Response to ACOG Committee Opinion #476
The American College of Obstetrics & Gynecology has released a new opinion paper on the "dangers" of home birth and the questionable qualifications of those that attend them. Just writing these words leaves me speechless....or keyboard frozen....or whatever! If you have a chance to get a copy of this document please read it critically. It is proprietary so I cannot copy it here but I have written a letter to ACOG president, Richard Waldman, responding to this embarassing, biased, unscientific and inconsistent opinion piece. (see below)
It has been 2 1/2 years since my first letter to ACOG on the subject of home birth. Sadly, they have learned nothing.
January 22, 2011
Richard N. Waldman, MD, President
The American Congress of Obstetricians and Gynecologists
Department of Executive Board Affairs
409 12th Street, SW
PO Box 96920
Washington, DC 20090-6920
Re: Committee Opinion Number 476
Dear Dr. Waldman,
I am an obstetrician who has collaborated with both certified nurse midwives (CNM) and licensed midwives (LM/CPM) in California for more than 25 years and I am a Fellow of the American College of Obstetrics & Gynecology. I, myself, also attend home deliveries. I use my knowledge and experience to make safe, evidenced based decisions and provide true informed consent to my patients. I feel qualified and obligated to, once again, comment on the position taken by ACOG against home birthing in Committee Opinion #476 and on the data from which it seems to be based. It seems from the very outset to be a document biased against home birth choices and those who provide support for them. This paper prefaces its conclusions with claims to support a woman’s right to make a medically informed decision about her birth path but evidently has an agenda to obstruct that right.
In the text of this paper it clearly states that in every measurable parameter of morbidity, except neonatal death, home birth is superior to hospital birth (page 2, paragraph 1) in comparable low risk women. Yet, in the abstract, this conceded fact is minimized in the words, “Specifically, they should be informed that although the absolute risk may be low…” No, the absolute benefits are, indeed, well documented as every reputable study shows. The college does not recommend informing patients that these are hard facts yet goes out of its way to say that “Specifically, they should be informed that…….planned home birth is associated with a twofold to threefold increased risk of neonatal death...” which is an assumption based on very controversial data.
It seems the College relied heavily on a paper by Joseph R Wax, MD in formulating its opinions. I have written the college before regarding the use of level C evidence (consensus opinion) to dictate policy and recommendations. Those of us who truly support a woman’s right to choose her own path based on true, not skewed, informed consent know the damage that can be done by a legitimate organization like ours when it puts out an opinion. The paper by Wax and colleagues is an extremely flawed article. It has been reviewed extensively by many who express legitimate criticisms. None of which ACOG chooses to address. This study demands a critical reading. The meta-analysis of Wax, et al is the weakest type of data and should never be used as an exclusive measure of a topic. The fact that the authors cherry picked this data, including the use of one tiny study with 11 women, to prove its point while ignoring the largest studies from North America and Europe on planned homebirth demonstrates the clear bias. His paper compares apples to oranges. He goes back 40 years, mixes matched cohorts with prospective cohorts and record reviews, mixes urban and rural statistics and admits to many difficulties in interpreting this information including whether an attendant was even present and excludes many legitimate studies that do not fit his theory. His bias is evident throughout his comment section and it seems his sole negative conclusion, of a higher neonatal death rate, from this flawed study is simply mirrored and emphasized by ACOG in Committee Opinion number 476.
Oddly, it seems that combining data from more than 40 years ago to the present time is accepted for the purpose of denigrating midwives and home birth. Would you be so eager to accept that sort of chronology for a conclusion on hospital obstetric practice? Wasn’t it just 25 years ago that ACOG was pushing VBAC so much that their influence led the insurance industry to mandate trials of labor for every woman? And didn’t that lead to an increase in morbidity for mothers and babies resulting in the more draconian ACOG endorsed (but NIH Consensus Statement of March, 2010 refuted) policies that so many hospitals have now embraced to ban VBAC? Would we consider including all those years of ignorance in formulating a consensus opinion paper today to be good science? Let’s be honest here. Of course not! So why is ACOG wedded to the controversial Wax article? In it he also quotes a transfer rate of 25-37% for nulliparous women. This, with modern day selection protocols, is simply untrue. In my extensive experience as a backup physician I can state it is far closer to 10% and only a tiny fraction of those are for anything close to an emergency.
In the ACOG opinion paper the limitations of any meaningful data interpretation are outlined (page 1, paragraph 2). Yet, it seems this awareness is totally disregarded when one analyzes the language of certainty used against home birth in the text. When facts favor homebirth it is written off as “selection bias”. From my decades in the role of a physician backup to Licensed Midwives here in Southern California I can tell you of the excellence of this group of professionals. These midwives go through an extensive training program and apprenticeship, have ongoing education and regular peer review and do wonderful work. Patient satisfaction from the midwifery model of care is consistently rated higher than from care given under the obstetric model. In California, they are licensed by the State Medical Board. This is the same body that licenses physicians. It is simply wrong and rather malicious to state that for “quality and safety” reasons ACOG does not support care given by licensed midwives or certified professional midwives. They deserve far more respect than our organization grants them. I think you know this.
