New ACOG Opinion on Home Birth Touts Rights, Nixes HBAC and CPMs

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By Jill Arnold

ACOG issued a Committee Opinion yesterday on planned home birth which emphasized respect for the rights of a woman to make medically informed decision about birth.

Here is the summary of the opinion: 

Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence.  Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.

The Wax meta-analysis was prominently featured in the opinion, with limitations of the current body of research noted.

The relative risk versus benefit of a planned home birth, however, remains the subject of current debate. High-quality evidence to inform this debate is limited. To date there have been no adequate randomized clinical trials of planned home birth.

VBAC is considered a contradiction to home birth.

Although patients with one prior cesarean delivery were considered candidates for home birth in both Canadian studies, neither report provided details of the outcomes specific to patients attempting vaginal birth after cesarean delivery at home. Because of the risks associated with a trial of labor after cesarean delivery and that uterine rupture and other complications may be unpredictable, the American College of

Obstetricians and Gynecologists recommends that a trial of labor after cesarean delivery be undertaken in facilities with staff immediately available to provide emergency care. The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice considers a prior cesarean delivery to be an absolute contraindication to planned home birth.

CPMs are not recognized as suitable care providers because “recognition and regulation of certified professional midwives and lay midwives varies tremendously from state to state.”

According to the National Center for Health Statistics, more than 90% of attended home births in the United States are attended by midwives. However, only approximately 25% of these are attended by certified nurse–midwives or certified midwives. The remaining 75% are attended by other midwives; the category used by the National Center for Health Statistics that includes certified professional midwives, lay midwives, and others. The recognition and regulation of certified professional midwives and lay midwives varies tremendously from state to state. At this time, for quality and safety reasons, the American College of Obstetricians and Gynecologists does not support the provision of care by lay midwives or other midwives who are not certified by the American Midwifery Certification Board.

ACOG speaks favorably of integrated health care systems which facilitate timely intrapartum transfer to a hospital with an existing arrangement. Because the U.S. does not have this, international observational studies are not considered generalizable to current practice in the U.S.

Another factor influencing the safety of planned home birth is the availability of safe and timely intrapartum transfer of the laboring patient. The relatively low perinatal and newborn mortality rates reported for planned home births from Ontario, British Columbia, and the Netherlands were from highly integrated health care systems with established criteria and provisions for emergency intrapartum transport. Cohort studies conducted in areas without such integrated systems and those where the receiving hospital may be remote with the potential for delayed or prolonged intrapartum transport generally report higher rates of intrapartum and neonatal death. The Committee on Obstetric Practice believes that the availability of timely transfer and an existing arrangement with a hospital for such transfers is a requirement for consideration of a home birth.