ACOG Up to Dirty Tricks

A recent press release details some of the lengths that the American College of Obstetricians and Gynecologists (ACOG) is willing to go to preserve its near-monopoly over maternity care in the United States. In an effort to deter growing numbers of women from seeking out-of-hospital maternity care, ACOG urged its members to submit anecdotal, anonymous "data" (i.e. horror stories) about women who planned out-of-hospital births. This represents an effort to develop an unscientific case against out-of-hospital birth.

ACOG is not a protector of maternal or fetal life -- it is primarily concerned with avoiding competition from midwives that could negatively affect the incomes of its members. A campaign to expose ACOG's efforts to collect unscientific evidence used social networking tools like Facebook, Twitter, and email to encourage thousands of women to submit their own stories about healthy births in private homes and freestanding birth centers on ACOG's website. How did ACOG respond? It "quickly moved to scrub its website and placed its request for unsourced data from members behind a password-protected firewall" (http://www.thebigpushformidwives.org/_ccLib/downloads/8-31-2009_PushNews_RELEASE_Viral_Internet_Campaign_Exposes_Bogus_Research.pdf). The survey is still there, in the members-only section, where it is "protected" from the public. What is likely to happen is that ACOG will then use the unscientific anecdotal data that it can collect from members to support lobbying campaigns directed at denying access to out-of-hospital birth and the midwives who are trained to provide it.

Will this work? Unfortunately it might, because ACOG has professional legitimacy and receives a lot of respect from members of the media and the general public. That's why advocates of reproductive rights -- which includes the choice of where and with whom to give birth - must increase awareness of what ACOG is doing. Otherwise ACOG will bring out their "data" to support opposition to out-of-hospital birth whenever the press offers them some attention. More people need to recognize that ACOG is a trade association (i.e. a cartel) that tries to protect its members from competition. Its primary goals do not include promoting science or evidence-based maternity care -- obstetrics is one of the least evidence-based specialties in all of medicine. In fact, the cherry-picked horror stories are designed to discourage women from examining the evidence and making rational decisions about where, and with whom, to give birth. Meanwhile, two recent well-designed, scientific studies of homebirth in the Netherlands and Canada, both published this year, provide solid evidence that planned out-of-hospital births have comparable perinatal mortality rates, lower rates of serious maternal and neonatal morbidity, and fewer interventions than hospital births among women who meet eligibility requirements for homebirth. These studies were well-designed scientifically because they compared women with the same level of "risk." (See Amy Romano's excellent summary of the results here, or a press release on the Canadian results here.) Given an opportunity to examine real evidence, like that in these recent studies, many women may rationally choose to give birth outside a hospital setting, and that's exactly what ACOG is going to desperate measures to prevent.

Obviously birth activists who want pregnant women to have the option of midwifery are interested in this, but really everyone should care about ACOG's self-serving behavior, which violates principles of anti-trust and is also relevant for the health reform debate. Maternity care in the U.S. is much more expensive than any other developed nation and has far worse results -- higher infant and maternal mortality, more premature and low birth-weight babies, and more infants in the NICU. Having a baby is the most common cause of hospitalization, and cesarean sections are the most common surgery in the United States. Out-of-control cesarean rates (around 1 in 3 births) and high-intervention obstetric care for low-risk women represent huge cost burdens on the system as a whole. The health reform debate has said little about maternity care, and that is a major omission. One of the best ways to reduce health care costs while improving results is to better integrate midwifery care and out-of-hospital birth into the health care system. But ACOG clearly doesn't want that to happen, since it would reduce its members' bottom lines. It's time for this cartel to be broken up.

Follow Louise Marie Roth on Twitter: www.twitter.com/louiseroth

Comments

[femadvocate]

Amy, it is important to note that there are not only two types of midwives. You have referred only to Certified Nurse Midwives and to lay midwives, forgetting about the Certified Professional midwife. CNMs are university trained and most of them have their clinical training in hospital settings. CPMs on the other hand, are trained through apprenticeship, do most of their clinical work in homes, and then become certified through the North American Registry of Midwives. In order to becomed certified they have to meet a series of requirements, which include a certain number of contact hours with clients prenatally, during birth and in the post-partum period, all under supervision. There is a long list of clinica skills which they have to prove to be proficient in, and thay have to sit for a nationally recognized board exam. This is VERY different than what you are calling a lay midwife, which is somebody who has no legal certification. This is not to say that many, many lay midwives don't provide extremely proficient care and carry much experience, I just thought it important to point out the difference. It is not a two-tiered system (CNMs vs. lay midwives), as you suggest, rather it is three-tiered. And in my opinion, both CNMs and CPMs fulfill requirements that render them completely capable of caring for women in their child bearing years.

