Erin E. Tracy, MD, MPH

Medical students learn early in their education that alcohol is a teratogen. Despite this widespread knowledge, many obstetricians counsel patients about the safety of low doses of alcohol in pregnancy.¹ Indeed, the Royal College of Obstetricians and Gynaecologists’ position on this is, “while the safest approach may be to avoid any alcohol during pregnancy, it remains the case that there is no evidence of harm from low levels of alcohol consumption, defined as no more than one or two units of alcohol once or twice a week.”²

Like many providers, I was aware of this controversy, but it became truly personal when a beloved family member was diagnosed with fetal alcohol syndrome (FAS). In this paper, I will review some of the controversy regarding alcohol in pregnancy, highlight findings from the literature, provide tools for prevention, and identify new developments regarding this devastating, preventable condition.

Charlie

To know my nephew Charlie is to fall in love with my nephew Charlie. One of the happiest moments of my life was when I learned my brother and sister-in-law had adopted twins from Kazakhstan. When my little niece and nephew started their new life in the United States, certain medical issues seemed to merit additional attention. Although both were very small for their age and required significant nutritional support, Charlie seemed to be a bit more rambunctious and required additional supervision.

The children were fortunate enough to have incredibly loving, dedicated parents, who have access to exceptional medical care as residents of Philadelphia, Pennsylvania. After extensive testing, it became clear what was causing Charlie’s developmental delay; his pediatric team made the diagnosis of FAS. My brother and sister-in-law became incredibly well-read about this challenging disorder, and threw themselves into national advocacy work to help prevent this unnecessary tragedy.

Recent data point to teratogenicity, but media confuse the issue

Some recent media coverage³ of celebrities who apparently drank while pregnant was in response to an article in the Journal of Epidemiology and Community Health.⁴ The authors of this study concluded that, “at age 5 years, cohort members born to mothers who drank up to one to two drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioral difficulties or cognitive deficits, compared with children of mothers in the not-in-pregnancy group.”

This is certainly not the first occasion the popular press has covered a published study that seems to indicate no ill effects of alcohol use in pregnancy. A 2008 report by Kelly and colleagues,⁵ and its subsequent media coverage, prompted the Fetal Alcohol Spectrum Disorders Study Group to state that the panel of experts was “alarmed” by recent newspaper reports suggesting that light drinking during pregnancy may be beneficial for an unborn child.⁶ They noted misleading and irresponsible media reports of the findings, which suggested that 3-year-old children whose mothers drank “lightly” during pregnancy were not at risk for certain behavioral problems.

What the study authors proceeded to note, however (that the media did not mention), was that the light drinkers in their study had socioeconomic advantages, compared with nondrinkers.⁵ (Advantaged economic status is established to be beneficial for childhood development.) They also noted that the study involved preschool-aged children, stating “Generally the adverse effects of light drinking during pregnancy are subtle and may go undetected in young children. However, other group studies of more moderate or ‘social’ drinking levels during pregnancy have shown an adverse impact on multiple aspects of development through adolescence and young adulthood, even when important environmental factors are taken into account.” A sentence I thought was most compelling in their statement was, “It is an inconvenient fact of life that alcohol is a teratogen.” Now, this fact is well supported in the literature.⁷

There are animal studies regarding the use of “low-dose” or “moderate” alcohol in pregnancy that demonstrate adverse behavioral outcomes with exposure to even small doses of alcohol.^8,9 It is an American tragedy that, according to the Centers for Disease Control and Prevention (CDC), rates of FAS in this country range from 0.2 to 2.0 cases per 1,000 live births. Indeed, the rates of fetal alcohol spectrum disorders (FASD) might be at least three times this rate.¹⁰ As is the case with other disorders, there are health disparities regarding the prevalence of this condition as well.¹¹

FAS: A long history of preventable disease

1973: Identified. FAS was first described in a 1973 Lancet report, “Pattern of malformation in offspring of chronic alcoholic mothers.”¹²

1996: Call for prevention. In 1995, the US Surgeon General issued a statement regarding alcohol use in pregnancy, noting, “We do not know what, if any, amount of alcohol is safe.”¹³ In 1996, the Institute of Medicine released a paper calling FAS and FASD “completely preventable birth defects and neurodevelopmental abnormalities.”¹⁴

2000: The troubling effects gathered. The American Academy of Pediatrics (AAP) published a monograph on FAS in 2000, defining it as a constellation of physical, behavioral, and cognitive abnormalities.¹⁵

These features classically define FAS:

• dysmorphic facial features
• prenatal and postnatal growth abnormalities
• mental retardation.

Approximately 80% of children with this condition have:

• microcephaly
• behavioral abnormalities.

As many as 50% of affected children also exhibit:

• poor coordination
• hypotonia
• attention-deficit hyperactivity disorder
• decreased adipose tissue
• identifiable facial anomalies (such as maxillary hypoplasia, cleft palate, and micrognathia).

Also common:

• cardiac defects
• hemangiomas
• eye or ear abnormalities.

The AAP further noted that data current to the time (and still true today) did not support the concept of a safe level of alcohol consumption by pregnant women below which no damage to a fetus will occur.¹⁵

Alcohol intake during pregnancy puts the fetus at risk for cognitive and neuropsychological impairment and physical abnormalities, including dysmorphic facial features (such as micrognathia), restricted prenatal growth, cardiac defects, and eye and ear abnormalities. There is no threshold dose of alcohol that is safe during pregnancy, according to the American College of Obstetricians and Gynecologists.

Despite the knowledge we’ve gained, FAS persists

According to a 2006–2010 CDC analysis involving more than 345,000 women of reproductive age from all 50 states, 7.6% of pregnant women reported alcohol use and 1.4% (or 1 in 71) reported binge drinking (defined, respectively, as at least one alcoholic drink and four or more alcoholic drinks on one occasion in the past 30 days).¹⁶ The highest prevalence of obstetric alcohol consumption occurs in women who are:

• aged 35 to 44 years
• white
• college graduates
• employed.

The problem may be bigger than reported. The incidences of alcohol and binge drinking found in the CDC report include women’s self-report—but women drink alcohol without knowing they’re pregnant. Only 40% of women realize they’re pregnant at 4 weeks of gestation, a critical time for organogenesis, and approximately half of all births are unplanned.⁹

When my brother and sister-in law adopted my beautiful niece and nephew, they were very aware of the risk for conditions like FAS. In an evaluation of 71 children adopted from Eastern Europe at 5 years of age, FAS was diagnosed in 30% of children and “partial FAS” in another 9%.¹⁷ Birth defects attributed to alcohol were present in 11% of the children.

Are women’s health providers up to date on FAS education?

In recognition of alcohol’s potentially life-altering consequences for the developing fetus, the American College of Obstetricians and Gynecologists (ACOG) produced an FASD prevention tool kit in 2006 and published a 2011 committee opinion on at-risk drinking and alcohol dependence and their implications for obstetrics and gynecology.^18,19 Both guidelines direct clinicians to advise patients to abstain from alcohol during pregnancy.

Results from a 2010 survey of 800 ACOG fellows revealed that only 78% of obstetricians advised abstinence from alcohol during pregnancy. Fifty-eight percent of respondents did not use a validated screening tool for alcohol use in their pregnant patients, and only 72% felt prepared to screen for risky or hazardous drinking.¹⁹ (Most were unaware of the ACOG tool kit, which had been published several years earlier.)

In a survey of pediatricians, obstetricians, and family physicians, clinicians said that about 67% of their patients asked about alcohol use in pregnancy, with about 2% of those patients specifically mentioning FAS. About 41% of these same physicians erroneously placed the threshold for FAS at one to three drinks per day,²⁰ when in fact there is no threshold of drinking that has been proven to be safe.

A survey of 1,000 actively practicing ACOG fellows revealed that, while 97% of obstetricians routinely asked their patients about alcohol use, only 20% of providers reported to their patients that abstinence was safest, and 4% of providers didn’t believe that consumption of eight or more drinks weekly posed fetal risk.²¹

How can we educate our patients about the dangers of alcohol in pregnancy?

