Not all obstetricians agree with ACOG's February 2008 statement reiterating its longstanding opposition to home births. Here are some obstetrician's letters that have been made public on the internet:
Dr. Lauren Plante
Dr. Andrew Kotaska
Dr. Stuart J Fischbein
These obstetricians discuss how ACOG's statement disregards the ethical concept of autonomy, or a person's right to make decisions about their own care, including place of birth and birth attendant.
Birth Action Coalition's website posts the response from ACOG's Executive Vice-President Ralph Hale to Dr. Stuart Fischbein's letter. Although Dr. Hale cites concerns over safety, he provides no evidence that planned hospital births are safer for mother or baby. Instead he refers to anecdotes from other obstetricians to justify condemning planned home births. The problem with using anecdotes is the bias involved.
Referral bias occurs when a referral center sees a different group of patients than those who are not referred. So for example, as a surgeon, almost every patient with abdominal pain I saw needed an operation. From my point of view, most people with abdominal pain need operations. In truth, however, many patients with abdominal pain never got to see me because the first doctor they saw correctly thought that they were unlikely to need a surgeon. The opposite of what I thought was true is actually true. Most people with abdominal pain do not need surgery. Which is why a general surgeon shouldn't be seeing every person with abdominal pain.
In the same way, obstetricians only see planned home births that required transfer to the hospital and further treatment. Therefore, they could conclude that births shouldn't be planned for home. They should be in the hospital. In fact, many planned home births (approximately 85%) never come to the hospital. If obstetricians could experience the uncomplicated home births, they might have a different opinion.
Confirmation bias is a bias to selectively focus on events that confirm what you already believe. For example, if I think that someone doesn't like me, I may notice that they didn't call me. I take this as evidence that they indeed do not like me. Of course, I forgot that they were going out of town that day.
Physicians generally already have a preconceived notion that home birth is unsafe. Caring for or hearing about a home birth transfer to the hospital is often enough to confirm this notion. They stop looking for more information about home births. Hearing about 1000 normal births wouldn't clear the memory of a single terrible complication.
People also confuse how memorable something is with how often it actually happens. This is called availability bias. For example, stories of lottery or casino winners are on billboards and in the newspaper. Losing lottery-ticket holders are not interviewed on the six o'clock news. Seeing ordinary people winning millions makes it seem more likely to happen to me. In reality I am more likely to be killed by lightning than I am to win the lottery. A tragedy in the setting of a planned home birth is very memorable. Even a single poor outcome makes obstetricians think that complications happen more often with home births than they actually do.
Of course, these same biases exist for those who fear birthing in a hospital. Hmm .... sounds like another blog for another day.
Comments