[AmyTuteurMD]

Certified Professional Midwives are just a form of lay (direct entry midwife). CPMs are the ones who are grossly undereducated and undertrained. The CPM credential does not meet the standard for any midwifery in Canada, the Netherlands, Australia or any first world country.

For example, this is a comparison of the clinical requirements for European midwives and CPMs:

EU midwife---­----------­----------­-- homebirth midwife

100 ----- pre-natal examinations----- 75

40 ----- deliveries----- 25

40 ----- caring for high risk patients----- none

100 ----- postpartum patients----- 40

40 ----- newborns who need special care----- none

So when it comes to clinical requirements, CPMs have 25-60% LESS experience caring for healthy women, and NO experience caring for pregnancy complications and NO experience caring for newborn complications. This illustrates one of the central shortcomings of CPM training; there is no experience diagnosing and managing complications.

Anyone can catch a baby; no special training is required. The most critical function of a birth attendant is to diagnose, prevent and manage complications. CPMs have literally no clinical training in doing so.

[sburgernutr]

I will certainly read the statistics from the CDC link that Amy has posted. Yet, even if the way in which the statistics are collected provides probable and plausible evidence that American home birth midwives are not as well trained and safe as certified nurse midwifes, this is still irrelevant to the fact that ACOG is proposing an epidemiologically invalid "fishing" expedition designed to restrict trade. It is junk science of the worst and most deceptive nature. The answer would not be to restrict home births, but to improve the training.

Furthermore, this is a serious deflection from the much larger morbidity and mortality caused by many unnecessary procedures that hospitals inflict upon women without evidence or consent on a much much larger population of American women. This is the larger problem that ACOG should be addressing. The United States has abysmal statistics on neonatal mortality compared to any other developed country.

And the evidence itself may be skewed by who is collecting and analyzing the data. Most evaluations of birthing practices stop at the APGAR score. Many complications and even deaths occur much later than in the hospital, particularly in regards to breastfeeding. On a daily basis I see a huge array of iatrogenic­ally-induc­ed breastfeeding problems. Rogan and Chen showed that the increased risk of death is over 20% higher in infants who are formula fed.

Amy, is it true that you are not licenced? Have you taken any epidemiology courses?

Susan E. Burger, MHS, PhD, IBCLC

[AmyTuteurMD]

I just explained that homebirth with an American homebirth midwife nearly TRIPLES the rate of neonatal death. That means that even when you take into account the so-called "unnecessary" procedures that you claim increase mortality, homebirth increases it even more.

I strongly recommend to you and to anyone interested in the subject to review the scientific evidence for yourself. The only people who claim that homebirth is safe are homebirth advocates. That's because the actual scientific evidence shows exactly the opposite.

All the existing scientific evidence (including papers that claim to show that homebirth is safe) actually shows that homebirth nearly triples the risk of neonatal death. All the state and national statistics show exactly the same thing: homebirth nearly triples the risk of neonatal death.

No one in a position to dispute this point has been willing or able to do so. Henci Goer does not dispute it. Jennifer Block does not dispute it. Amy Romano of Lamaze does not dispute it. They simply ignore it.

The choice to have a homebirth is up to the individual woman, but no one can make an informed choice if they don't have accurate information. The truth is available for anyone to see, and I believe strongly that any woman can understand it if she looks at the actual data. Don't take anyone else's word for it. Make up your own minds.

[Louise Marie Roth - Huffpost Blogger]

Dr. Burger,

I couldn't agree more about improving training rather than restricting home births. I was speaking to someone recently who is a midwifery advocate who has been involved with midwifery schools and birth centers for a long time and believes that the current training of Certified Professional Midwives (CPMs) should be more rigorous. I do not know enough about CPM training myself to make that kind of call. But even if CPM training could be improved, that is not a reason to restrict access to out-of-hospital birth and tell women that they have no choice. The goal of everyone who cares about birth, and about neonatal and maternal mortality and morbidity, should be to improve outcomes for all choices. One thing that would help would be to better integrate midwifery into the health care system in the U.S., thus improving back-up for cases that require it. Ensuring that CPMs receive training that is equally rigorous to that in countries where midwifery has been better integrated and where out-of-hospital births have a good track record would be useful as well.

[enjoybirth]

Thanks for your article! It is crazy to me that they are fishing for information this way. There is no way that it could be considered valid responses.
A doula friend came up with a survey of her own.
http://enjoybirth.wordpress.com/2009/08/28/response-to-acog-homebirth-survey/

[clementine mec]

Why is it that OB's do not feel compelled to offer true data? Midwives are so used to being scrutinized that they go out of their way make apparent the validity of their data. OB's are so used to not being scrutinized, so used to being believed without question, that they make statements they cannot back up with solid data. It is taking time, but slowly women are becoming aware of the fact that OB's do not have their (or their baby's) best interest in mind. The AMA is a for-profit enterprise, looking out for its' own interests, and obstetrics is a litigation-driven practice, as far from evidence-based medicine as you can get.

