Last month we saw the pre-release of a homebirth meta-analysis piece that claimed worse outcomes for babies born at home than in the hospital. I wrote about it and the ensuing Lancet insult to women’s rights here. Decades of well-conducted research does in fact support the safety of planned homebirth for women and babies, although here in the US the research has fallen on deaf ears among physicians, their trade union ACOG, and hospitals. In light of the solid new research of the past few years clearly demonstrating the safety of homebirth, how likely is it that “evidence” will ever win the medical industry’s approval of midwife-attended homebirth? I am doubtful. Here’s why.
First, here in the US, the field of obstetrics has effectively limited birthing options and autonomy for women since its inception as a medical specialty earlier last century. While it has had decades to reconsider its “management” of normal birth and repair its relationship with midwives, we haven’t seen much evidence of that. What we have seen are even more aggressive attempts to keep birth under physician domain in the hospital, including fear-based media tactics, the double teaming of the American Medical Association and ACOG to outlaw homebirth, and even attacks against nurse-midwives.
Second, there is ACOG’s confusing relationship with evidence-based practice. In developing clinical guidelines for physicians, it seems to pick and choose among the evidence, sometimes waiting decades after the release of new evidence to update guideline, sometimes ignoring the evidence all together, and commonly flip-flopping its protocols in response to the same evidence. How can we have faith in this entity’s ability to respond timely and sensibly to solid, internationally supported scientific evidence?
In 1998 ACOG published guidelines for the management of Premature Rupture of Membranes (“PROM”) stating: “with term PROM, labor may be induced at the time of presentation or patients may be observed for up to 24-72 hours for the onset of spontaneous labor.” Then, in 2007, ACOG updated the PROM management guidelines in Practice Bulletin No. 80. calling for immediate induction with term PROM, no more wait-and-see allowed. No new evidence was generated before the release of the new guidelines. In fact, the same “Level A” research was used in support of both sets of guidelines.
Then there was the recent VBAC flip-flop. ACOG revised its restrictive VBAC guidelines this summer, offering slightly more wiggle room in its criteria for which women should be allowed to VBAC. It acknowledged the “need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate,” but this admittance only came after the NIH Conference on VBAC convened earlier in the year, where experts evaluated all available evidence and made explicit recommendations directly to ACOG to reevaluate its stance on VBAC. Again, no new research was published. In this instance ACOG simply needed to be held accountable by an independent entity monitoring the quality of maternity care protocols in this country.
And finally, one last example of a “standard of care” protocol not supported by research, but employed by nearly every practicing physician in almost every labor in the US: continuous electronic fetal monitoring. Women were first subject to continuous fetal monitoring in the 1970’s before any studies were conducted on its safety or ability to save baby’s lives. It soon became standard practice across the country and remains so today. We now know that the primary effect of continuous EFM is not more healthy babies — the primary effect of continuous EFM is twice as many c-sections. No less babies are dying because of continuous EFM. ACOG admitted this much in a statement last year on fetal monitoring:
“Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.”
But hold on, burried in a practice bulletin somewhere ACOG actually approves of intermittent fetal monitoring in labor (ACOG Practice Bulletin No. 70 2005): “Given that the available data do not clearly support EFM over intermittent auscultation, either option is acceptable in a patient without complications.” So why, despite all the available evidence demonstrating increased risk to the baby and mother — and ACOG’s support of intermittent monitoring — are women today laboring in hospitals, per physician’s protocols, with monitors strapped to their bellies the entire time? Evidence, you seemed to have wandered off somewhere…..
Back in the world of birth change, many homebirth advocates (as well as opponents) want randomized controlled clinical trials (RCT), often considered to be the “gold standard” in research design, to prove the safety of homebirth. An RCT however is really not an appropriate method for analyzing homebirth. We can’t sensibly randomize women to a certain birthplace and expect to see the same outcomes that women would experience had they chosen their own birth environment, there are endless confounding factors in birthplace that would skew the results, there is the whole psycho-spiritual component to birth experience that cannot be measured quantitatively, etc.
But hypothetically, what if we eliminated all these obstacles to a homebirth RCT and we produced clean, solid research involving thousands of American women and midwives? Given their tenuous relationship with evidence-based practice, is it reasonable to think that obstetricians and ACOG, when presented with impeccable, irrefutable, studies on homebirth, will do an about-face and suddenly embrace the safety, and wisdom of homebirth? From my vantage point, the roots of the anti-midwife, anti-homebirth campaign extend beyond the realm of scientific “evidence” and into more the more mucky dynamics of authority, medical ethnocentrism, hegemonic control of women’s “rights” in childbearing, profit, etc. I’m not holding my breath while we keep piling up the evidence.