As an OBGYN trained in the US, my knee jerk reaction was to shout “NO!” I have been in too many situations where a seemingly normal delivery turns into an emergency situation.
That being said, I do believe that too often the obstetrical care in the US takes a normal physiologic process and turns it into a medical condition that requires repeated testing, monitoring and intervention. Often we are advised that rather than wait for a condition to develop, we should proactively monitor for its onset. And clearly, when we are speaking of high risks pregnancies this is a prudent approach.
But what about the low risk, uncomplicated pregnancy – are we meddling too much? Is this the reason approximately one third of the deliveries are cesarean sections rates? Have we convinced women that better obstetrical care means more tests, more fetal monitoring, and more ultrasounds? Do we do all this to avoid being sued for malpractice? So it was with interest that I read the recent articles about out of hospital births.
In 2008, the American College of OBGYN reiterated its opposition to home births stating that home births placed the process of birth ahead of the goal of having a healthy baby.
In 2009, the Canadian Medical Association Journal published a study of planned home births in British Columbia attended by registered midwives. When compared to planned hospital births, there were low and comparable rates of fetal deaths and reduces rated of obstetric interventions with the planned home births.
By 2011, the American College of OBGYN issued an opinion that while it 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
In 2014, the National Institute for Health and Care Excellence (NICE) in the United Kingdom recommended that all women with low risk, uncomplicated pregnancies between 37 and 41 weeks be given the option of delivering at:
· a free standing midwifery clinic
· a midwifery clinical alongside of a hospital obstetrical unit
· a hospital obstetrical unit.
This recommendation was based on 1) comparable fetal outcomes irrespective of site. The quidelines also made note of the lower rate of intervention(s) – with home and free standing midwifery deliveries.
While out of hospital births are relatively rare in the US comprising 1.36% of the births, Oregon has one of the highest rates of out of hospital births. A study was conducted in Oregon comparing the fetal outcomes with out-of-hospital and in-hospital births. There were 3.9 fetal deaths per 1000 births with the out of hospital births compared to the 1.8 fetal deaths per 1000 births with the in hospital deliveries.
When compared to the studies done in Canada and the United Kingdom, a major difference is that both Canada and the UK have their out of hospital births integrated into their healthcare system meaning that there are protocols as to how to select women for out of hospital births, regulations and processes for transfer of laboring moms to the hospital if needed. In the US, there is no integration of such services.
In the US, we currently don’t have the processes in place in safeguard of out of hospital births. Moreover, we live in a litigious society where few OBGYNs would want to risk being involved with out of hospital births. Out of hospital births could potentially place midwives in direct competition with OBGYNs and reduced revenues for hospitals. At best, a pregnant woman in the US desiring a “low tech, non-interventional” delivery should consider seeing the midwives within a hospital obstetrical unit.