[AwmaSes]

The real issue is that American OBs chemcially and mechanically manpulate labor and childbirth in the U.S., harming babies and their mothers, and by extension the whole family. Sadly, the board room doors have remained closed to the public, keeping the truth under wraps for far too long.

This alone is chilling: almost all American women giving birth are given two unnecessary puncture wounds (in the vein and in the spinal column) plus a catheter, AND the amniotic sac is very often ruptured artificially with a metal or plastic instrument. THEN most women receive frequent vaginal/cervical exams by several different people (again, technically unnecessary, unless you're running an birth factory). All that takes place in a hospital where supergerms run rampant. Several major risks for entry of infection without any original medical need for any of them, and in a normal birth there is no benefit to any of the procedures, either. That is despicable.

Then add the statistical chances of a mistake. Every single procedure carries an error rate. By the time the baby is just five or 10 minutes old there have been DOZENS of medically unecessary procedures done, all which carry inherent risks and offer no real physiological benefits to offset the risks.

The fact that midwives take a more scientifically sound, hands-off approach and monitor but don't manipulate, in a nutshell, is why midwives have a much lower infection and injury rate than OB's (even when comparing only low risk women).

[AmyTuteurMD]

I noticed that no one has addressed the basic issue. American homebirth midwives have a neonatal mortality rate almost triple the rate of low risk hospital birth. It also triple the neonatal death rate for homebirth in Canada and the Netherlands.

Are American women supposed to ignore the fact that American homebirth midwives have dismal mortality statistics? Are American women not entitled to the same level of safety in homebirth as Canadian and Dutch women? Are American women not entitled to midwives with the same level of education and training as Canadian and Dutch women?

There is a two tier midwifery system in the US: highly trained nurse midwives, and homebirth midwives who merely have post-high school certificates. No other country in the industrialized world has a two tier system. In every other first world country, all midwives are educated and trained to the same high standard.

Canada used to have a two tier system until they insisted that so called "direct entry" midwives must meet the same standards as university trained midwives. The US should do the same. American women and babies deserve no less.

[Jennifer Carter]

Amy, I could not find the statistic on CDC website to which you are referring. Would you care to post a link?

[AmyTuteurMD]

You can find the data on the CDC Wonder Website. Click on Infant Deaths, and then click on Linked Birth/ Infant Death Records 2003-2005. This gives you access to the complete database.

You can search the database for neonatal mortality rates (infant mortality is not the relevant measure of obstetric care) by provider and place of birth. Be sure to limit the query to term pregnancies in low risk women.

[Gina Crosley-Corcoran]

I certainly have a hard time understanding how an MD, in any good conscience, could ignore statistical and empirical evidence and spread lies the way Amy Tuteur and the ACOG does. She's not even a licensed physcian anymore, so I venture to say she's not afraid of this information hurting her practice. Or maybe it will just hurt her blog revenue?

How could a physician deny me autonomy and reproductive health, all in the name of keeping their dance card full? It seems criminal, doesn't it? Well, it actually is criminal to force a woman to have any type of treatment she does not want (and usually doesn't need). Unfortunately not enough women know their legal rights, so this is where we end up.

[Stuart Fischbein]

As a newly trained physician just out of residency back in the 80s I remember inviting my parents to Las Vegas for my formal acceptance ceremony into the fellowship of ACOG. I was so proud to be a part of what I thought was the pinnacle of my profession. ACOG does many good things and their continuing education isbeneficial. But, all too often of late, they have done some really stupid things. ACOG has released several Committee Opinions that defy evidenced based research, common sense and fail to respect a woman's autonomy and choice. Whether they or their blind supporters and shills like Amy agree with out of hospital birth is not the real question. To make statements based on "consensus opinion" that are purposely designed to remove choice is unscientific, unprofessional and belittles their organization. Those that are behind these pronouncements know what they are doing will influence policy, insurers and hospital administrators. It is an abuse of power and wholly unhypocratic. Patient autonomy and choice as well as honesty are the issue here. Whether readers, shills or ACOG are supportive of home birth and midwifery or not we should all strive for respect of the patient's intelligence, dignity and liberty. ACOG comes out last year with a statement against out of hospital birthing and now puts out a call for stories to back up their opinion? Isn't that sort of backwards, insulting and poor research technique? Simply embarassing. Not the pinnacle anymore.

