American College of Obstetricians and Gynecologists (ACOG) Statement of Policy as issued by the ACOG Executive Board on Out-of-Hospital Births in the United States

Labor and delivery is a physiologic process that most women experience without complications. Ongoing surveillance of the mother and fetus is essential because serious intrapartum complications may arise with little or no warning, even in low risk pregnancies. In some of these instances, the availability of expertise and interventions on an urgent or emergent basis may be life-saving for the mother, the fetus or the newborn and may reduce the likelihood of an adverse outcome. For these reasons, the American College of Obstetricians and Gynecologists (ACOG) believes that the hospital, including a birthing center within a hospital complex, that conforms to the standards outlined by American Academy of Pediatrics and ACOG,(1) is the safest setting for labor, delivery, and the immediate postpartum period. ACOG also strongly supports providing conditions that will improve the birthing experience for women and their families without compromising safety.

Studies comparing the safety and outcome of U.S. births in the hospital with those occurring in other settings are limited and have not been scientifically rigorous. The development of well-designed research studies of sufficient size, prepared in consultation with obstetric departments and approved by institutional review boards, might clarify the comparative safety of births in different settings. Until the results of such studies are convincing, ACOG strongly opposes out-of-hospital births. Although ACOG acknowledges a woman's right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births.

(1) American Academy of Pediatrics and /American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 5th Edition. Elk Grove Village, IL, AAP/ACOG, 2002.

Approved by the Executive Board October 2006

The American College of Obstetricians and Gynecologists
409 12th Street, SW, PO Box 96920
Washington, DC 20090-6920
Telephone 202 6385577

MANA's Resonse

MANA decided to sign on to the American College of Nurse-Midwives response (below) and the White Ribbon Alliance response (coming soon).

We feel no additional response is necessary.

Following is the response written by the American College of Nurse-Midwives

Click here for more information from the ACNM web page.

November 20, 2006

Douglas W. Laube, MD President, ACOG 409 12th Street, SW Washington, DC 20024-2188

Dear Dr. Laube,

Some families, after thoughtful consideration, choose home birth or birth in an out-of-hospital birth center. On behalf of those families, we are writing to express our concern about the recent ACOG Policy Statement, Out-of-Hospital Birth in the United States. The troubling nature of this statement places in jeopardy access to a valid, evidence-based system of care. Providers who support evidence-based care have an ethical responsibility to offer access to care at all levels and in all settings for these families.

The safety of birth in any setting is of utmost priority. Unfortunately, studies which have not differentiated between planned and unplanned home birth or attendance by qualified versus unqualified attendants, and/or that do not clearly define appropriate inclusion criteria, have been used to discredit all out-of-hospital birth.

The implication that there is insufficient evidence to support the safety of planned out-of-hospital birth is unsubstantiated. After a review of the evidence, ACNM published a position statement in 2005 in support of planned home birth under specific conditions. That statement is reflective of similar interpretations of the evidence by national and international panels. Furthermore, we are not aware of evidence supporting the assertion that the hospital is the safest setting for labor, birth and the immediate postpartum period for low risk women.

Across health care disciplines, it is well documented that safety can be best assured when health care professionals and institutions collaborate to ensure that women have access to qualified providers. Indeed, many health care institutions and obstetrician-gynecologists support the right of women to choose out-of-hospital birth by actively working to maintain respectful collaborative relationships, provide expert consultation, and facilitate transfer of care.

In contrast, the ACOG statement discourages collaborative practice and support for out-of-hospital birth providers. This position could potentially harm the culture of safety around birth, for patients and providers.

We agree that there is much to be learned from further studies. Research that focuses on the characteristics and management of normal birth, the impact of various care processes on morbidity, and variables that affect client satisfaction and experience as related to birth site are all necessary.

In order to ensure the provision of safe and appropriate care, research should be focused on the ways in which all health care providers and institutions can establish seamless systems of care when transfer is needed from the home or birth center to the hospital. The data needed for such research can only be provided if we continue to offer safe, comprehensive and appropriate care in all settings.

Finally, we are distressed that this statement is published at a time when the public health system is preparing for pandemic influenza. The National Pandemic Flu Plan calls for hospitals to develop 'surge capacity' plans to maximize their capability to care for seriously ill patients, and create alternative care sites for routine care. Specifically, the plan calls for health systems to explore ways of "increasing the role of home care, and developing off-site care facilities." It seems likely that in an influenza pandemic, a hospital bed - in short supply and in close proximity to those ill with a virulent virus - may not be the safest place for healthy women to give birth.

In other disaster situations, access to care based on technology may not be available even in a hospital. Preserving our competencies in providing perinatal care in low resource settings is critical to adequate preparedness in the United States and our continued support of midwifery education and safe motherhood in the developing world.

Since potential necessity and strong patient desire by a small percentage of women assure that birth outside the hospital setting will likely persist, we encourage ACOG to partner with other health care providers to enhance the safety of birth in out-of-hospital settings by promoting an agenda for continued research, developing policies to ensure seamless coordination of care across settings, and encouraging collaborative management across disciplines. ACNM proposes the development of a joint task force to develop guidelines for out-of-hospital birth and to establish a research agenda to explore issues of safety across birth settings.

We look forward to our continuing dialogue and the opportunity to work collaboratively on this issue.

Sincerely,

Katherine Camacho Carr, CNM, PhD, FACNM, President, ACNM

Co-signed by:
American Association of Birth Centers
American Nurses Association
Birth Network National
Citizens for Midwifery
Coalition for Improving Maternity Services
Lamaze International
Midwives Alliance of North America
White Ribbon Alliance for Safe Motherhood

The American Association of Birth Centers Response

The AABC has also written a response to ACOG. Click here to read it.

Home :: Site Map :: Contact :: Join :: View Members Only Section
What is MANA? :: News :: Definitions :: Conferences :: Resources :: Links