Fetal death. A recent Danish study of 79,216 pregnant women revealed that 45% had consumed some alcohol during pregnancy. Two percent reported at least four drinks per week, and 25% admitted to binge drinking during pregnancy. Term infants born to women in the latter two groups had increased neonatal mortality, with hazard ratios of 3.56 (95% confidence interval [CI], 1.15–8.43) and 2.69 (95% CI, 1.27–5.69), respectively.²²

Decreased cognitive status. A study by Willford and colleagues evaluated the relationship between prenatal alcohol exposure and cognitive status of 1,360 10-year-old children.²³ The authors utilized the Stanford-Binet Intelligence Test, including the composite scores and verbal, abstract/visual, quantitative, and short-term memory scores. After controlling for other variables, among African American offspring they found that, for each additional drink, the average composite score decreased by 1.9 points. This difference was more striking for second-trimester use, and was significant even for one drink daily versus abstention from alcohol.

Impaired neuropsychological development. Another study evaluating light to moderate amounts of prenatal alcohol exposure in 10- and 11-year-old children found significantly worse scores regarding a number of neuropsychological developmental assessments.²⁴

No threshold dose of causation. Results of a 2012 prospective study in California, with data collected on 992 subjects from 1978 until 2005, revealed that many physical FAS features, including microcephaly, smooth philtrum, and thin vermillion border; reduced birth length; and reduced birth weight, were associated with alcohol exposure at specific gestational ages, and were dose-related.²⁵ This paper didn’t reveal any evidence of a threshold dose of causation.

Neurobehavioral outcomes of FAS are not always considered

Another recent study that the media recently highlighted as finding “no association between low or moderate prenatal alcohol exposure and birth defects” was by O’Leary and colleagues.²⁶ Like other similarly limited studies, this one involved only children younger than 6 years and didn’t assess any of the important neurobehavioral outcomes of FAS.

FAS encompasses much more than visible birth defects. As the aforementioned ACOG tool kit stated, “For every child born with FAS, many more children are born with neurobehavioral deficits caused by alcohol exposure but without the physical characteristics of FAS.”

The costs of FAS are felt with dollars, too

The financial cost to our nation is extraordinary. In 1991, Abel and Sokol estimated the incremental annual cost of treating FAS at nearly $75 million, with about three-quarters of that cost associated with FAS cases involving mental retardation.²⁷

A 2002 assessment estimated the lifetime cost for each individual with FAS (adjusting for the change in the cost of medical care services, lost productivity, and inflation) at $2 million. This figure consists of $1.6 million for medical treatment, special education, and residential care for persons with mental retardation, and $0.4 million for productivity losses.²⁸

Where human studies fall short, animal studies can help elucidate causation

Unquestionably, there are flaws in the existing literature on the causation of FAS. Many studies rely on self-reporting by pregnant women, and underreporting in these cases is a real concern. There often are other confounders potentially negatively affecting fetal development, making it difficult to differentiate causation. The animal studies that don’t share these limitations do suggest a causal relationship between antenatal alcohol exposure and poor obstetric outcomes, however.²⁹ These studies suggest mechanisms such as altered gene expression, oxidative stress, and apoptosis (programmed cell death).³⁰

Warren, Hewitt, and Thomas describe how intrauterine alcohol exposure interferes with the function of L1CAM, the L1 cell-adhesion molecule.³¹ They noted that just one drink could interfere with the ability of L1CAM to mediate cell adhesion and axonal growth. Prenatal alcohol exposure is also thought to contribute to interference in neurotransmitter and N-methyl-D-aspartate receptor coupling, which may have potential therapeutic implications.³²

Considerations in FAS identification and treatment

There is a potential to identify alcohol exposure in the womb. The majority of ingested alcohol is eventually converted to carbon dioxide and water in both maternal and fetal circulations, which has hampered the identification of biomarkers for clinical use in FAS. Fatty acid ethyl esters (FAEEs), nonoxidative metabolites of ethanol, may prove to be such markers.³³ FAEEs have been measured in a variety of tissues, including blood and meconium. FAEEs can be measured in both neonatal and maternal hair samples.

A study evaluating the utility of such testing in 324 at-risk pregnancies revealed 90% sensitivity and 90% specificity for identifying “excessive drinking” using a cutoff of 0.5 ng/mg.³⁴

Research shows potential therapeutic approaches during pregnancy. While the use of biomarkers has the potential to assist with the identification of at-risk newborns, it merely identifies past alcohol use; it doesn’t necessarily permit identification and prevention of the known negative pediatric sequelae. Preliminary animal studies reveal the potential benefit of neuroprotective peptides to prevent brain damage in alcohol-exposed mice.³⁵ Further research is ongoing.

Treatment: The earlier the better

Early diagnosis and a positive environment improve outcomes. It is well established that early intervention improves outcomes. One comprehensive review of 415 patients with FAS noted troubling outcomes in general for adolescents and adults.³⁶ Over their life spans, the prevalence of such outcomes was:

• 61% for disrupted school experiences
• 60% for trouble with the law
• 50% for confinement (in detention, jail, prison, or a psychiatric or alcohol/drug inpatient setting)
• 49% for inappropriate sexual behaviors on repeated occasions
• 35% for alcohol/drug problems.

The odds of escaping these adverse life outcomes are increased up to fourfold when the individual receives a FAS or FASD diagnosis at an earlier age and is reared in a stable environment.³⁶

Barrier to treatment: A mother’s guilt. One of the challenges I’ve learned from my sister-in-law is the stigma mothers face when they bring their child in for services once the diagnosis of FAS is suspected. While adoptive mothers obviously can’t be held accountable for the intrauterine environment to which a fetus is exposed, the same can’t be said of biologic mothers. Therefore, there is a real risk that a mother who is unwilling or unable to face the potentially devastating news that her baby’s issues might be related to choices she made during pregnancy, might not bring her child in for necessary assessment and treatment. Therefore, prevention is a key proponent of treatment.

Prevent FAS: Provide contraception, screen for alcohol use, intervene

While ObGyns aren’t likely to diagnose many children with FAS, we are in an excellent position to try to prevent this tragedy through our counseling of reproductive-aged women. I suspect that most obstetricians spend a considerable amount of time discussing much less frequent obstetric sequelae, such as listeriosis, in the prenatal care setting. Validated alcohol screening tools take moments to administer, and once patients who might have alcohol problems are identified, either a serious discussion about contraception or an honest discussion of FAS may be appropriate. There have been a number of screening tools developed.

The CAGE screen is frequently taught in medical schools, but it isn’t as sensitive for women or minorities.¹⁹

The T-ACE (Tolerance, Annoyed, Cut Down, Eye-opener) tool involves four questions that take less than 1 minute to administer (FIGURE 1).³⁹

TWEAK is another potential tool identified by Russell and colleagues (Tolerance, Worry, Eye opener, Amnesia, and Cut down in drinking).³⁹ Other methods utilized include an AUDIT screen and a CRAFFT screen.⁴⁰ Regardless of which tool is utilized, screening is not time-consuming and is better than merely inquiring about alcohol consumption in general.

FIGURE 1 T-ACE validated alcohol screening tool
Source: American College of Obstetricians and Gynecologists. At risk drinking and illicit drug use: Ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2008;112(6):1449–1460.

When alcohol use is found, intervene

Once patients with at-risk behavior are identified, obstetric staff should offer brief interventions to influence problem drinking. Miller and Sanchez summarized the key elements that were most successful in these programs with the acronym FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy (FIGURE 2).⁴¹ This approach has been formally evaluated in the CDC’s multisite pilot study entitled Project CHOICES.⁴²

In this motivational intervention, sexually active, fertile women of reproductive age underwent up to four motivational counseling sessions and one visit to a provider. At 6 months, 69% of women reduced their risk for an alcohol-exposed pregnancy—although the women who drank the least amount had the greatest benefit, primarily by choosing effective contraception, but also by reducing alcohol intake.

FIGURE 2 FRAMES model to deliver brief interventions
Source: American College of Obstetricians and Gynecologists. Drinking and reproductive health: A fetal alcohol spectrum disorders prevention tool kit. Washington, DC: ACOG; 2006.

