ACOG Committee Opinion on Planned Home Birth: Opening the Door to Collaborative Care

by Melissa Garvey, ACNM Communications Manager

Just this morning, ACNM released an Issue Brief in response to the ACOG Committee Opinion on Planned Home Birth published in the February 2011 issue of Obstetrics & Gynecology.

At just over two pages, the Issue Brief is worth the read. While acknowledging that much of the ACOG Committee Opinion relies on a widely-criticized, flawed 2010 meta-analysis, the Issue Brief goes on to highlight parts of the opinion that open the door to supporting childbirth choices through collaborative care for women and infants. Specifically, this new Committee Opinion acknowledges a woman’s right to make informed decisions about where to give birth, in contrast to ACOG’s sharply worded 2007 policy statement, which declared that “ACOG does not support programs or individuals that advocate for or who provide home births.”

This excerpted quote by ACNM President Holly Powell Kennedy summarizes the tone of the brief:

ACNM views the 2011 ACOG Committee Opinion as a crack in ACOG’s long-standing negative stance on home birth. “We can focus on the negative aspects of this committee opinion, or we can seize this opportunity to redefine the discussion,” said Kennedy. “Beliefs and values about how to accomplish those outcomes are culturally steeped, experientially-based, and stem partially from professional training and socialization. Moving to a place of mutual understanding and agreement will require that we all use midwifery skills: patience with process, respect, listening, knowledge, presence, and strong leadership. ACNM is committed to working collegially with all health professionals involved in maternity care to clarify, define, and advocate for the best care practices for women in all birth settings.”

Also of note, ACOG’s new Committee Opinion comes on the heels of ACNM’s announcement that the Transforming Birth Fund (TBF) has awarded funding to a consortium of maternity organizations to convene a multi-disciplinary Home Birth Consensus Summit in late 2011. This forum represents a real chance to inform and influence change in home birth policy and practice.

ACNM Responds to ACOG’s 2010 VBAC Recommendations

On July 21, 2010, the American College of Obstetricians and Gynecologists (ACOG) released a revised practice bulletin on vaginal birth after previous cesarean section (VBAC). Today, ACNM released its response to the revised practice bulletin. Read on for an excerpt from the response, or read the full statement here [PDF].

ACNM’s philosophy is that all women—including those who have had a prior cesarean birth—should have access to information, counseling and birthing options provided by vigilant, skilled clinicians within a coordinated maternity care delivery system. While integrated resources should be made available in all settings, immediate access to emergency delivery solely to safeguard against the potential risks associated with TOLAC (trial of labor after cesarean) should not be the focus. Rather, risk associated with TOLAC should be considered within the spectrum of perinatal benefits and risks associated with nulliparous women in labor. Uterine rupture, a rare, often unpredictable complication of both trial of labor after cesarean as well as repeat elective cesarean delivery, is a primary factor underlying the ACOG recommendations. Yet the risk of uterine rupture associated with TOLAC is similar statistically to that of other obstetrical emergencies for a woman experiencing her first birth. Furthermore, it should be noted that the benefits of labor and vaginal birth are often omitted from this discussion. The focus is exclusively on risk, which does not yield a complete picture. Provided with the latest evidence and comprehensive counseling, women must be allowed to make decisions regarding TOLAC and give birth in the settings that best meet their individual needs. It is unclear how these fully informed women will be at liberty to choose a TOLAC when facilities continue to refuse them this option, claiming compliance with the 2010 ACOG guidelines.

ACOG’s 2010 practice guidelines may help to expand access to TOLAC for women with certain clinical presentations. However, ACOG’s continued recommendation that TOLAC be undertaken at facilities capable of immediate emergency deliveries virtually assures that the 2010 guidelines alone will fail to appreciably increase access to TOLAC and VBAC in the U.S. The NIH VBAC consensus statement recommends that “hospitals, maternity care providers, health care and professional liability insurers, consumers and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor” (p. 37). Only a long-term, system-wide, concerted effort based on quality evidence and further research in all settings will accomplish this goal. ACNM welcomes this important and necessary collaboration.

Read more [PDF]

Pregnant? This Caffeine Shot is for You…Maybe

by Melissa Garvey, ACNM Writer and Editor

The American College of Obstetricians and Gynecologists released a Committee Opinion this month entitled Moderate Caffeine Consumption During Pregnancy. The Committee Opinion examines a long-standing debate: is maternal caffeine consumption related to spontaneous miscarriage?

Caffeine raises a woman’s levels of catecholamines—hormones released into the blood in response to stress—and crosses the placenta to her unborn child. Sources of caffeine include coffee, tea, soft drinks, and chocolate.

Most studies on the relationship between caffeine and miscarriage have significant limitations, including small sample size and recall bias. The new Clinical Bulletin explores the results of several recent, higher-quality studies. The good news is that they found no link between moderate caffeine consumption and miscarriage. However, the results regarding higher levels of caffeine consumption are not black and white. The Committee Opinion states:

“Moderate caffeine consumption (less than 200mg per day) does not appear to be a major contributing factor in miscarriage or preterm birth. The relationship of caffeine to growth restriction remains undetermined. A final conclusion cannot be made at this time as to whether there is a correlation between high caffeine intake and miscarriage.”

Nutrition research can be especially challenging due to the difficulty of isolating various nutrients and controlling for confounding factors. For example, are the women consuming large amounts of caffeine in these studies getting a good night’s sleep? Are they using caffeine to keep up with a high-stress job?

What are your thoughts on this Committee Opinion? If you’re expecting, will it change your caffeine habit? Midwives, will this affect the advice you give to your patients and clients?

ACOG Encourages Laboring Women to Quench Their Thirst

Women who decide to give birth in a hospital may soon have access to more than ice chips during labor. The American College of Obstetricians and Gynecologists (ACOG) just released a committee opinion recommending that clear liquids (water, juice, sports drinks, etc.) be provided to women who have uncomplicated labor or are scheduled for a planned cesarean.

ACNM has long supported a liberal approach to providing oral nutrition to women in labor, including drinks and solid food. But for decades, many hospitals have restricted women’s oral intake for fear of aspiration—a potentially fatal occurrence that involves stomach contents entering the lungs while a woman is under anesthesia. Thanks to improvements in anesthesia, aspiration in pregnant women is now extremely rare.

Midwives emphasize that birth is a normal process that under normal circumstances does not require fasting. They educate clients about the small but potentially serious risk of aspiration and watch women throughout labor to identify when food and drink need to be restricted. While ACOG’s latest weigh-in is old news to midwives, hopefully it will encourage more hospitals to adopt less restrictive, more woman-centered policies.

ACOG Revises Labor Induction Guidelines

Midwives are applauding the American College of Obstetricians and Gynecologists (ACOG) latest revision to their labor induction guidelines. The new ACOG practice bulletin recommends avoiding labor induction before week 39 of pregnancy—an improvement over the previous 37-week recommendation.

This comes on the heels of more good news: a recent study at Brigham and Women’s Hospital in Boston found that 10-year episiotomy rates have steeply declined, thanks to peer pressure to stop performing the procedure as well as significant research on the topic. A Medscape article also says that researchers acknowledge "several other contributing factors, including long-standing CNM service in hospital-based practice, and the addition of CNMs to Harvard Vanguard Medical Associates in 1990."

Midwives may be blue in the face from their decades of trumpeting the need for judicious use of interventions, but it looks like their music has not fallen on deaf ears.