Friday, June 20, 2008

What Would an Evidence Based Statement from ACOG Say?

I just got the summer issue of Midwifery Today. In it was an article by Judy Slome Cohain in response to the ACOG homebirth statement issued in February. Given all of the recent uproar over the AMA's resolution, I thought her piece was very timely. It is called "What Would an Evidence-based Statement on Homebirth from ACOG Say?" and it opens like this:

"This is the statement ACOG would file if facts interested them: We at ACOG recognize that, according to our most recent poll, none of our members have homebirth practices and, therefore, making a homebirth statement is unnecessary since this subject is outside the expertise of ACOG members. For the purpose of making an informed choice, consumers should not look to ACOG for a statement on this subject."

:-D

2 comments:

judy said...

The article continues: Cochrane Reviews found only one qualified controlled study involving 11 women comparing hospital birth to homebirth. Cochrane reviews conclude:”The change to planned hospital birth for low-risk pregnant women in many countries during this century was not supported by good evidence. Planned hospital birth may even increase unnecessary interventions and complications without any benefit for low-risk women."
ACOG surmises that, according to the available research, planned homebirth with a trained attendant is as safe or safer than hospital birth for healthy women with a full term (37-42 weeks) single fetus in the head-down position. Approximately 80%, or over 3,000,000 US pregnancies per year fall into this category.
In the case of multiple fetuses, non-vertex position, pregnancies complicated by high blood pressure, Type 1 or Type 2 diabetes, second or third trimester bleeding, pre- or post-term pregnancy, research has established that hospitals have better outcomes. Further enumeration of every rare pregnancy complication that makes hospital birth safer than out-of-hospital birth is not appropriate here.
VBAC must be analyzed in terms of whether the woman intends future pregnancies. In the case of a pregnancy following a cesarean, healthy women who are sure they will have no subsequent pregnancies will have the best outcomes (infant mortality rate of 1/1000) if they deliver the current pregnancy in hospital. Healthy women who are considering subsequent pregnancies in addition to a current pregnancy that follows a cesarean delivery would do better to deliver out-of-hospital in a place that has a 10- to 15-minute transfer time to hospital and achieve an infant mortality rate of 2/1000, but have an infant mortality rate of 1/2000 on all subsequent pregnancies.
ACOG does not differentiate between birthing centers or homebirth, but rather suggests that women who deliver outside of hospital be aware of the availability of ambulance service in their area. In some areas, it is possible to pay an ambulance to sit outside the home at the time of birth for the rare need to transfer.
We suggest that medical insurance pay for homebirth as a way to bring down health care costs in the US. We recognize that at present homebirth is rare: Only 1/1000 women give birth out of hospital. We suggest that medical insurance companies pay women an incentive to have planned homebirths attended by a trained attendant, since they cost half of what the hospital costs.
ACOG regrets our current lack of commitment to reducing the cesarean delivery rate and the resulting spiraling increases in the cost of health insurance. We would like to change this by supporting the evidence-based 50% rate of cesarean in high-risk pregnancies and a 10% to 15% rate of cesarean section for low and no risk pregnancies in hospital and recognize that most out-of-hospital practices have documented excellent outcomes with 1%–4% cesarean section rate.
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judy said...

Cochrane Reviews found only one qualified controlled study involving 11 women comparing hospital birth to homebirth. Cochrane reviews conclude:”The change to planned hospital birth for low-risk pregnant women in many countries during this century was not supported by good evidence. Planned hospital birth may even increase unnecessary interventions and complications without any benefit for low-risk women."
ACOG surmises that, according to the available research, planned homebirth with a trained attendant is as safe or safer than hospital birth for healthy women with a full term (37-42 weeks) single fetus in the head-down position. Approximately 80%, or over 3,000,000 US pregnancies per year fall into this category.
In the case of multiple fetuses, non-vertex position, pregnancies complicated by high blood pressure, Type 1 or Type 2 diabetes, second or third trimester bleeding, pre- or post-term pregnancy, research has established that hospitals have better outcomes. Further enumeration of every rare pregnancy complication that makes hospital birth safer than out-of-hospital birth is not appropriate here.
VBAC must be analyzed in terms of whether the woman intends future pregnancies. In the case of a pregnancy following a cesarean, healthy women who are sure they will have no subsequent pregnancies will have the best outcomes (infant mortality rate of 1/1000) if they deliver the current pregnancy in hospital. Healthy women who are considering subsequent pregnancies in addition to a current pregnancy that follows a cesarean delivery would do better to deliver out-of-hospital in a place that has a 10- to 15-minute transfer time to hospital and achieve an infant mortality rate of 2/1000, but have an infant mortality rate of 1/2000 on all subsequent pregnancies.
ACOG does not differentiate between birthing centers or homebirth, but rather suggests that women who deliver outside of hospital be aware of the availability of ambulance service in their area. In some areas, it is possible to pay an ambulance to sit outside the home at the time of birth for the rare need to transfer.
We suggest that medical insurance pay for homebirth as a way to bring down health care costs in the US. We recognize that at present homebirth is rare: Only 1/1000 women give birth out of hospital. We suggest that medical insurance companies pay women an incentive to have planned homebirths attended by a trained attendant, since they cost half of what the hospital costs.
ACOG regrets our current lack of commitment to reducing the cesarean delivery rate and the resulting spiraling increases in the cost of health insurance. We would like to change this by supporting the evidence-based 50% rate of cesarean in high-risk pregnancies and a 10% to 15% rate of cesarean section for low and no risk pregnancies in hospital and recognize that most out-of-hospital practices have documented excellent outcomes with 1%–4% cesarean section rate.