A single, brief intervention is effective in already-pregnant women. Chang and colleagues conducted a randomized trial of a single-session brief intervention given to pregnant women with positive T-ACE screens and their partners (FIGURE 3).⁴³ Either the study nurse or physician participated in the intervention, and each single session took 25 minutes on average. The pregnant women with the highest level of alcohol use reduced their drinking the most, and this effect was even larger when their partners participated. Other studies of brief interventions showed similar benefits.^44,45

Another study evaluating a brief intervention involving training of health-care providers to improve screening rates revealed improved detection and therapy among at-risk patients.⁴⁶

FIGURE 3 Single session, 25-minute intervention for patients and their partners
Source: Chang G, McNamara T, Orav J, et al. Brief intervention for prenatal alcohol use: a randomized trial. Obstet Gynecol. 2005;105(5 Pt 1):991–998.

FAS prevention begins with routine counseling and contraception

Although FAS is often thought of in relation to obstetric populations, appointments for preconception counseling or routine health maintenance among women of reproductive age are an essential tool in FAS prevention. As previously mentioned, since approximately half of all pregnancies in this country are unplanned, long-acting reversible contraception is widely available to facilitate improved family planning.

Other contraceptive options also should be discussed. ACOG has teamed up with the CDC to develop a phone app for providers to use at the patient’s bedside to assist with identification and treatment of women at risk for alcohol use during pregnancy.⁴⁷

The stakes are high, it’s time to step up

As obstetricians, we are powerless to prevent many conditions—such as vasa previa, acute fatty liver of pregnancy, and amniotic band syndrome. FAS is 100% preventable.

There aren’t that many proven teratogens in our profession, and there are none that involve behavior that is more socially acceptable than alcohol consumption. It is time for our profession to encourage women to appreciate how small a percentage of one’s life is spent pregnant, how many more years there are to enjoy an occasional cocktail, and how very high the stakes are during this important period of their lives. Oh, how I wish someone had been able to communicate all of this to sweet Charlie’s biologic mother. I am so grateful he’s getting the exceptional care he’s getting and very optimistic regarding his future. I only hope others in his situation are given the same opportunities.

We want to hear from you! Tell us what you think.

Medical students learn early in their education that alcohol is a teratogen. Despite this widespread knowledge, many obstetricians counsel patients about the safety of low doses of alcohol in pregnancy.¹ Indeed, the Royal College of Obstetricians and Gynaecologists’ position on this is, “while the safest approach may be to avoid any alcohol during pregnancy, it remains the case that there is no evidence of harm from low levels of alcohol consumption, defined as no more than one or two units of alcohol once or twice a week.”²

Like many providers, I was aware of this controversy, but it became truly personal when a beloved family member was diagnosed with fetal alcohol syndrome (FAS). In this paper, I will review some of the controversy regarding alcohol in pregnancy, highlight findings from the literature, provide tools for prevention, and identify new developments regarding this devastating, preventable condition.

Charlie

To know my nephew Charlie is to fall in love with my nephew Charlie. One of the happiest moments of my life was when I learned my brother and sister-in-law had adopted twins from Kazakhstan. When my little niece and nephew started their new life in the United States, certain medical issues seemed to merit additional attention. Although both were very small for their age and required significant nutritional support, Charlie seemed to be a bit more rambunctious and required additional supervision.

The children were fortunate enough to have incredibly loving, dedicated parents, who have access to exceptional medical care as residents of Philadelphia, Pennsylvania. After extensive testing, it became clear what was causing Charlie’s developmental delay; his pediatric team made the diagnosis of FAS. My brother and sister-in-law became incredibly well-read about this challenging disorder, and threw themselves into national advocacy work to help prevent this unnecessary tragedy.

Recent data point to teratogenicity, but media confuse the issue

Some recent media coverage³ of celebrities who apparently drank while pregnant was in response to an article in the Journal of Epidemiology and Community Health.⁴ The authors of this study concluded that, “at age 5 years, cohort members born to mothers who drank up to one to two drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioral difficulties or cognitive deficits, compared with children of mothers in the not-in-pregnancy group.”

This is certainly not the first occasion the popular press has covered a published study that seems to indicate no ill effects of alcohol use in pregnancy. A 2008 report by Kelly and colleagues,⁵ and its subsequent media coverage, prompted the Fetal Alcohol Spectrum Disorders Study Group to state that the panel of experts was “alarmed” by recent newspaper reports suggesting that light drinking during pregnancy may be beneficial for an unborn child.⁶ They noted misleading and irresponsible media reports of the findings, which suggested that 3-year-old children whose mothers drank “lightly” during pregnancy were not at risk for certain behavioral problems.

What the study authors proceeded to note, however (that the media did not mention), was that the light drinkers in their study had socioeconomic advantages, compared with nondrinkers.⁵ (Advantaged economic status is established to be beneficial for childhood development.) They also noted that the study involved preschool-aged children, stating “Generally the adverse effects of light drinking during pregnancy are subtle and may go undetected in young children. However, other group studies of more moderate or ‘social’ drinking levels during pregnancy have shown an adverse impact on multiple aspects of development through adolescence and young adulthood, even when important environmental factors are taken into account.” A sentence I thought was most compelling in their statement was, “It is an inconvenient fact of life that alcohol is a teratogen.” Now, this fact is well supported in the literature.⁷

There are animal studies regarding the use of “low-dose” or “moderate” alcohol in pregnancy that demonstrate adverse behavioral outcomes with exposure to even small doses of alcohol.^8,9 It is an American tragedy that, according to the Centers for Disease Control and Prevention (CDC), rates of FAS in this country range from 0.2 to 2.0 cases per 1,000 live births. Indeed, the rates of fetal alcohol spectrum disorders (FASD) might be at least three times this rate.¹⁰ As is the case with other disorders, there are health disparities regarding the prevalence of this condition as well.¹¹

FAS: A long history of preventable disease

1973: Identified. FAS was first described in a 1973 Lancet report, “Pattern of malformation in offspring of chronic alcoholic mothers.”¹²

1996: Call for prevention. In 1995, the US Surgeon General issued a statement regarding alcohol use in pregnancy, noting, “We do not know what, if any, amount of alcohol is safe.”¹³ In 1996, the Institute of Medicine released a paper calling FAS and FASD “completely preventable birth defects and neurodevelopmental abnormalities.”¹⁴

2000: The troubling effects gathered. The American Academy of Pediatrics (AAP) published a monograph on FAS in 2000, defining it as a constellation of physical, behavioral, and cognitive abnormalities.¹⁵

These features classically define FAS:

• dysmorphic facial features
• prenatal and postnatal growth abnormalities
• mental retardation.

Approximately 80% of children with this condition have:

• microcephaly
• behavioral abnormalities.

As many as 50% of affected children also exhibit:

• poor coordination
• hypotonia
• attention-deficit hyperactivity disorder
• decreased adipose tissue
• identifiable facial anomalies (such as maxillary hypoplasia, cleft palate, and micrognathia).

Also common:

• cardiac defects
• hemangiomas
• eye or ear abnormalities.

The AAP further noted that data current to the time (and still true today) did not support the concept of a safe level of alcohol consumption by pregnant women below which no damage to a fetus will occur.¹⁵

Alcohol intake during pregnancy puts the fetus at risk for cognitive and neuropsychological impairment and physical abnormalities, including dysmorphic facial features (such as micrognathia), restricted prenatal growth, cardiac defects, and eye and ear abnormalities. There is no threshold dose of alcohol that is safe during pregnancy, according to the American College of Obstetricians and Gynecologists.

Despite the knowledge we’ve gained, FAS persists

According to a 2006–2010 CDC analysis involving more than 345,000 women of reproductive age from all 50 states, 7.6% of pregnant women reported alcohol use and 1.4% (or 1 in 71) reported binge drinking (defined, respectively, as at least one alcoholic drink and four or more alcoholic drinks on one occasion in the past 30 days).¹⁶ The highest prevalence of obstetric alcohol consumption occurs in women who are:

• aged 35 to 44 years
• white
• college graduates
• employed.

