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Re: ACEO Statement regarding ACOG StatementFrom: acmidwife@netscape.netMon Nov 27 15:24:12 2006
Hmmmmm. While 70% may be healthy aka low risk.... not all of them may not desire a home birth.... even if it might be the better option. Still.... this is an interesting statement..... considering what is transpiring on the political side of life for the homebirthing community and all those involved in providing care to women. ac mase CNM -----Original Message----- From: Stmidwife@aol.com To: ob-gyn-l@dns.obgyn.net Sent: Mon, 27 Nov 2006 3:55 PM Subject: ACEO Statement regarding ACOG Statement ACEO Statement of Policy As issued by the ACEO Executive Board OUT-OF-HOSPITAL BIRTHS IN THE UNITED STATES Seventy percent of the childbearing population in the US is healthy and enjoys a normal pregnancy. For this population, labor and delivery is a physiologic process that most women experience without complications.[1] Physiological management of normal childbirth is the science-based model of care for healthy women who are experiencing a normal pregnancy. [2] Physiological is defined by Stedman’s Medical Dictionary as "in accord with, or characteristic of, the normal functioning of a living organismâ€. It is the standard used worldwide by family practice physicians, midwives and obstetricians in countries that achieve better maternal-infant outcomes at much less expense than the US. [2, 3] The principles of physiological management are both preventative and protective.[4] They are associated with the lowest rate of mortality and morbidity for both mothers and babies; its methods are also protective of the mother’s pelvic floor. It is both safe and cost-effective, with a cesarean rate as low as 4%. [5] To achieve such good outcomes, birth attendants providing physiological care are careful not to disturb the natural process and to minimize technological interventions. [6] This model of normal childbirth includes monitoring the physical, psychological and social well-being of the mother via continuous hands-on assistance during labor and delivery. Women who require medical attention are identified and referred to the appropriate specialist. Normal management of childbirth emphasizes informed choice, continuity of care, patience, social and emotional support, maternal mobility and upright positions, non-drug methods of pain relief and the right use of gravity. The positive influence gravity, in combination with maternal mobility, stimulates labor, dilates the cervix and helps the decen t of the baby through the bony pelvis. [7,8,9,] This not only assists the biological process, but also diminishes the mother’s perception of pain, perhaps by stimulating the release of endorphins [10]. Obstetrical intervention is reserved for complications or at the mother’s requests. Due to a historical bias in medical training in the US, [11, 12,13,14] only professional midwives are currently being trained to provide physiologic care. As a result, the physiological management of normal childbirth in the US is only available in out-of-hospital settings – independent birth centers and planned home birth. The decision by healthy childbearing women with normal pregnancies to labor at home or in free-standing birth centers is a responsible choice amply supported by the scientific research. When labor progresses normally, it is as safe to give birth in an out-of-hospital setting as it is in a hospital. [3,5,6,15,17] 2 Healthy women do not normally benefit from the popular system of interventionist obstetrics known in the US as the “obstetrical packageâ€. [16,17] These hospital-based protocols include drastically increased rates of drug and anesthetic use, episiotomy, instrumental delivery (associated with stress incontinence), and cesarean surgery. [18,] High rates of obstetrical intervention are associated with greater frequency and severity of complications, including delayed and downstream problems in future pregnancies. [19-24] When the obstetrical package is applied routinely to healthy women with normal pregnancies, as it is in the US, it provides the opposite of evidence-based care. None the less, the obstetrical profession remains convinced that immediate availability of obstetrical expertise and interventions associated with planned hospital birth is an important component in saving the life of mother, fetus or newborn and reducing the likelihood of an adverse outcome. Unfortunately, the lack of obstetrical support for normal biology, paired with the excessive use of obstetrical interventions in hospital birth (often the result of practicing ‘defensive medicine’) introduces such a high rate of iatrogenic complications that any potential advantage is eliminated and the rate of complications for healthy women is actually increased two to ten fold [5,6]. The obstetrical package for a healthy population – including the elective use of cesarean – is not healthier, safer, cheaper or better for society than physiologic birth. [17-24] For these reasons, the American College of Evidence-based Obstetrics (ACEO) believes that the hospital, including a birthing center within a hospital complex, is NOT the safest setting for labor, delivery and the immediate postpartum period. The only exception to this is for women who are planning to receive labor stimulants, n arcotic pain medications and/or anesthetics, and thus will need and benefit from medicalized care. As currently practiced, obstetrics is an ‘expert’ system that has failed most in the very area it was supposed to have the most mastery and expertise -- preserving the health and well-being of already healthy mothers and babies. [16,17,18] Until the time-tested principles of physiological management are incorporated into medical training and the obstetrical profession routinely utilizes physiological management when providing care to healthy women, the ACEO strongly opposes hospital births for healthy women. However, ACEO supports providing conditions that will improve the childbirth experience for women and their families without compromising safety, regardless of the setting chosen by the mother or required by necessity. As noted through out this policy statement, studies comparing safety, intervention rates and outcomes of planned hospital births with planned home and birth-center births have been scientifically rigorous in nature and abundant in number. It is the consensus of the scientific literature that planned home birth and independent birth center