[mkruse21]

But seriously, my wife is pregnant (due in about three weeks) and we are planning a home birth with a CNM and so happy with all of the choices we've made.

As Louise pointed out, OB's are surgeons trained to handle complications. Most women don't have complications if you let their bodies do what they have evolved to do. But then the OB's will have a much more boring job, and they won't get paid as much, so there you go.

[mkruse21]

More myths about birth...

2.) A woman in labor can hardly be called a person with rights - it is more accurate to think of her as a vessel that is carrying a baby. As we already know that pregnancy and labor are dangerous medical conditions, the job of hospital staff is to get that baby out of the mother as quickly as possible, all the while monitoring the baby for any signs of fetal distress.

As such, the convenience of hospital staff is paramount, and the woman should keep her mouth shut and do what she is told to allow them to save he baby from the toxic environment of the womb. She should lie on her back and not move unless told to, so as to better allow the electronic fetal monitoring that is the baby's best chance of survival.

3.) OB/GYN's are busy, what with having to save so many babies and all. They need some time to rest and relax, which is why we should be concerned about the C-section rate in this country. 1/3 is far too low. We should work for 100% so that each procedure can be scheduled so as not to interfere with the doctor's tee time.

[mkruse21]

Louise, you seem to be laboring (forgive the pun) under a few plainly false assumptions, and I'd like to take some time to dispel them. Please insert tongue into cheek...

1.) Being pregnant is a medical condition, and thus is requires a medical procedure to cure it. At least, that's what insurance companies call it, as they consider it to be a 'planned illness.' We all know that insurance companies are the ultimate authority on medical issues, and they have no goal whatsoever besides keeping Americans healthy, so how can you argue with them?

Pregnancy and birth are not in any way natural life processes that have been happening just fine without medical intervention for the entire history of the human race. We all know that humanity was very lucky to propagate itself at all in the tens of thousands of years when women gave birth at home wife midwives or (God forbid!) a female family member. It is only since birth was moved to hospitals in the last 100+ years (by men, of course) that women have had a fighting chance.

[Elizabeth Allemann]

You accurately summarized the study, but not in clear enough terms. Women cared for at home and their babies did much better than the women cared for in hospital. Lowest rates of maternal bleeding, serious vaginal tears, maternal fever, need for newborn resuscitation, low assessments of newborn well-being (Apgar), need for ventillor for >24 hours were in the group cared for at home.

Had the results gone the other way, many would call for the elimination of home birth. It is time to demand that hospital-based maternity care up to the standards of midwifery care at home. Maybe we physicians have a lot to learn from midwives.

Elizabeth Allemann, MD

[chandasz]

Add this to the list of patronizing and absurd pronouncements from ACOG. They also recently released that women should be "allowed" moderate amounts of liquids in labor and how "welcome" that will be. The absurdity is that restricting our access to food and drink in labor is completely without scientific merit and does more harm than good and we've known that for many years yet they still continue to control this.

Yet another example of bad science from ACOG

[AwmaSes]

No, Amy, it is more important that people understand that most birth emergencies in hospital births are caused by the setting or the habit-based procedures which defy scientific evidence, much like your posts. Google "pit to distress" for just one atrocious example of how American obstetrics systematically hurts women and babies. Your statistics are unscientific and have been refuted by far more reputable sources.

In fact, the public health community is strongly behind out-of-hospital birth, and the world's most prestigious peer-reviewed journals have published manystudies that show certified professional midwives provide safer care than healthy women can expect in the average hospital birth for themselves or their babies. The United States has a shameful track record at the hands of obstetricians.

It's time for America to wake up and throw off the vultures that are gorging on birthing mothers and our babies.

[AmyTuteurMD]

It is well known that planned homebirth with an American homebirth midwife dramatically increases the risk of neonatal death. According to the Linked Birth Infant Death data collected by the CDC from 2003-2005, homebirth with a direct entry midwife (as opposed to a certified nurse midwife) nearly triples the risk of neonatal death.

The Midwives Alliance of North America, the trade union for homebirth midwives has been collecting safety data as well, encompassing the years 2001-2008. That data has been offered publicly to those who can prove they will use it for the "advancement" of midwifery and who sign a confidentiality agreement legally prohibiting them from sharing the information with anyone else. It does not take a rocket scientist to suspect that MANA is hiding its own safety data because it shows that homebirth with a homebirth midwife increases the risk of neonatal death.

It is important to understand that American homebirth midwives are grossly undereducated and undertrained. They have far less education and training than certified nurse midwives, Canadian midwives, Dutch midwives, Australian midwives, or any other midwives in the industrialized world. The lack of education and training is reflected in their dismal mortality statistics.