The problem may be bigger than reported. The incidences of alcohol and binge drinking found in the CDC report include women’s self-report—but women drink alcohol without knowing they’re pregnant. Only 40% of women realize they’re pregnant at 4 weeks of gestation, a critical time for organogenesis, and approximately half of all births are unplanned.⁹

When my brother and sister-in law adopted my beautiful niece and nephew, they were very aware of the risk for conditions like FAS. In an evaluation of 71 children adopted from Eastern Europe at 5 years of age, FAS was diagnosed in 30% of children and “partial FAS” in another 9%.¹⁷ Birth defects attributed to alcohol were present in 11% of the children.

Are women’s health providers up to date on FAS education?

In recognition of alcohol’s potentially life-altering consequences for the developing fetus, the American College of Obstetricians and Gynecologists (ACOG) produced an FASD prevention tool kit in 2006 and published a 2011 committee opinion on at-risk drinking and alcohol dependence and their implications for obstetrics and gynecology.^18,19 Both guidelines direct clinicians to advise patients to abstain from alcohol during pregnancy.

Results from a 2010 survey of 800 ACOG fellows revealed that only 78% of obstetricians advised abstinence from alcohol during pregnancy. Fifty-eight percent of respondents did not use a validated screening tool for alcohol use in their pregnant patients, and only 72% felt prepared to screen for risky or hazardous drinking.¹⁹ (Most were unaware of the ACOG tool kit, which had been published several years earlier.)

In a survey of pediatricians, obstetricians, and family physicians, clinicians said that about 67% of their patients asked about alcohol use in pregnancy, with about 2% of those patients specifically mentioning FAS. About 41% of these same physicians erroneously placed the threshold for FAS at one to three drinks per day,²⁰ when in fact there is no threshold of drinking that has been proven to be safe.

A survey of 1,000 actively practicing ACOG fellows revealed that, while 97% of obstetricians routinely asked their patients about alcohol use, only 20% of providers reported to their patients that abstinence was safest, and 4% of providers didn’t believe that consumption of eight or more drinks weekly posed fetal risk.²¹

How can we educate our patients about the dangers of alcohol in pregnancy?

Fetal death. A recent Danish study of 79,216 pregnant women revealed that 45% had consumed some alcohol during pregnancy. Two percent reported at least four drinks per week, and 25% admitted to binge drinking during pregnancy. Term infants born to women in the latter two groups had increased neonatal mortality, with hazard ratios of 3.56 (95% confidence interval [CI], 1.15–8.43) and 2.69 (95% CI, 1.27–5.69), respectively.²²

Decreased cognitive status. A study by Willford and colleagues evaluated the relationship between prenatal alcohol exposure and cognitive status of 1,360 10-year-old children.²³ The authors utilized the Stanford-Binet Intelligence Test, including the composite scores and verbal, abstract/visual, quantitative, and short-term memory scores. After controlling for other variables, among African American offspring they found that, for each additional drink, the average composite score decreased by 1.9 points. This difference was more striking for second-trimester use, and was significant even for one drink daily versus abstention from alcohol.

Impaired neuropsychological development. Another study evaluating light to moderate amounts of prenatal alcohol exposure in 10- and 11-year-old children found significantly worse scores regarding a number of neuropsychological developmental assessments.²⁴

No threshold dose of causation. Results of a 2012 prospective study in California, with data collected on 992 subjects from 1978 until 2005, revealed that many physical FAS features, including microcephaly, smooth philtrum, and thin vermillion border; reduced birth length; and reduced birth weight, were associated with alcohol exposure at specific gestational ages, and were dose-related.²⁵ This paper didn’t reveal any evidence of a threshold dose of causation.

Neurobehavioral outcomes of FAS are not always considered

Another recent study that the media recently highlighted as finding “no association between low or moderate prenatal alcohol exposure and birth defects” was by O’Leary and colleagues.²⁶ Like other similarly limited studies, this one involved only children younger than 6 years and didn’t assess any of the important neurobehavioral outcomes of FAS.

FAS encompasses much more than visible birth defects. As the aforementioned ACOG tool kit stated, “For every child born with FAS, many more children are born with neurobehavioral deficits caused by alcohol exposure but without the physical characteristics of FAS.”

The costs of FAS are felt with dollars, too

The financial cost to our nation is extraordinary. In 1991, Abel and Sokol estimated the incremental annual cost of treating FAS at nearly $75 million, with about three-quarters of that cost associated with FAS cases involving mental retardation.²⁷

A 2002 assessment estimated the lifetime cost for each individual with FAS (adjusting for the change in the cost of medical care services, lost productivity, and inflation) at $2 million. This figure consists of $1.6 million for medical treatment, special education, and residential care for persons with mental retardation, and $0.4 million for productivity losses.²⁸

Where human studies fall short, animal studies can help elucidate causation

Unquestionably, there are flaws in the existing literature on the causation of FAS. Many studies rely on self-reporting by pregnant women, and underreporting in these cases is a real concern. There often are other confounders potentially negatively affecting fetal development, making it difficult to differentiate causation. The animal studies that don’t share these limitations do suggest a causal relationship between antenatal alcohol exposure and poor obstetric outcomes, however.²⁹ These studies suggest mechanisms such as altered gene expression, oxidative stress, and apoptosis (programmed cell death).³⁰

Warren, Hewitt, and Thomas describe how intrauterine alcohol exposure interferes with the function of L1CAM, the L1 cell-adhesion molecule.³¹ They noted that just one drink could interfere with the ability of L1CAM to mediate cell adhesion and axonal growth. Prenatal alcohol exposure is also thought to contribute to interference in neurotransmitter and N-methyl-D-aspartate receptor coupling, which may have potential therapeutic implications.³²

Considerations in FAS identification and treatment

There is a potential to identify alcohol exposure in the womb. The majority of ingested alcohol is eventually converted to carbon dioxide and water in both maternal and fetal circulations, which has hampered the identification of biomarkers for clinical use in FAS. Fatty acid ethyl esters (FAEEs), nonoxidative metabolites of ethanol, may prove to be such markers.³³ FAEEs have been measured in a variety of tissues, including blood and meconium. FAEEs can be measured in both neonatal and maternal hair samples.

A study evaluating the utility of such testing in 324 at-risk pregnancies revealed 90% sensitivity and 90% specificity for identifying “excessive drinking” using a cutoff of 0.5 ng/mg.³⁴

Research shows potential therapeutic approaches during pregnancy. While the use of biomarkers has the potential to assist with the identification of at-risk newborns, it merely identifies past alcohol use; it doesn’t necessarily permit identification and prevention of the known negative pediatric sequelae. Preliminary animal studies reveal the potential benefit of neuroprotective peptides to prevent brain damage in alcohol-exposed mice.³⁵ Further research is ongoing.

Treatment: The earlier the better

Early diagnosis and a positive environment improve outcomes. It is well established that early intervention improves outcomes. One comprehensive review of 415 patients with FAS noted troubling outcomes in general for adolescents and adults.³⁶ Over their life spans, the prevalence of such outcomes was:

• 61% for disrupted school experiences
• 60% for trouble with the law
• 50% for confinement (in detention, jail, prison, or a psychiatric or alcohol/drug inpatient setting)
• 49% for inappropriate sexual behaviors on repeated occasions
• 35% for alcohol/drug problems.

The odds of escaping these adverse life outcomes are increased up to fourfold when the individual receives a FAS or FASD diagnosis at an earlier age and is reared in a stable environment.³⁶

Barrier to treatment: A mother’s guilt. One of the challenges I’ve learned from my sister-in-law is the stigma mothers face when they bring their child in for services once the diagnosis of FAS is suspected. While adoptive mothers obviously can’t be held accountable for the intrauterine environment to which a fetus is exposed, the same can’t be said of biologic mothers. Therefore, there is a real risk that a mother who is unwilling or unable to face the potentially devastating news that her baby’s issues might be related to choices she made during pregnancy, might not bring her child in for necessary assessment and treatment. Therefore, prevention is a key proponent of treatment.

Prevent FAS: Provide contraception, screen for alcohol use, intervene

While ObGyns aren’t likely to diagnose many children with FAS, we are in an excellent position to try to prevent this tragedy through our counseling of reproductive-aged women. I suspect that most obstetricians spend a considerable amount of time discussing much less frequent obstetric sequelae, such as listeriosis, in the prenatal care setting. Validated alcohol screening tools take moments to administer, and once patients who might have alcohol problems are identified, either a serious discussion about contraception or an honest discussion of FAS may be appropriate. There have been a number of screening tools developed.