births are associated with safety, good outcomes and cost-effectiveness, with significantly reduced rates of medical and surgical intervention, operative delivery and subsequent complications. California studies suggest that low-risk women who choose a physiologically managed birth in an out-of-hospital setting will experience as low a perinatal mortality as low-risk women who choose a hospital birth under management of an obstetrician, including unfavorable results for transfer from the home to the hospital. [6, 25] 3 The development of well-designed studies of sufficient size, prepared in consultation with professional midwives and other birth attendants trained and skilled in physiological management, might further clarify the comparative safety for births managed under these dramatically different styles. This would lead to the reform of our national maternity care policy by integrating physiological principles of management with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. Physiological management should be the foremost standard for all healthy women with normal pregnancies, used by all practitioners (physicians and midwives) and in all birth settings. [26] Although ACEO acknowledges a woman’s right to make informed decisions regarding normal birth, the ACEO questions the ethics and efficacy of exposing healthy women with normal pregnancies to the iatrogenic and nosocomial component of the obstetrics package and the added expense of associated complications. Until such studies are able to establish beyond a reasonable doubt that the obstetrical package is no longer a vector for iatrogenic complications in healthy childbirth, the ACEO must continue to oppose hospital-based maternity care for normal childbirth. For that reason, ACEO does not support programs or individuals that advocate for or who provide hospital birth services that impose the protocols of interventionist obstetrics on healthy women with normal pregnancies. References: 1. Statement of Policy on Out-of-Hospital Birth in the US; American College of Obstetricians and Gynecologists (ACOG); Executive Board, October 2006 2. Care in Normal Birth; a practical guide, Maternal and Newborn Health / Safe Motherhood Unit; World Health Organization Geneva. 1996 3. A Guide to Effective care in pregnancy and childbirth, Enkins, M et al 3rd ed. Oxford University Press 2000 4. The Preventable Cesarean Section Program, Sagady, M and Gordon, H, (1998) Outcome Management Associates, Raleigh, NC 919-558-8202 5. Outcomes of Planned Home Births in North America by certified professional midwives: large prospective study, Johnson, K and Daviss, B; British Medical Journal, June 2005; 6. Safe Alternatives in Childbirth; Peter Schlenzka, PhD, Doctorial Thesis, Stanford University, 1999 current contact info: 135 Seabreeze Place, Aptos, CA 95003 7. Women Giving Birth; Astrid Limburg & Beatrijs Smulders; (originally published in the Netherlands) Celestial Arts, 1992 8. Vertical position during the first stage of the course of labor and neonatal outcome; Caldeyro- Barcia, R, et al; Eur J Obstet Gynecol Reprod Biol 1980; 11:1-7 9. Why Deliver in the Supine Position? Allahbadia, G, Vaidya, P, Aust NZ J Obstet Gynecol; 32/2 104-106, 1992 10. Non-pharmacological methods of pain relief during labour; in: Chalmers I et al (eds) Effective care in pregnancy and childbirth, Oxford University Press, 1989 11. The Midwife Problem and Medical Education in the US; Williams. J; Transactions, Am. Assoc. for the Study and Prevention of Infant Mortality; Franklin Press, Baltimore, Md 1911 12. The Fads and Fancies of Obstetrics: a comment on the pseudoscientific trend in modern obstetrics, (1921) Am J. Obstet. Gynecol. Vol 2, page 233 13. The Principles and Practices of Obstetrics; DeLee, J, 4th ed. W.B. Sounders, 1924 14. The Elimination of Midwifery in the United States -- 1900 through 1935, DeVitt, N; doctoral thesis, Harvard Press, 1975 15. Where to be Born? The Debate and the Evidence, Campbell, R. & Macfarlanes, A (1994) 4 National Perinatal Epidemiological Unit, Oxford, UK 16. Safer Childbirth? A critical history of maternity care, Marjorie Tew, Medical Research Statistician, (1990) Chapman & Hall 17. Obstetrics Myth Versus Research Realities – a guide to the Medical Literature; Henci Goer, Berrgin& Garbey, 1995 18. Listening to Mothers Surveys (2002, 2004, 2006) @ http://www.maternityWise.org 281 Park Ave S New York, NY 10010 (212) 777-5000 19. What Every Pregnant Woman Needs to Know about Cesarean Section, a systemic review of the scientific literature by the Maternity Center Association of NYC, 2004 20. The Use of Episiotomy in Obstetrical Care: A Systematic Review; Agency for Healthcare Research and Quality, Evidence Report /Technology Assessment Number 112, May 2005 21. Report of the ACOG Task Force on Neonatal Encephalopathy & Cerebra Palsy July 2003 22. Postpartum Maternal Mortality and Cesarean Delivery; C. Deneux-Tharanux, MD et. al; Vol 108, No 3, September 2006Obstetrics and Gynecology 23. Public Health Implications of Cesarean on Demand, Plante, L; CME REVIEW ARTICLE Volume 61, Number 12 2006 by Lippincott Williams & Wilkins 24. Ob.Gyn.News – http://www.obgynnews.com Elective C-section Revisited - by Dr. Elaine Waetjen 08/01/02 C-Section Linked to Stillbirth in Next Pregnancy 05/15/03 Maternal Morbidity Rises Sharply with Repeat Cesareans 03/15/05 Prior C-Section Assoc. with Worse Outcomes – ICU Admit, PP infection 03/01/05 Study Shows Elective Cesarean Riskier than Vaginal Delivery 05/01/04 Asthma Associated with Planned Cesarean 05/14/03 Cesarean Birth Associated with Adult Asthma 06/15/01; Offering C-Section ‘On Demand’ Can Be Ethical: ACOG 12/01/03 Cesarean Rate Portends Rise in Placenta Accreta 03/01/01 Placental Invasion on the Increase, hike in C-Section may be responsible 01/15/03 Placenta Pr rnia State Legislature - Declaration of Intent - Amendment to the 1993 LMPA, 2000 26. The Future of Midwifery, Joint Report of the Pew Health Professions Commission and the University of California, April 1999 Approved by the Executive Board, November 2006 The American College of Evidence-based Obstetrics http://www.sciencebasedbirth.com contact: info@sciencebasedbirth.com ________________________________________________________________________ Check Out the new free AIM(R) Mail -- 2 GB of storage and industry-leading s= ________________________________________________________________________ pam and email virus protection.
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