Read the Subtext: ACOG's Position on Home Birth


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Guest post by Rachel_in_WY

Until recently I had never read ACOG’s statement on home births.  I expect these kinds of things to be routinely depressing, so I tend to avoid them.  I pretty much know what they’re going to say.  But recently, Jill sent me an email with a link to ACOGs statement and a request to pick it apart, to critique it the way I teach my Logic and Critical Thinking students to critique arguments.  And this, of course, is fun.  So here we go.

First, a couple of procedural notes: when I’m teaching students how to analyze and critique an argument, one of the places we start is with implied premises and unstated assumptions that are essential to the argument.  It’s often the case that these implied premises and hidden assumptions are not shared by both sides of a debate, but they are precisely the thing that prevents the opposing parties from ever being able to reach a consensus, or even really respond to each other in a meaningful way (think of the abortion debate, here).  The result is a huge mess of a non-conversation that goes on and on with increasing vitriol but little progress.  This is clearly the case here.  As we’ll see, home birth and natural birth advocates start with very different assumptions, values, and goals from those of medicalized birth advocates.

Another thing I train my students to watch for is how terms are defined.  There can be a lot of subtle meaning packed into a word, and so carefully defining your terms, and watching how others define terms is essential.  Generally speaking, the party who defines the terms will have the upper hand in the debate.  Notice how people who are anti-abortion but pro-war and pro-death penalty call themselves pro-life?  Notice how conservative groups that spread bigoted attitudes claim that they are the sole proprietors of “family values”?  It’s a masterful use of language, and it’s often quite effective, so it’s an area where we should be particularly wary.

ACOG begins with this:

The American College of Obstetricians and Gynecologists (ACOG) reiterates its long-standing opposition to home births. While childbirth is a normal physiologic process that most women experience without problems, monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies.

ACOG’s position is that complications are always possible, and it’s these potential complications that make medicalized birth necessary.  And this seems really reasonable, right?  But here’s your first point of departure.  A home birth advocate is going to point to studies that show that each instance of medical birth management and intervention actually increases the chances of complications.  For a mother who chooses home birth, avoiding the complications that are often caused by the actions of medical professionals counts as a reason to avoid a hospital birth.  Induction, epidurals, pitocin, fetal monitoring, etc, all lead to higher rates of complications and interventions.  And here’s where the underlying goals, values, and assumptions conflict.  An advocate of medicalized birth doesn’t see a problem with higher rates of complications and interventions as long as the outcome – a seemingly healthy baby – is reached.  Most natural birth advocates, on the other hand, see complications and interventions as inherently unhealthy, and something to be avoided if at all possible.  From this stance, the natural processes that occur within the mother’s and child’s body during labor and birth have their own unique contribution to the long-term health of the mother and baby, so merely producing a live baby over which the hospital/doctor cannot be sued is an inadequate goal to strive for. 

The relevant question here might be “how do you define healthy?”  If you simply mean “not dead,” then sure, a hospital birth probably will produce a healthy baby.  But if you mean a baby who has had a birth that was not traumatic, that didn’t involve exposure to unnecessary pharmaceuticals and environmental toxins, that will be most likely to result in a baby who thrives over the long-term, and who doesn’t have a mother who was traumatized by her birth experience, then reducing medical interventions is a central goal.  And if reducing medical interventions is a goal to you then, generally speaking, you’re not going to prefer a hospital birth.  So in this first case we have a fundamental difference between the two sides that could be summed up as complication treatment vs complication prevention.

ACOG goes on to make this statement:

ACOG acknowledges a woman’s right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births. … Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby.

The first line here seems a bit contradictory, right?  ACOG wants mothers to be able to make choices, as long as they choose the choice ACOG chooses for them.  So here the concept of “informed decisions” is in question.  If you’ve ever been involved in raising a toddler, you’ve been through this, right?  You want to give your child choices to encourage their sense of autonomy, but you know they’re not mature enough to make certain choices.  The restaurant has soda on the menu, but you only ask them if they want milk or juice.  Because a toddler isn’t ready to make informed decisions about nutrition.  They don’t know what you know about the long-term effects of soda consumption on their little pancreases.  So you limit their choices, for their own good.  And this is OK, because you’re the parent and they’re the child.  Except that the relationship between ACOG and adult women is not a parent-child relationship.  True informed consent and informed decision-making is inconsistent with the machinery of curtailed choices that characterizes parent-child relations.  Unless you believe that adult women are the equivalent of toddlers, this analogy, and the accompanying behavior, is inappropriate.  The rest of this excerpt furthers the theme of infantilizing adult women and belittling their choices.  By implicitly stating that women who choose to give birth at home or in a less medicalized environment are only choosing to do so because it’s fashionable and trendy, ACOG neatly categorizes adult women as irrational and childish. Of course she couldn’t have any good reasons to object to the medical machinery surrounding childbirth.  She’s a woman, after all, and a pregnant one at that!  This subtly and effectively delegitimizes a woman’s choice to avoid the medicalized route even if it was based on research and solid scientific evidence and thoughtful discussions with friends, family, and experienced care providers.

Finally, we have ACOG’s concluding statement (the part Jill highlighted to me, and boy is it a doozy):

Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.

Wow is there a lot to unpack here.  We are told, first of all, that one must make a choice between the outcome and the process.  It’s the old healthy baby vs desired birth experience false dilemma.  “You must choose!” we’re told over and over again. And obviously any mother who would choose anything other than a healthy baby is an unfit mother.  How could you not choose a healthy baby?!?  But of course, in reality these aren’t mutually exclusive.  In fact, they’re not even incompatible in the vast majority of cases.  And they’re not unrelated.  An informed natural or home birth advocate will point to evidence that the birth experience of both mother and baby is a significant factor in the long-term health of the baby.  If the birth experience is traumatic and micro-managed and intervened in at every turn, the outcome is less healthy in a variety of ways.  That is of course, if you’re defining healthy as more than just “breathing.”  And so here we have to prod this implicit claim that mothers who choose natural birth don’t care about the outcome, only the process.  Of course they care about the outcome – they just define a successful outcome differently than ACOG does.  For a medical professional or a hospital administrator, success boils down to lower liability, smooth and convenient timelines, passive, docile “patients,” and larger profit margins.  And of course, profit margins increase with each additional intervention.  Insurance companies pay every time another procedure is added to the list.  Given that the hospital is a business that’s staffed with people who work set shifts and have other patients to tend to, these are all totally reasonable outcomes to be desired from an administrative standpoint.  The problem is, they’re not consistent with the outcomes that it’s rational for a mother to desire.  For her, the long-term health and well-being (mental and physical) of both her and her baby are of the utmost importance.  Profit margins and hospital schedules and lawsuits have nothing to do with her values and goals concerning childbirth.  So the implication that mothers who choose natural births don’t care about outcomes is absurd.  Sure they don’t care about the hospital’s goals and desired outcomes.  Obviously.  But that’s very different from not caring about the outcomes, short-term and long-term, of the birth.

Once you unpack the rhetoric involved here you get a pretty clear picture of ACOGs view of women, and of the processes they go through when planning their birth experiences.  You also see the subtle manipulation they’re willing to engage in in order to secure compliance and submission of pregnant women.  And they wonder why some of us regard them with caution and distrust…