In a letter I wrote to your predecessor in 2008 I asked for an explanation as to the actual experience with regards to home birthing of those who make up the opinion committee. For it defies common sense to believe that anyone on this panel who has actually spent a lifetime supporting or attending home births could condone this paper. In respectful correspondence with Dr. Ralph Hale I received no answer to my question about that nor about why the College felt obliged to so vehemently pursue or support potential legislation against the informed choice option of about 0.6% of pregnant women. It is not that ACOG puts out an opinion that matters to me. It is that this opinion lacks any foundation of solid evidenced based medicine. Truth is our most important value. ACOG should never lower its standards of excellence in research to accept evidence against home birth, HBAC and selected twin or breech vaginal delivery simply because they may disagree with these choices. And where can a woman turn to when her local hospital bans these options and then defends its position citing ACOG opinions and recommendations?
These sorts of opinion documents are biased and self-serving. Physicians and midwives share the same noble goals. The College’s continuing crusade against home birth only serves to hurt its reputation amongst our colleagues in the midwifery, nursing and alternative medicine professions and damages the confidence of the patients we are avowed to care for. It is divisive, unnecessary and fear based. It is especially so when those positions taken are based on flawed data and the motives for doing so remain unexplained. If it looks suspicious it probably is. The College often hides behind the canard of “safety” in its reasoning. It is a bit arrogant to think that only ACOG considers safety a virtue. Albert Camus said,” The welfare of humanity is always the alibi of tyrants”. Ironically, the modern experience and majority of current literature does not support your safety argument when low risk women choose home birth with qualified professionals. There is so much damage being done to women in the hospital setting through interventions that we know to be harmful all in the name of safety and, yet, there you remain silent. Separating mothers from babies, policies prohibiting VBAC and breech, continuous fetal monitoring, immediate cord clamping and unnecessary inductions of labor are but a few. Cesarean section rates of 35-40% are an abomination and inflicting, as yet, untold physical and emotional damage on an entire generation of women and babies.
ACOG committee opinions such as number 476 are misguided at best and will only further restrict options and choice and lead some low risk pregnant women to forced hospital based birthing and its tendencies toward interventions and morbidity that even ACOG agrees often occurs unnecessarily. It may also force informed mothers committed to experiencing their birth plan to have no option but an out of hospital birth. Is this really where our organization’s energy is needed? I consider it my professional, moral and ethical responsibility to write to you in adamant opposition to the questionable conclusions stated in committee opinion 476. For they do not serve us or our patients well and should be reconsidered. I would hope to have the courtesy of a personal response and to an honest dialogue with you.
Sincerely and with respect,
Stuart James Fischbein, MD FACOG
It has been 2 1/2 years since my first letter to ACOG on the subject of home birth. Sadly, they have learned nothing.
January 22, 2011
Richard N. Waldman, MD, President
The American Congress of Obstetricians and Gynecologists
Department of Executive Board Affairs
409 12th Street, SW
PO Box 96920
Washington, DC 20090-6920
Re: Committee Opinion Number 476
Dear Dr. Waldman,
I am an obstetrician who has collaborated with both certified nurse midwives (CNM) and licensed midwives (LM/CPM) in California for more than 25 years and I am a Fellow of the American College of Obstetrics & Gynecology. I, myself, also attend home deliveries. I use my knowledge and experience to make safe, evidenced based decisions and provide true informed consent to my patients. I feel qualified and obligated to, once again, comment on the position taken by ACOG against home birthing in Committee Opinion #476 and on the data from which it seems to be based. It seems from the very outset to be a document biased against home birth choices and those who provide support for them. This paper prefaces its conclusions with claims to support a woman’s right to make a medically informed decision about her birth path but evidently has an agenda to obstruct that right.
In the text of this paper it clearly states that in every measurable parameter of morbidity, except neonatal death, home birth is superior to hospital birth (page 2, paragraph 1) in comparable low risk women. Yet, in the abstract, this conceded fact is minimized in the words, “Specifically, they should be informed that although the absolute risk may be low…” No, the absolute benefits are, indeed, well documented as every reputable study shows. The college does not recommend informing patients that these are hard facts yet goes out of its way to say that “Specifically, they should be informed that…….planned home birth is associated with a twofold to threefold increased risk of neonatal death...” which is an assumption based on very controversial data.
It seems the College relied heavily on a paper by Joseph R Wax, MD in formulating its opinions. I have written the college before regarding the use of level C evidence (consensus opinion) to dictate policy and recommendations. Those of us who truly support a woman’s right to choose her own path based on true, not skewed, informed consent know the damage that can be done by a legitimate organization like ours when it puts out an opinion. The paper by Wax and colleagues is an extremely flawed article. It has been reviewed extensively by many who express legitimate criticisms. None of which ACOG chooses to address. This study demands a critical reading. The meta-analysis of Wax, et al is the weakest type of data and should never be used as an exclusive measure of a topic. The fact that the authors cherry picked this data, including the use of one tiny study with 11 women, to prove its point while ignoring the largest studies from North America and Europe on planned homebirth demonstrates the clear bias. His paper compares apples to oranges. He goes back 40 years, mixes matched cohorts with prospective cohorts and record reviews, mixes urban and rural statistics and admits to many difficulties in interpreting this information including whether an attendant was even present and excludes many legitimate studies that do not fit his theory. His bias is evident throughout his comment section and it seems his sole negative conclusion, of a higher neonatal death rate, from this flawed study is simply mirrored and emphasized by ACOG in Committee Opinion number 476.
