but rather to assess whether, at the 2-year interval, home birth was safe enough to continue to be offered as a choice for women in the context of ongoing evaluation.


The small number of adverse outcomes among an essentially healthy population of women limits the power of a single study to make valid conclusions.

2. Murphy and Fullerton's 1998 paper in the ACOG journal, Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study which shows a neonatal death rate at homebirth of 4.1/1000. The neonatal death rate for hospital birth of low risk white women during the same time period was 2.5/1000.

3. And the study quoted most often, Johnson and Daviss' 2005 BMJ study, Outcomes of planned home births with certified professional midwives: large prospective study in North America which showed a neonatal death rate of 2/1000. The actual control group is low risk white women who delivered in the hospital that year. The neonatal death rate in that group was only 1/1000.

Initially I was quite suprised that Ken Johnson, a professional statistician made such a serious error. Then I learned that Dr. Johnson held another position: head of the MANA (Midwives Alliance of North America) Statistics and Research Committee. In fact, as you undoubtedly know, Johnson and Daviss have been passionate homebirth advocates for many years, long before they embarked on the study. Furthermore, the study was not funded by an academic institution or a government agency. Rather, it was funded by Foundation for the Advancement of Midwifery, a homebirth advocacy group. The study itself was commissioned by NARM (the North American Registry of Midwives).

So using money from a homebirth advocacy group, NARM, a homebirth advocacy group, hired homebirth advocates Johnson and Daviss to produce a study on homebirth. The conclusion appears to be predetermined. When an industry hires known allies to do a study about that industry, the results are going to be favorable.

The bottom line is that to date, there NO SCIENTIFIC EVIDENCE that shows homebirth to be as safe as hospital birth. Reading the actual papers and understanding the statistical requirements for valid research shows this to be true.

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