Letter to ACOG President Dr. Richard Waldman

Florida Friends of Midwives has added our organization's name to a list of endorsers to the following letter from the Coalition for Improving Maternity Services. We encourage all who are in support of this letter to endorse it here.

Richard N. Waldman, MD

American College of Obstetricians and Gynecologists

PO Box 96920

Washington, DC 20090-6920

Dear Dr. Waldman:

The Coalition for Improving Maternity Services (CIMS) supports the March 2010 National Institutes of Health (NIH) Consensus Statement on VBAC (vaginal birth after cesarean) and welcomes the American College of Obstetricians and Gynecologists' (ACOG) revised guidelines, Vaginal Birth After Previous Cesarean Delivery (August 2010) aimed at providing women increased access to VBAC and clearly emphasizing women's autonomy and their right to make informed decisions about how they choose to give birth. However, CIMS is concerned that ACOG's unrevised recommendation that trial of labor after cesarean (TOLAC) should take place in hospitals where resources for emergency cesarean are "immediately available" will continue to deter providers and hospitals from supporting this option.

The NIH found that this "immediately available" recommendation was based on consensus and expert opinion rather than strong support from high-quality evidence. The NIH also reported that this recommendation has influenced about one-third of hospitals and one-half of physicians to no longer provide care for women who want a VBAC. All women in labor face unpredictable risks that may require an emergency cesarean, not just women laboring for a VBAC. This recommendation selectively applies a higher standard of safety for women who choose a trial of labor.

CIMS urges ACOG to reassess this specific guideline and remove the current barrier to women's access to VBAC.

In addition to respecting women's autonomy, the current guidelines emphasize the need for physicians to discuss the benefits and risks of both trial of labor and elective repeat cesarean early on in the pregnancy. This is a recommendation that CIMS strongly supports. The NIH identified the importance of evidence-based processes that incorporate women's values and preferences to help women with a previous cesarean make informed choices about mode of birth. Similarly, a key recommendation identified in the multi-stakeholder consensus report, Blueprint for Action: Steps Toward a High-Quality, High-Value, Maternity Care System is expanding the opportunities and capacity for a shared decision-making process and developing tools and resources to facilitate informed choices in maternity care.

In the light of these recommendations, CIMS urges ACOG to revise its patient education publications and on-line consumer resources to include comprehensive information on the benefits and risks of cesarean section and VBAC.

CIMS, whose mission is to promote the Mother-Friendly Childbirth Initiative, an evidence-based wellness model of maternity care that will improve outcomes and reduce costs, urges ACOG to reconsider the "immediately available" recommendation and update its decision-making consumer resources. We believe that ACOG can make an even greater impact on increasing VBAC, reducing cesareans, and ultimately avoiding unnecessary harms to mothers and infants.

Sincerely,

Michelle Kendell, MBA, AAHCC

Chair, Coalition for Improving Maternity Services (CIMS)

On behalf of CIMS and the following organizational members of the Coalition for Improving Maternity Services (CIMS)

Co-Signed By:

Academy of Certified Birth Educators

American Association of Birth Centers

American College of Nurse-Midwives

The Big Push for Midwives

Birth Matters Virginia

Birth Network National

Birth Network of Santa Cruz

Choices in Childbirth

DONA International

International Childbirth Education Association (ICEA)

Lamaze International

Midwives Alliance of North America

North American Registry of Midwives

Our Bodies Ourselves

Perinatal Education Associates

Tatia Oden French Memorial Foundation

toLabor: The Organization of Labor Assistants for Birth Options and Resources

Where's My Midwife?

Response to the July AJOG Meta-Analysis Against Homebirth

Florida Friends of Midwives supports and aligns ourselves with the efforts of The Midwives Alliance of North America (MANA) and The Big Push for Midwives. In July's American Journal of Obstetrics and Gynecology, an article denounced homebirth for increased neonatal mortality. This conclusion was based on a study that our allied organizations have proven misleading. Florida Friends of Midwives endorses the following responses to the study from both MANA and The Big Push.

Response from the Midwives Alliance of North America:

A new meta-analysis rushed to on-line publication well before its availability in print, concluded that less medical intervention, which is a characteristic feature of planned home birth, is associated with a tripling of the neonatal mortality rate compared with planned hospital births. In a study published online on July 1, 2010 in the American Journal of Obstetrics and Gynecology (AJOG), researchers at Maine Medical Center in Portland, Maine analyzed the results of multiple studies from around the world. The lead investigator, Joseph R. Wax, MD, Department of Obstetrics and Gynecology, Maine Medical Center, stated, “Our findings raise the question of a link between the increased neonatal mortality among planned home births and the decreased obstetric intervention in this group.”

However, Canadian researchers whose data showing the safety of home birth in a well-organized and regulated system, were used in the meta-analysis, are sharply critical of the study. Dr. Michael C. Klein, a senior scientist at the Child and Family Research Institute in Vancouver and emeritus professor of family practice and pediatrics at the University of British Columbia said the U.S. conclusions did not consider the facts. “A meta-analysis is only as good as the articles entered into the meta-analysis—garbage in, garbage out. Moreover, within the article, Wax et al did their own sub-analysis of the studies in the meta-analysis, after removing out-of-date and low quality studies, and found no difference between home and hospital births for perinatal or neonatal mortality. Yet in the conclusion, they choose to report the results of the flawed total meta-analysis, which showed the increased neonatal mortality rate.” Klein said that this is apparently a “politically motivated study in line with the policy of the American College of Obstetricians and Gynecolgists (ACOG) who is unalterably opposed to homebirth.”