Oddly, it seems that combining data from more than 40 years ago to the present time is accepted for the purpose of denigrating midwives and home birth. Would you be so eager to accept that sort of chronology for a conclusion on hospital obstetric practice? Wasn’t it just 25 years ago that ACOG was pushing VBAC so much that their influence led the insurance industry to mandate trials of labor for every woman? And didn’t that lead to an increase in morbidity for mothers and babies resulting in the more draconian ACOG endorsed (but NIH Consensus Statement of March, 2010 refuted) policies that so many hospitals have now embraced to ban VBAC? Would we consider including all those years of ignorance in formulating a consensus opinion paper today to be good science? Let’s be honest here. Of course not! So why is ACOG wedded to the controversial Wax article? In it he also quotes a transfer rate of 25-37% for nulliparous women. This, with modern day selection protocols, is simply untrue. In my extensive experience as a backup physician I can state it is far closer to 10% and only a tiny fraction of those are for anything close to an emergency.
In the ACOG opinion paper the limitations of any meaningful data interpretation are outlined (page 1, paragraph 2). Yet, it seems this awareness is totally disregarded when one analyzes the language of certainty used against home birth in the text. When facts favor homebirth it is written off as “selection bias”. From my decades in the role of a physician backup to Licensed Midwives here in Southern California I can tell you of the excellence of this group of professionals. These midwives go through an extensive training program and apprenticeship, have ongoing education and regular peer review and do wonderful work. Patient satisfaction from the midwifery model of care is consistently rated higher than from care given under the obstetric model. In California, they are licensed by the State Medical Board. This is the same body that licenses physicians. It is simply wrong and rather malicious to state that for “quality and safety” reasons ACOG does not support care given by licensed midwives or certified professional midwives. They deserve far more respect than our organization grants them. I think you know this.
In a letter I wrote to your predecessor in 2008 I asked for an explanation as to the actual experience with regards to home birthing of those who make up the opinion committee. For it defies common sense to believe that anyone on this panel who has actually spent a lifetime supporting or attending home births could condone this paper. In respectful correspondence with Dr. Ralph Hale I received no answer to my question about that nor about why the College felt obliged to so vehemently pursue or support potential legislation against the informed choice option of about 0.6% of pregnant women. It is not that ACOG puts out an opinion that matters to me. It is that this opinion lacks any foundation of solid evidenced based medicine. Truth is our most important value. ACOG should never lower its standards of excellence in research to accept evidence against home birth, HBAC and selected twin or breech vaginal delivery simply because they may disagree with these choices. And where can a woman turn to when her local hospital bans these options and then defends its position citing ACOG opinions and recommendations?
These sorts of opinion documents are biased and self-serving. Physicians and midwives share the same noble goals. The College’s continuing crusade against home birth only serves to hurt its reputation amongst our colleagues in the midwifery, nursing and alternative medicine professions and damages the confidence of the patients we are avowed to care for. It is divisive, unnecessary and fear based. It is especially so when those positions taken are based on flawed data and the motives for doing so remain unexplained. If it looks suspicious it probably is. The College often hides behind the canard of “safety” in its reasoning. It is a bit arrogant to think that only ACOG considers safety a virtue. Albert Camus said,” The welfare of humanity is always the alibi of tyrants”. Ironically, the modern experience and majority of current literature does not support your safety argument when low risk women choose home birth with qualified professionals. There is so much damage being done to women in the hospital setting through interventions that we know to be harmful all in the name of safety and, yet, there you remain silent. Separating mothers from babies, policies prohibiting VBAC and breech, continuous fetal monitoring, immediate cord clamping and unnecessary inductions of labor are but a few. Cesarean section rates of 35-40% are an abomination and inflicting, as yet, untold physical and emotional damage on an entire generation of women and babies.
ACOG committee opinions such as number 476 are misguided at best and will only further restrict options and choice and lead some low risk pregnant women to forced hospital based birthing and its tendencies toward interventions and morbidity that even ACOG agrees often occurs unnecessarily. It may also force informed mothers committed to experiencing their birth plan to have no option but an out of hospital birth. Is this really where our organization’s energy is needed? I consider it my professional, moral and ethical responsibility to write to you in adamant opposition to the questionable conclusions stated in committee opinion 476. For they do not serve us or our patients well and should be reconsidered. I would hope to have the courtesy of a personal response and to an honest dialogue with you.
Sincerely and with respect,
Stuart James Fischbein, MD FACOG