AMA Home Birth Resolution

The American Medical Association (AMA) has recently adopted a frightening resolution (205) on home birth, which states,

"That our AMA support state legislation that helps ensure safe deliveries and healthy babies by acknowledging of the concept that the safest setting for labor, delivery and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers."

While there may be much debate regarding the safety of home birth (I firmly believe home birth is at least as safe, if not safer than hospital birth), the real issue here is that the AMA is looking to strip women in this country of their right to make their own choices regarding their pregnancies and deliveries. We are already in a situation where choosing a home birth is far more difficult than a hospital birth. Most insurance plans will not cover home birth and in many states, midwives are prevented from practicing due to state law or because they cannot obtain insurance for themselves. Why are so many women in this country acquiescing to the wishes of a medical community which is coercing us into unnecessary and sometimes dangerous interventions? Reasonable evidence suggests that this is overwhelmingly what happens when we deliver our children in hospitals. We need to demand the right to birth our children where we want and in what manner is best for both us and our babies!

Dr. Andrew Kasota, a Canadian physician and researcher, issued this response to the AMA resolution:

I would invite ACOG to join the rest of us in the 21st century. Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficience, whether such recommendations are founded on sound scientific evidence or the pre-historic musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not “offering” VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, RCT (randomized controlled trials). Science supports homebirth as a reasonably safe option. Even if it didn’t, it still would be a woman’s choice. ACOG and the AMA are, by nature, conservative organizations; and they are entitled to their opinion about the safety of birth at home. As scientific evidence supporting its safety mounts, however, (to which BC’s prospective data is a compelling addition) they will be forced to accede or get left behind. The concerning part of this proposed AMA resolution is the “model legislation. ”

If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women’s autonomy and patient-centered care. Hopefully the public and lawmakers realize the primacy of informed choice enough to justify Deborah Simone’s words: “We don’t need to be angry or even react to these overtly hostile actions from the medical community. We just need to keep doing what we do best; the proof is always in the pudding.”

It is sad to see the obstetrical community still trying to earn itself a wooden club as well as the wooden spoon; if the resolution passes, it is sad to see the politico-medical community helping them.

Andrew Kotaska
Yellowknife

When we were deciding where to have Eliot, cost was a significant factor for us and ultimately resulted in our having a hospital birth with a midwife and doula. We were extremely lucky that our care providers were so great and the hospital had a long history of natural birth. You can read our birth story in a previous post. However, it still really bothers me that my insurance would not pay for a home birth because both they and my employer believed it be dangerous. While I was pregnant, I wrote to the Executive Vice President of Human Resources at my company to ask that my homebirth be covered at the out-of-network level. While it was ultimately unsuccessful, I believe that we must be relentless in our efforts to bring about change in regard to home birth. If this resolution were be be made law, our already limited choices would shrink even further.

Here is a portion of my letter to my company, which contains some additional information regarding home birth:

...it grieves me that I do not have the option to choose a home birth over a hospital birth for the delivery of my child. Home birth is proven to be a low cost, extremely safe alternative to hospital birth. If we are truly concerned regarding the increased costs of health care, then it only makes sense that cheaper, yet safe alternatives would be made available to us as consumers and employees.

Being forced to birth at a hospital greatly increases the likelihood of interventions, such as use of forceps or a vacuum, episiotomy or Cesarean Section which also significantly increases the cost of a birth by tens of thousands of dollars. I believe that ** my company ** should be supporting home birth for healthy mothers like me because pregnancy is a normal physiologic condition and not a medical condition. If I were allowed to birth at home and our insurance plan provided coverage at the Out of Network Rate of 80%, it could save the company upwards of thousands of dollars. Below, I have compared the cost of a home birth in Minnesota to different types of hospital births in both Ramsey and Hennepin counties.

1. Home Birth in Minnesota ~ Average Charge with a qualified Midwife: $2000 - $3500

2. St. Joseph’s Hospital, St. Paul, MN

• Average Charge for a Vaginal Delivery (without complications): $7,023 (Source: http://www.mnhospitalpricecheck.org/report1.aspx?FID=13&DRG=373&DRGGroup=11)
• Average Charge for a Vaginal Delivery (with complications): $8,507 (Source: http://www.mnhospitalpricecheck.org/report1.aspx?FID=13&DRG=372&DRGGroup=11)
• Average Charge for a Cesarean Section: $20,528 (Source: http://www.mnhospitalpricecheck.org/report1.aspx?FID=13&DRG=371&DRGGroup=11)