Saraswathi Vedam, a nurse midwife and researcher at the University of British Columbia who is considered to be an expert on assessing the quality of literature related to homebirth, states that the study is deeply flawed for several reasons, particularly, “the authors’ conclusions are not supported by their own statistical analysis.” Vedam states that Dr. Wax et al acknowledges the consistent findings of low perinatal and neonatal mortality in planned home births across the best quality studies they reviewed “but amazingly Wax does not emphasize or even mention this in his sole conclusion.” This begs the question of whether the author’s analysis and reporting of reviewed articles on homebirth do not support his foregone conclusion about the safety of homebirth.

The Midwives Alliance of North America, a professional organization of over 1200 members, believes childbearing women and those involved in maternal and child health policy should be made aware of the flaws and erroneous claims in the Wax et al study. There is a substantial body of evidence-based literature from well-designed studies that establishes the safety of planned homebirth with a skilled birth attendant. The fact that the American College of Obstetricians and Gynecologists maintains its position in opposition to homebirth, despite the evidence of its safety and efficacy, makes one question ACOG’s motive in publishing Wax’s substandard study.

Midwives are the primary care providers in out of hospital settings. Whether their work is studied and scrutinized here in the US or abroad the findings are consistent. Trained midwives are qualified health professionals with the requisite expertise to provide mothers and newborns with outstanding care, using less intervention, resulting in maternal and infant outcomes as good as those in hospital settings under the care of obstetricians.

The American public, particularly women in the childbearing years and those who care for them, have a right to high quality research on childbirth. Research literature should not be used to cause undue alarm or limit a woman’s choice regarding care providers, including skilled midwives, and place of birth.

Response from The Big Push for Midwives Campaign:

As New York and Massachusetts moved to pass pro-midwife bills in the final weeks of their legislative sessions, the American Journal of Obstetrics and Gynecology fast-tracked publicity surrounding the results of an anti-home birth study that is not scheduled for publication until September. Described as unscientific and politically motivated, the study draws conclusions about home birth that stand in direct contradiction to the large body of research establishing the safety of home birth for low-risk women whose babies are delivered by professional midwives.

“Many of the studies from which the author’s conclusions are drawn are poor quality, out-of-date, and based on discredited methodology. Garbage in, garbage out.” said Michael C. Klein, MD, a University of British Columbia emeritus professor and senior scientist at The Child and Family Research Institute. “The conclusion that this study somehow confirms an increased risk for home birth is pure fiction. In fact, the study is so deeply flawed that the only real conclusion to draw is that the motive behind its publication has more to do with politics than with science.”

Advocates working to expand access to out-of-hospital maternity care questioned the timing of AJOG’s public relations efforts on behalf of a study that won’t be published until next fall.

“Given the fact that New York just passed a bill providing autonomous practice for all licensed midwives working in all settings, while Massachusetts is poised to do the same, the timing of this study could not be better for the physician groups that have been fighting so hard to defeat pro-midwife bills there and in other states,” said Susan M. Jenkins, Legal Counsel for The Big Push for Midwives Campaign. “Clearly the intent is to fuel fear-based myths about the safety of professional midwifery care in out-of-hospital settings. Their ultimate goal is obviously to defeat legislation that would both increase access to out-of-hospital maternity care for women and their families and increase competition for obstetricians.”

The United States recognizes two categories of midwives: Certified Nurse-Midwives, who are trained to practice in hospital settings and who also provide primary and well-woman care, and Certified Professional Midwives, who undergo specialized clinical training to provide maternity care in out-of-hospital settings. Research consistently shows that midwife outcomes in all settings are equivalent to those of physicians, but with far fewer costly and preventable interventions, including a significant reduction in pre-term and low birth weight births, and as much as a five-fold decrease in cesarean surgeries.

The Big Push for Midwives Campaign represents thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives includes educating state and national policymakers about the reduced costs and improved outcomes associated with births managed by CPMs in private homes and freestanding birth centers.

FFOM Wants to Hear Your Birth Story

Due to the volume of quick responses, the ACOG website survey on homebirth was password protected after 18 hours. The effort to flood them with positive birth stories was an immediate success. Visit the Citizens for Midwifery Grassroots Network and The Big Push for Midwives campaign for more information. Thanks for your support!

The ACOG survey demonstrates that the opposition to home birth is powerful and organized. Midwives and consumers of midwifery care need to stay informed, and be ready to support midwives politically. Stay connected to events and actions in Florida by joining Florida Friends of Midwives. There is an e-group, forums, and a newsletter to keep you informed of important events.

We still want to hear your positive birth story! To tell your birth story to support midwives, please submit it to the Florida Friends of Midwives website. Follow the instructions below, and email birth stories to stories@flmidwifery.org.

How to Submit Your Birth Story:

If you would like to submit of your birth with a Florida midwife, here is what to do:

1. Submit your story in a .txt or .doc format. All stories should be accompanied by photographs in .jpeg, .jpg, .eps format.

2. Include your name and a title for the story.

3. Stories should be ¾ page to 1 ½ pages. Try to separate your story in to several paragraphs.

Please spell check your story before you send to us! It sounds very basic, but it is important and helps us get the stories up sooner. We will make corrections if necessary, but you will help us out greatly if you spend some time checking your story for accurate spelling and grammar.

We will notify you if your story is used and provide you with a link to view it on the website. Again, please be aware that we may edit your story for grammar, punctuation, spelling and length if necessary. It may take us up to a month to post your story, if it's used. Try to be patient with us.

VERY IMPORTANT! You MUST include a statement with your story that you give FFOM permission to print your story. We cannot publish it to the web without this statement!