The CAGE screen is frequently taught in medical schools, but it isn’t as sensitive for women or minorities.¹⁹

The T-ACE (Tolerance, Annoyed, Cut Down, Eye-opener) tool involves four questions that take less than 1 minute to administer (FIGURE 1).³⁹

TWEAK is another potential tool identified by Russell and colleagues (Tolerance, Worry, Eye opener, Amnesia, and Cut down in drinking).³⁹ Other methods utilized include an AUDIT screen and a CRAFFT screen.⁴⁰ Regardless of which tool is utilized, screening is not time-consuming and is better than merely inquiring about alcohol consumption in general.

FIGURE 1 T-ACE validated alcohol screening tool
Source: American College of Obstetricians and Gynecologists. At risk drinking and illicit drug use: Ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2008;112(6):1449–1460.

When alcohol use is found, intervene

Once patients with at-risk behavior are identified, obstetric staff should offer brief interventions to influence problem drinking. Miller and Sanchez summarized the key elements that were most successful in these programs with the acronym FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy (FIGURE 2).⁴¹ This approach has been formally evaluated in the CDC’s multisite pilot study entitled Project CHOICES.⁴²

In this motivational intervention, sexually active, fertile women of reproductive age underwent up to four motivational counseling sessions and one visit to a provider. At 6 months, 69% of women reduced their risk for an alcohol-exposed pregnancy—although the women who drank the least amount had the greatest benefit, primarily by choosing effective contraception, but also by reducing alcohol intake.

FIGURE 2 FRAMES model to deliver brief interventions
Source: American College of Obstetricians and Gynecologists. Drinking and reproductive health: A fetal alcohol spectrum disorders prevention tool kit. Washington, DC: ACOG; 2006.

A single, brief intervention is effective in already-pregnant women. Chang and colleagues conducted a randomized trial of a single-session brief intervention given to pregnant women with positive T-ACE screens and their partners (FIGURE 3).⁴³ Either the study nurse or physician participated in the intervention, and each single session took 25 minutes on average. The pregnant women with the highest level of alcohol use reduced their drinking the most, and this effect was even larger when their partners participated. Other studies of brief interventions showed similar benefits.^44,45

Another study evaluating a brief intervention involving training of health-care providers to improve screening rates revealed improved detection and therapy among at-risk patients.⁴⁶

FIGURE 3 Single session, 25-minute intervention for patients and their partners
Source: Chang G, McNamara T, Orav J, et al. Brief intervention for prenatal alcohol use: a randomized trial. Obstet Gynecol. 2005;105(5 Pt 1):991–998.

FAS prevention begins with routine counseling and contraception

Although FAS is often thought of in relation to obstetric populations, appointments for preconception counseling or routine health maintenance among women of reproductive age are an essential tool in FAS prevention. As previously mentioned, since approximately half of all pregnancies in this country are unplanned, long-acting reversible contraception is widely available to facilitate improved family planning.

Other contraceptive options also should be discussed. ACOG has teamed up with the CDC to develop a phone app for providers to use at the patient’s bedside to assist with identification and treatment of women at risk for alcohol use during pregnancy.⁴⁷

The stakes are high, it’s time to step up

As obstetricians, we are powerless to prevent many conditions—such as vasa previa, acute fatty liver of pregnancy, and amniotic band syndrome. FAS is 100% preventable.

There aren’t that many proven teratogens in our profession, and there are none that involve behavior that is more socially acceptable than alcohol consumption. It is time for our profession to encourage women to appreciate how small a percentage of one’s life is spent pregnant, how many more years there are to enjoy an occasional cocktail, and how very high the stakes are during this important period of their lives. Oh, how I wish someone had been able to communicate all of this to sweet Charlie’s biologic mother. I am so grateful he’s getting the exceptional care he’s getting and very optimistic regarding his future. I only hope others in his situation are given the same opportunities.

We want to hear from you! Tell us what you think.

Medical students learn early in their education that alcohol is a teratogen. Despite this widespread knowledge, many obstetricians counsel patients about the safety of low doses of alcohol in pregnancy.¹ Indeed, the Royal College of Obstetricians and Gynaecologists’ position on this is, “while the safest approach may be to avoid any alcohol during pregnancy, it remains the case that there is no evidence of harm from low levels of alcohol consumption, defined as no more than one or two units of alcohol once or twice a week.”²

Like many providers, I was aware of this controversy, but it became truly personal when a beloved family member was diagnosed with fetal alcohol syndrome (FAS). In this paper, I will review some of the controversy regarding alcohol in pregnancy, highlight findings from the literature, provide tools for prevention, and identify new developments regarding this devastating, preventable condition.

Charlie

To know my nephew Charlie is to fall in love with my nephew Charlie. One of the happiest moments of my life was when I learned my brother and sister-in-law had adopted twins from Kazakhstan. When my little niece and nephew started their new life in the United States, certain medical issues seemed to merit additional attention. Although both were very small for their age and required significant nutritional support, Charlie seemed to be a bit more rambunctious and required additional supervision.

The children were fortunate enough to have incredibly loving, dedicated parents, who have access to exceptional medical care as residents of Philadelphia, Pennsylvania. After extensive testing, it became clear what was causing Charlie’s developmental delay; his pediatric team made the diagnosis of FAS. My brother and sister-in-law became incredibly well-read about this challenging disorder, and threw themselves into national advocacy work to help prevent this unnecessary tragedy.

Recent data point to teratogenicity, but media confuse the issue

Some recent media coverage³ of celebrities who apparently drank while pregnant was in response to an article in the Journal of Epidemiology and Community Health.⁴ The authors of this study concluded that, “at age 5 years, cohort members born to mothers who drank up to one to two drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioral difficulties or cognitive deficits, compared with children of mothers in the not-in-pregnancy group.”

This is certainly not the first occasion the popular press has covered a published study that seems to indicate no ill effects of alcohol use in pregnancy. A 2008 report by Kelly and colleagues,⁵ and its subsequent media coverage, prompted the Fetal Alcohol Spectrum Disorders Study Group to state that the panel of experts was “alarmed” by recent newspaper reports suggesting that light drinking during pregnancy may be beneficial for an unborn child.⁶ They noted misleading and irresponsible media reports of the findings, which suggested that 3-year-old children whose mothers drank “lightly” during pregnancy were not at risk for certain behavioral problems.

What the study authors proceeded to note, however (that the media did not mention), was that the light drinkers in their study had socioeconomic advantages, compared with nondrinkers.⁵ (Advantaged economic status is established to be beneficial for childhood development.) They also noted that the study involved preschool-aged children, stating “Generally the adverse effects of light drinking during pregnancy are subtle and may go undetected in young children. However, other group studies of more moderate or ‘social’ drinking levels during pregnancy have shown an adverse impact on multiple aspects of development through adolescence and young adulthood, even when important environmental factors are taken into account.” A sentence I thought was most compelling in their statement was, “It is an inconvenient fact of life that alcohol is a teratogen.” Now, this fact is well supported in the literature.⁷

There are animal studies regarding the use of “low-dose” or “moderate” alcohol in pregnancy that demonstrate adverse behavioral outcomes with exposure to even small doses of alcohol.^8,9 It is an American tragedy that, according to the Centers for Disease Control and Prevention (CDC), rates of FAS in this country range from 0.2 to 2.0 cases per 1,000 live births. Indeed, the rates of fetal alcohol spectrum disorders (FASD) might be at least three times this rate.¹⁰ As is the case with other disorders, there are health disparities regarding the prevalence of this condition as well.¹¹

FAS: A long history of preventable disease

1973: Identified. FAS was first described in a 1973 Lancet report, “Pattern of malformation in offspring of chronic alcoholic mothers.”¹²

1996: Call for prevention. In 1995, the US Surgeon General issued a statement regarding alcohol use in pregnancy, noting, “We do not know what, if any, amount of alcohol is safe.”¹³ In 1996, the Institute of Medicine released a paper calling FAS and FASD “completely preventable birth defects and neurodevelopmental abnormalities.”¹⁴

2000: The troubling effects gathered. The American Academy of Pediatrics (AAP) published a monograph on FAS in 2000, defining it as a constellation of physical, behavioral, and cognitive abnormalities.¹⁵

These features classically define FAS:

• dysmorphic facial features
• prenatal and postnatal growth abnormalities
• mental retardation.