3. Hennepin County Medical Center, Minneapolis, MN

• Average Charge for a Vaginal Delivery (without complications): $8,389 (Source: http://www.mnhospitalpricecheck.org/report1.aspx?FID=13&DRG=373&DRGGroup=11)
• Charge for a Vaginal Delivery (with complications): $10,388 (Source: http://www.mnhospitalpricecheck.org/report1.aspx?FID=13&DRG=372&DRGGroup=11)
• Average Charge for a Cesarean Section: $14,662 (Source: http://www.mnhospitalpricecheck.org/report1.aspx?FID=22&DRG=371&DRGGroup=11)

Keep in mind that the hospital's charge does not include professional fees such as for a physician's or surgeon's services, which can greatly increase the total cost of birth. While large insurance companies receive a discount from the hospital, the total cost of a hospital birth is still significantly higher than the cost of a home birth.

The attached 2005 study by the British Medical Journal concluded, “Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.” (Source: http://www.bmj.com/cgi/content/full/330/7505/1416)

A 1997 meta-study of other statistical studies of home and hospital births concluded, “[N]o empirical evidence exists to support the view that it is less safe for most low-risk women to plan a home birth, provided that the pregnant woman is motivated and, furthermore, selected and assisted by an experienced home birth practitioner, and provided that the home birth practitioner, in turn, is backed up by a modern hospital system should a transfer be needed. It is further concluded that home birth as managed in the included studies may well have other advantages compared with standard hospital care.” (Source: Olsen, Ole. 1997. “Meta-analysis of the Safety of Home Birth.” Birth 24.1.)

An article written by David A. Andersen, RE concluded that, “As health care costs increase and a growing number of women are without insurance, the one health service that every family needs deserves further attention. Even for the 40% of births covered by Medicaid, safe birthing alternatives that permit a reduction in the $150 billion Medicaid burden would allow the United States to devote more resources to other urgent priorities. Informed birthing decisions cannot be made without information on costs, success rates, and any necessary tradeoffs between the two. This article provides the relevant information for hospital, home, and birth center births. The average uncomplicated vaginal birth costs 68% less in a home than in a hospital, and births initiated in the home offer a lower combined rate of intrapartum and neonatal mortality and a lower incidence of cesarean delivery.” (Source: J Nurse Midwifery. 1999 Jan-Feb;44(1):30-5.)

According to Mothering magazine, “Understanding the potential danger in the overuse of childbirth technology, the World Health Organization has repeatedly implored the U.S. medical authorities to return to a midwife-based system of maternity care as one way to help reduce our scandalously high mortality rates.” (Source: Mothering, Jan/Feb, 1990.

The World Health Organization also indicates, “Midwives are the most appropriate primary health care provider to be assigned to the care of normal birth.” (Source: Maternal and Newborn Health/Safe Motherhood Unit of the World Health Organization, Care in Normal Birth: A practical guide. World Health Organization, 1996.)

For additional information, you may also wish to refer to the following publications:

• Planned Home Birth is Safe for Most Mothers and Babies (Source: http://www.cfmidwifery.org/pdf/safety.pdf)
• Fighting for Access to Midwifery Care and Home Birth: The Minnesota Story (Source: http://www.hhh.umn.edu/img/assets/9681/midwifery_homebirth.pdf) Blais, Regis, et al. (2002)
• Are home births safe? Canadian Medical Association Journal. The Association. 166(3):335-6. Janssen, Patricia, et al. (2002)
• Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. Canadian Medical Association Journal. The Association. 166(3):315-23. Janssen, Patricia, et al. (1994)
  
• Licensed midwife-attended, out-of-hospital births in Washington state: are they safe? Birth. Blackwell Science, Inc. 21(3): 141-148. Johnson, Kenneth and Betty-Anne Daviss. (2005)
  
• Outcomes of planned home births with certified professional midwives: large perspective study in North America. British Medical Journal 18;330:1416. Pang, Jenny, et al. (2002)
  
• Outcomes of planned home birth in Washington State: 1989-1996. Obstetrics and Gynecology. Elsevier. 100(2):253-259. Vedam, Saraswathi. (2003)
  
• Home birth versus hospital birth: questioning the quality of the evidence on safety. Blackwell Publishing, Inc. 30(1):57-63.

If this issue is important to you (and I hope that it is!), the easiest thing to do and a good place to start is to sign the petition to keep home birth legal. From there, I recommend that you educate yourself regarding home birth. In addition to the resources listed above, you will definitely want to read the book, Pushed: The Painful Truth About Childbirth and Modern Maternity Care and view the documentary, The Business of Being Born. Once you have some knowledge under your belt, talk about this issue with every woman you know, write your politicians, blog - make your voice heard in whatever forum you can.