Birthing turf wars

This spring, the American Medical Association decided to support a legislation "that
helps ensure safe deliveries and healthy babies by acknowledging that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital" or accredited birth center.

So the AMA is against ANY women choosing to give birth at home. This appears to be based more on turf management than evidence.

(The issue erupted following the release of the documentary, "The Business of Being Born," by former talk show host Ricki Lake in which she haves her baby at home. The American College of Obstetricians and Gynecologists and AMA publicly criticized Lake, who wrote about the ordeal last month for the Huffington Post.)

Given that the human species requires birth as a requirement for
survival, and given that for the vast majority of our existence, said
births did not occur in a hospital, it seems a little far-fetched to me
that the birthing process is a medical condition requiring the full
resources of a hospital, especially when evidence exists that the
process is safe for low-risk mothers and on the flip side, use of fetal
monitoring has been shown to increase surgical procedures in low-risk
pregnancies, without showing improvements in outcome.

This highlights the issues we face in helping consumers make
appropriate health decisions. Under the guise of guidelines and
professional expertise, we see all kinds of interest groups making
broad statements that push their own agendas, rather than helping
individuals determine the best course of action for them (will your
doctor give you a personal risk vs. side effect analysis prior to
putting you on a medication?)

Until we understand risks to the patients at the margins of the
studies we’ve done, its irresponsible to default to more action/expense
against the wishes of patients. Simply taking results in high-risk
populations and generalizing benefits to lower risk is junk science and
further reduces the credibility of our once proud profession.

Vijay Goel is a doctor and former McKinsey & Co. consultant based in Los Angeles. He blogs regularly at Consumer-focused Healthcare.

7 replies »

  1. This is exactly the kind of debate that will be discussed at the Controversies in Childbirth Conference (March 2009). Is delivering a baby at home the safest, smartest, and healthiest choice, or is it reckless behavior bordering on child endangerment? Our presenters will base their cases on the “best available medical evidence.”
    This session promises to be one of the most exciting and contentious of the conference.

  2. It seems that the options that are supported by a minority (midwifery, homebirth) are the ones being “the most punished” in the US, frankly, when we talk about childbirth.

  3. Max,
    Sorry, I didn’t mean to imply that those nations necessarily would make those choices, only that it was in their power to do so. As long as midwifery is politically and socially acceptable, it will not be targeted for elimination. It is the options that are supported by a minority that will be the most punished under a Universal System.

  4. Bret, I am puzzled by your assertion that the UK, Canada and Europe control costs by limiting options, when those places generally provide more choice of fully covered childbirth attendants and locales. Providing choice in childbirth is what keeps costs down, as low-risk women will trend toward choosing less expensive and more personal birth support. Here in Canada we can hardly keep up with the demand for low-cost maternity care (midwifery).
    Maggie, I think you are overly concerned about the first-time mothers. While more experienced mums are more likely to chose homebirth, I assure you that I am just one of many parents who had a wonderful first birth experience at home. In fact I am certain that being in hospital would have been much more frightening than being in the comfort of my own home with a qualified midwife by my side the whole time.
    n.b. An interesting phenomenon is hospitals with no VBAC policies forcing women who want to attempt vaginal childbirth into homebirths for their subsequent children.

  5. Every mother should have the right to choose the option she wants. Are there statistics available that compare the % of mother/baby deaths now vs. 50 or 100 years ago? Every birth these days is expected to happen perfectly, and I don’t know that everyone is prepared to accept the number of natural anomalies that might not be as controllable in a home birth setting vs. a hospital. That said, hospitals often create their own anomalies. Is there a truly objective way to view this controversy?

  6. It’s not much of a turf war when you have government on your side. Universal healthcare systems of all flavors are constantly making decisions like this, but when they make them they’re not toothless proclamations, they’re actually law. UK, Canada, and most of mainland Europe learned fairly quickly that the best way to keep costs down is to limit options.

  7. Essentially, I agree. Some
    hospitals and some doctors are forcing more
    and more women into ceasarians.
    Though I would add that I would
    be somewhat concerned for a first-time
    mother unless she is fully prepared
    for the experience.
    A 30-something woman who I know
    quite well recently gave birth.
    She had a mid-wife as well as a doctor
    but it was a very hard,long labor (as the
    first tiime often is.)
    Afterwards, she said to me “Why doesn’t
    anyone tell you?–It’s a conspiracy of
    The truth is noone wants to frighten someone who is
    pregnant for the first time. But
    unfortunately childbirth is usually
    extremely painful (taking you well beyond
    your pain threshold)and can be traumatic.
    (I do believe that if men gave birth,
    we would have figured out a less painful
    way to do it by now. I’ve used Lamaze, and
    it works–but only up to a point.)
    My concern is just that if a woman is giving
    birth at home she could suddenly become
    very frightened. Ideally, she would have seen
    realistic films of women giving birth, and
    be prepared.
    Alternatively, home births might make more
    sense the second time you have a baby.
    But if the hospital forces into a ceasarian
    the first time, then you’ll probably have to
    have a ceasarian the second time as well.