Approximately 80% of children with this condition have:

• microcephaly
• behavioral abnormalities.

As many as 50% of affected children also exhibit:

• poor coordination
• hypotonia
• attention-deficit hyperactivity disorder
• decreased adipose tissue
• identifiable facial anomalies (such as maxillary hypoplasia, cleft palate, and micrognathia).

Also common:

• cardiac defects
• hemangiomas
• eye or ear abnormalities.

The AAP further noted that data current to the time (and still true today) did not support the concept of a safe level of alcohol consumption by pregnant women below which no damage to a fetus will occur.¹⁵

Alcohol intake during pregnancy puts the fetus at risk for cognitive and neuropsychological impairment and physical abnormalities, including dysmorphic facial features (such as micrognathia), restricted prenatal growth, cardiac defects, and eye and ear abnormalities. There is no threshold dose of alcohol that is safe during pregnancy, according to the American College of Obstetricians and Gynecologists.

Despite the knowledge we’ve gained, FAS persists

According to a 2006–2010 CDC analysis involving more than 345,000 women of reproductive age from all 50 states, 7.6% of pregnant women reported alcohol use and 1.4% (or 1 in 71) reported binge drinking (defined, respectively, as at least one alcoholic drink and four or more alcoholic drinks on one occasion in the past 30 days).¹⁶ The highest prevalence of obstetric alcohol consumption occurs in women who are:

• aged 35 to 44 years
• white
• college graduates
• employed.

The problem may be bigger than reported. The incidences of alcohol and binge drinking found in the CDC report include women’s self-report—but women drink alcohol without knowing they’re pregnant. Only 40% of women realize they’re pregnant at 4 weeks of gestation, a critical time for organogenesis, and approximately half of all births are unplanned.⁹

When my brother and sister-in law adopted my beautiful niece and nephew, they were very aware of the risk for conditions like FAS. In an evaluation of 71 children adopted from Eastern Europe at 5 years of age, FAS was diagnosed in 30% of children and “partial FAS” in another 9%.¹⁷ Birth defects attributed to alcohol were present in 11% of the children.

Are women’s health providers up to date on FAS education?

In recognition of alcohol’s potentially life-altering consequences for the developing fetus, the American College of Obstetricians and Gynecologists (ACOG) produced an FASD prevention tool kit in 2006 and published a 2011 committee opinion on at-risk drinking and alcohol dependence and their implications for obstetrics and gynecology.^18,19 Both guidelines direct clinicians to advise patients to abstain from alcohol during pregnancy.

Results from a 2010 survey of 800 ACOG fellows revealed that only 78% of obstetricians advised abstinence from alcohol during pregnancy. Fifty-eight percent of respondents did not use a validated screening tool for alcohol use in their pregnant patients, and only 72% felt prepared to screen for risky or hazardous drinking.¹⁹ (Most were unaware of the ACOG tool kit, which had been published several years earlier.)

In a survey of pediatricians, obstetricians, and family physicians, clinicians said that about 67% of their patients asked about alcohol use in pregnancy, with about 2% of those patients specifically mentioning FAS. About 41% of these same physicians erroneously placed the threshold for FAS at one to three drinks per day,²⁰ when in fact there is no threshold of drinking that has been proven to be safe.

A survey of 1,000 actively practicing ACOG fellows revealed that, while 97% of obstetricians routinely asked their patients about alcohol use, only 20% of providers reported to their patients that abstinence was safest, and 4% of providers didn’t believe that consumption of eight or more drinks weekly posed fetal risk.²¹

How can we educate our patients about the dangers of alcohol in pregnancy?

Fetal death. A recent Danish study of 79,216 pregnant women revealed that 45% had consumed some alcohol during pregnancy. Two percent reported at least four drinks per week, and 25% admitted to binge drinking during pregnancy. Term infants born to women in the latter two groups had increased neonatal mortality, with hazard ratios of 3.56 (95% confidence interval [CI], 1.15–8.43) and 2.69 (95% CI, 1.27–5.69), respectively.²²

Decreased cognitive status. A study by Willford and colleagues evaluated the relationship between prenatal alcohol exposure and cognitive status of 1,360 10-year-old children.²³ The authors utilized the Stanford-Binet Intelligence Test, including the composite scores and verbal, abstract/visual, quantitative, and short-term memory scores. After controlling for other variables, among African American offspring they found that, for each additional drink, the average composite score decreased by 1.9 points. This difference was more striking for second-trimester use, and was significant even for one drink daily versus abstention from alcohol.

Impaired neuropsychological development. Another study evaluating light to moderate amounts of prenatal alcohol exposure in 10- and 11-year-old children found significantly worse scores regarding a number of neuropsychological developmental assessments.²⁴

No threshold dose of causation. Results of a 2012 prospective study in California, with data collected on 992 subjects from 1978 until 2005, revealed that many physical FAS features, including microcephaly, smooth philtrum, and thin vermillion border; reduced birth length; and reduced birth weight, were associated with alcohol exposure at specific gestational ages, and were dose-related.²⁵ This paper didn’t reveal any evidence of a threshold dose of causation.

Neurobehavioral outcomes of FAS are not always considered

Another recent study that the media recently highlighted as finding “no association between low or moderate prenatal alcohol exposure and birth defects” was by O’Leary and colleagues.²⁶ Like other similarly limited studies, this one involved only children younger than 6 years and didn’t assess any of the important neurobehavioral outcomes of FAS.

FAS encompasses much more than visible birth defects. As the aforementioned ACOG tool kit stated, “For every child born with FAS, many more children are born with neurobehavioral deficits caused by alcohol exposure but without the physical characteristics of FAS.”

The costs of FAS are felt with dollars, too

The financial cost to our nation is extraordinary. In 1991, Abel and Sokol estimated the incremental annual cost of treating FAS at nearly $75 million, with about three-quarters of that cost associated with FAS cases involving mental retardation.²⁷

A 2002 assessment estimated the lifetime cost for each individual with FAS (adjusting for the change in the cost of medical care services, lost productivity, and inflation) at $2 million. This figure consists of $1.6 million for medical treatment, special education, and residential care for persons with mental retardation, and $0.4 million for productivity losses.²⁸

Where human studies fall short, animal studies can help elucidate causation

Unquestionably, there are flaws in the existing literature on the causation of FAS. Many studies rely on self-reporting by pregnant women, and underreporting in these cases is a real concern. There often are other confounders potentially negatively affecting fetal development, making it difficult to differentiate causation. The animal studies that don’t share these limitations do suggest a causal relationship between antenatal alcohol exposure and poor obstetric outcomes, however.²⁹ These studies suggest mechanisms such as altered gene expression, oxidative stress, and apoptosis (programmed cell death).³⁰

Warren, Hewitt, and Thomas describe how intrauterine alcohol exposure interferes with the function of L1CAM, the L1 cell-adhesion molecule.³¹ They noted that just one drink could interfere with the ability of L1CAM to mediate cell adhesion and axonal growth. Prenatal alcohol exposure is also thought to contribute to interference in neurotransmitter and N-methyl-D-aspartate receptor coupling, which may have potential therapeutic implications.³²

Considerations in FAS identification and treatment

There is a potential to identify alcohol exposure in the womb. The majority of ingested alcohol is eventually converted to carbon dioxide and water in both maternal and fetal circulations, which has hampered the identification of biomarkers for clinical use in FAS. Fatty acid ethyl esters (FAEEs), nonoxidative metabolites of ethanol, may prove to be such markers.³³ FAEEs have been measured in a variety of tissues, including blood and meconium. FAEEs can be measured in both neonatal and maternal hair samples.

A study evaluating the utility of such testing in 324 at-risk pregnancies revealed 90% sensitivity and 90% specificity for identifying “excessive drinking” using a cutoff of 0.5 ng/mg.³⁴

Research shows potential therapeutic approaches during pregnancy. While the use of biomarkers has the potential to assist with the identification of at-risk newborns, it merely identifies past alcohol use; it doesn’t necessarily permit identification and prevention of the known negative pediatric sequelae. Preliminary animal studies reveal the potential benefit of neuroprotective peptides to prevent brain damage in alcohol-exposed mice.³⁵ Further research is ongoing.

Treatment: The earlier the better

Early diagnosis and a positive environment improve outcomes. It is well established that early intervention improves outcomes. One comprehensive review of 415 patients with FAS noted troubling outcomes in general for adolescents and adults.³⁶ Over their life spans, the prevalence of such outcomes was:

• 61% for disrupted school experiences
• 60% for trouble with the law
• 50% for confinement (in detention, jail, prison, or a psychiatric or alcohol/drug inpatient setting)
• 49% for inappropriate sexual behaviors on repeated occasions
• 35% for alcohol/drug problems.

The odds of escaping these adverse life outcomes are increased up to fourfold when the individual receives a FAS or FASD diagnosis at an earlier age and is reared in a stable environment.³⁶

Barrier to treatment: A mother’s guilt. One of the challenges I’ve learned from my sister-in-law is the stigma mothers face when they bring their child in for services once the diagnosis of FAS is suspected. While adoptive mothers obviously can’t be held accountable for the intrauterine environment to which a fetus is exposed, the same can’t be said of biologic mothers. Therefore, there is a real risk that a mother who is unwilling or unable to face the potentially devastating news that her baby’s issues might be related to choices she made during pregnancy, might not bring her child in for necessary assessment and treatment. Therefore, prevention is a key proponent of treatment.

Prevent FAS: Provide contraception, screen for alcohol use, intervene

While ObGyns aren’t likely to diagnose many children with FAS, we are in an excellent position to try to prevent this tragedy through our counseling of reproductive-aged women. I suspect that most obstetricians spend a considerable amount of time discussing much less frequent obstetric sequelae, such as listeriosis, in the prenatal care setting. Validated alcohol screening tools take moments to administer, and once patients who might have alcohol problems are identified, either a serious discussion about contraception or an honest discussion of FAS may be appropriate. There have been a number of screening tools developed.

The CAGE screen is frequently taught in medical schools, but it isn’t as sensitive for women or minorities.¹⁹

The T-ACE (Tolerance, Annoyed, Cut Down, Eye-opener) tool involves four questions that take less than 1 minute to administer (FIGURE 1).³⁹

TWEAK is another potential tool identified by Russell and colleagues (Tolerance, Worry, Eye opener, Amnesia, and Cut down in drinking).³⁹ Other methods utilized include an AUDIT screen and a CRAFFT screen.⁴⁰ Regardless of which tool is utilized, screening is not time-consuming and is better than merely inquiring about alcohol consumption in general.

FIGURE 1 T-ACE validated alcohol screening tool
Source: American College of Obstetricians and Gynecologists. At risk drinking and illicit drug use: Ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2008;112(6):1449–1460.

When alcohol use is found, intervene

Once patients with at-risk behavior are identified, obstetric staff should offer brief interventions to influence problem drinking. Miller and Sanchez summarized the key elements that were most successful in these programs with the acronym FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy (FIGURE 2).⁴¹ This approach has been formally evaluated in the CDC’s multisite pilot study entitled Project CHOICES.⁴²

In this motivational intervention, sexually active, fertile women of reproductive age underwent up to four motivational counseling sessions and one visit to a provider. At 6 months, 69% of women reduced their risk for an alcohol-exposed pregnancy—although the women who drank the least amount had the greatest benefit, primarily by choosing effective contraception, but also by reducing alcohol intake.

FIGURE 2 FRAMES model to deliver brief interventions
Source: American College of Obstetricians and Gynecologists. Drinking and reproductive health: A fetal alcohol spectrum disorders prevention tool kit. Washington, DC: ACOG; 2006.

A single, brief intervention is effective in already-pregnant women. Chang and colleagues conducted a randomized trial of a single-session brief intervention given to pregnant women with positive T-ACE screens and their partners (FIGURE 3).⁴³ Either the study nurse or physician participated in the intervention, and each single session took 25 minutes on average. The pregnant women with the highest level of alcohol use reduced their drinking the most, and this effect was even larger when their partners participated. Other studies of brief interventions showed similar benefits.^44,45

Another study evaluating a brief intervention involving training of health-care providers to improve screening rates revealed improved detection and therapy among at-risk patients.⁴⁶

FIGURE 3 Single session, 25-minute intervention for patients and their partners
Source: Chang G, McNamara T, Orav J, et al. Brief intervention for prenatal alcohol use: a randomized trial. Obstet Gynecol. 2005;105(5 Pt 1):991–998.

FAS prevention begins with routine counseling and contraception

Although FAS is often thought of in relation to obstetric populations, appointments for preconception counseling or routine health maintenance among women of reproductive age are an essential tool in FAS prevention. As previously mentioned, since approximately half of all pregnancies in this country are unplanned, long-acting reversible contraception is widely available to facilitate improved family planning.

Other contraceptive options also should be discussed. ACOG has teamed up with the CDC to develop a phone app for providers to use at the patient’s bedside to assist with identification and treatment of women at risk for alcohol use during pregnancy.⁴⁷

The stakes are high, it’s time to step up

As obstetricians, we are powerless to prevent many conditions—such as vasa previa, acute fatty liver of pregnancy, and amniotic band syndrome. FAS is 100% preventable.

There aren’t that many proven teratogens in our profession, and there are none that involve behavior that is more socially acceptable than alcohol consumption. It is time for our profession to encourage women to appreciate how small a percentage of one’s life is spent pregnant, how many more years there are to enjoy an occasional cocktail, and how very high the stakes are during this important period of their lives. Oh, how I wish someone had been able to communicate all of this to sweet Charlie’s biologic mother. I am so grateful he’s getting the exceptional care he’s getting and very optimistic regarding his future. I only hope others in his situation are given the same opportunities.

We want to hear from you! Tell us what you think.

The author reports no financial relationships relevant to this article.

Few issues in obstetrics spark as much controversy as home birth—and where controversy rages, media attention follows.

Press reports of a 2008 policy statement on home birth issued by the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) highlight the rift between the formal medical establishment and advocates of home birth.^1-3

On one side, the AMA and ACOG assert that the hospital or an accredited birthing center “is the safest setting for labor, delivery, and the immediate postpartum period.”¹ On the other side, advocates of home birth argue that having the option adds to women’s empowerment and choice.

Some people have accused the medical community of trying to corner the “baby birthing industry.”⁴ The title of a recent Baltimore Sun article sums up this sentiment: “Home birth battle: Doctors strong-arm women away from healthy alternative to hospital care.”⁵

Neither ACOG nor the AMA advocates criminalization of home deliveries, but their statements on home birth have generated considerable fear that they will.

This article explores the controversy, focusing on the literature on home birth, gaps in knowledge, the state of regulation, liaison with midwives, and other issues. It also offers suggestions on how to discuss labor and delivery with patients so that they clearly understand the risks involved and do not feel that they have “failed” at meaningful childbirth when they choose hospital delivery.

Did a rise in hospital births reduce maternal mortality?

Obstetric care changed dramatically in the mid-20th century. In 1940, 55.8% of deliveries occurred in the hospital, but that percentage rose to 99.4 by 1970 and hasn’t changed appreciably since.⁶

Some proponents of hospital delivery note that, in 1940, when 44% of births occurred outside the hospital, the maternal mortality rate was 608 deaths for every 100,000 live births, compared with 37 deaths for every 100,000 live births in 1960, when fewer than 4% of deliveries occurred outside the hospital.⁶ And in 2003, with only 1% of deliveries occurring in a home setting, the maternal mortality rate was even lower: 12 deaths for every 100,000 live births.⁷

Others argue that this sharp decrease in maternal mortality cannot be attributed solely to the change in location of the delivery (and subsequent availability of services and personnel), but reflects universal advancement in safe practices such as aseptic technique.⁸

What do the data show? All studies of home birth have serious methodologic flaws, thanks largely to the nature of the subject matter. A recent Cochrane review observes that there is only one randomized, controlled trial—with a sample size of only 11 women—from which to draw conclusions.⁹ The review concludes that “there is no strong evidence to favour either home or hospital birth for selected, low-risk pregnant women.”¹⁰

Most data come from abroad

Much of the literature on home birth comes from international sites because of the higher prevalence of home delivery in other countries. These data reveal that:

• Two percent of deliveries in the United Kingdom occur in the home.¹¹ The British National Institute for Health and Clinical Excellence recommended that all women be offered the option to have their baby at home or in the hospital, although, depending on the “trust” (a geographically based public-system cooperative that provides care), 8% to 76% of women weren’t given this choice formally.¹²
• One study conducted in Switzerland involved 489 women who opted for home birth and 385 who chose hospital birth. Of the former, 37 were referred to a specialist during pregnancy, and 70 were referred during labor. The groups had similar birth weights, gestational ages, and clinical conditions.¹³
• In the Netherlands, 30% of infants are born at home.¹⁴ If a woman has an uncomplicated pregnancy, she remains under midwifery care and can decide where to deliver. A study of 280,000 “low-risk” women under primary midwifery care found that 68.1% completed childbirth under that care, 3.6% were referred urgently, and 28.3% were referred without urgency.¹⁴ When referrals were considered as a whole, 11.2% involved urgency, primarily for fetal distress (50.2%) and postpartum hemorrhage (33%). Adverse neonatal outcomes were most common in urgently referred cases, followed by nonurgent referrals. The authors acknowledge the importance of transport time once a referral is initiated, stating that, “The Netherlands is a very densely populated country where the average distance to the hospital is relatively short.” (The same cannot be said of many parts of rural America.)
• A study involving home deliveries in Australia from 1985 to 1990 identified 50 perinatal deaths out of 7,002 planned home births.¹⁵ The perinatal death rate of infants weighing more than 2,500 g exceeded the national average (5.7 versus 3.6 for every 1,000 deliveries), with a relative risk (RR) of 1.6 (95% confidence interval [CI], 1.1–1.4). Intrapartum death not attributable to prematurity or fetal malformation was also higher (2.7 versus 0.9 for every 1,000 deliveries), with a RR of 3.0 (95% CI, 1.9–4.8). According to the authors, the main contributors to excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy, and breech presentation, and a lack of response to fetal distress.

Is the evidence on water birth just too murky?

In the summer of 1999, a woman delivered a 7.7-lb infant after 42 weeks of gestation. The birth took place in the woman’s home in Japan, and the baby was delivered in a bathtub of warm water. The woman had had an uneventful pregnancy, and the baby appeared to be perfectly normal.

Four days later, the infant developed fever and jaundice and was admitted to the hospital, where she was treated with phototherapy. She improved, but her symptoms recurred 3 days later, and she began to vomit. Eight days after birth, she suffered cardiopulmonary arrest and died. An autopsy revealed the cause of death to be legionellosis—infection with Legionella pneumonia. The most likely source was the bathtub in which she was born.⁴³

Other case reports describe similar tragedies associated with water birth (among them, drowning, infection, and a snapped umbilical cord), but no randomized, clinical trial has systematically compared delivery in water with conventional land-based birth.

The death, morbidity, and lack of data so troubled members of the American Academy of Pediatrics that the Committee on Fetus and Newborn issued an advisory in 2005:

• The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed randomized clinical trial after informed parental consent.⁴⁴

This statement contrasts the conclusion of the most recent Cochrane review of the subject, which found that, “Immersion in water during the first stage of labour significantly reduces women’s perception of pain and use of epidural/spinal analgesia.”⁴⁵ The review also noted, however, that, “No trials could be located that assessed the immersion of women in water during the third stage of labour.”⁴⁵

No studies have explored immersion in water during the third stage of labor.

What’s in that water?

Amy Tuteur, MD, an ObGyn who publishes a popular blog (“The Skeptical OB”), focused on the topic of water birth earlier this year. “What’s in the water at waterbirth?” she asks.⁴⁶

To answer the question, Dr. Tuteur cites a 1999 study of 4,030 deliveries in water, which found that 35 infants suffered serious morbidity and three died—although it is unclear if any of the deaths were a direct result of water birth. “However, of the 32 survivors who were admitted to the NICU,” writes Dr. Tuteur, “13 had significant respiratory problems, including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include five babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth.”⁴⁷

Dr. Tuteur also points to the poor quality of the water in birthing pools, arguing that it is “essentially toilet water.”⁴⁶ “The water in a birth pool, conveniently heated to body temperature, the optimum temperature for bacterial growth, is a microbial paradise,” she writes.⁴⁶ She cites a study of 1,500 water births that included analysis of the water found in the birthing pools (before anyone entered the water) and identified:

• coliforms in 21% of samples
• enterococcus in 19% of samples
• Escherichia coli in 10% of samples
• Legionella pneumophila in 12% of samples
• Pseudomonas aeruginosa in 11% of samples.⁴⁸

After a special water filter was installed, contamination diminished but did not disappear completely.

Pools in the home setting were not the only ones implicated in contamination; some hospital pools also were affected.

What’s the bottom line?

The American College of Obstetricians and Gynecologists has yet to weigh in on the matter. Until it does, ObGyns may be wise to heed the words of Ruth Gilbert, MD, of the Centre for Paediatric Epidemiology and Biostatistics at the Institute of Child Health in London.

“Can delivery in water cause serious adverse outcomes?” she asks, rhetorically, it turns out.

“Undoubtedly, the answer is ‘yes.’”⁴⁹ —JANELLE YATES, SENIOR EDITOR

The data we do have are difficult to interpret

Among the limitations of studies of home birth are:

• lack of follow-up after the delivery
• varying definitions of perinatal mortality internationally
• lack of clarity regarding the identity and education of delivering providers
• the fact that there are often “too few neonatal deaths from which to extrapolate reliable rate calculations.”¹⁶

One meta-analysis found a rate of intrapartum transfer ranging from 7.4% to 16.5%, and a rate of primary cesarean delivery of 1.4% to 17.7% (it was 13.8% to 28.25% in the “comparison group”).¹⁶

A challenge inherent in many of these studies is identifying exactly what the comparison group is. In addition, some of the data are obtained from discharge summary records, which don’t always reflect the level of risk or acuity.

Oft-cited study has weaknesses

The study that many advocates of home birth cite was conducted in the United States and Canada and published in 2005.¹⁷ It evaluated “all 5,418 women expecting to deliver in 2000 supported by midwives with a common certification [certified professional midwives] and who planned to deliver at home when labour began.” The hospital transfer rate was 12.1%, in line with other studies. The risk of adverse outcomes was lower in the group that planned to have home delivery, compared with a “relatively low-risk hospital group.”

The study focused on:

• electronic fetal monitoring, used in 9.6% of deliveries in the home-birth group, versus 84.3% of the hospital group
• episiotomy, performed in 2.1% of home deliveries, compared with 33% of hospital births
• cesarean delivery, 3.7% of planned home deliveries, versus 19% of hospital births
• vacuum-assisted vaginal delivery, performed in 0.6% of planned home deliveries, versus 5.5% of hospital births
• neonatal death, at a rate of 2.0 deaths for every 1,000 intended home births. No comparison figure was cited.

One of the weaknesses of this study, as of others, was identification of a comparison group as a “low-risk” population without data to back up that designation. In addition, this study derived its data from birth certificates for 3,360,868 singleton, vertex births at 37 weeks or more of gestation. Data from birth certificates are limited as a basis for accurate risk assessment. Moreover, although the authors of this study asserted that they had no conflict of interest, the investigation was funded by The Foundation for the Advancement of Midwifery.

Study cited by advocates of hospital birth is also flawed

One of the studies many hospital and birthing center advocates cite was published in 2002.¹⁸ It involved an analysis of birth registry information on uncomplicated singleton pregnancies at 34 weeks or more of gestation in Washington state between 1989 and 1996. These pregnancies were either:

• delivered at home by a health professional (n=5,854)
• transferred to medical facilities after attempted home delivery (n=279)
• planned to be delivered in the hospital (n=10,593).

Infants whose mothers planned to deliver at home had a higher risk of neonatal death (RR, 1.99; 95% CI, 1.06–3.73) and a higher risk of having a 5-minute Apgar score of less than 3 (RR, 2.31; 95% CI, 1.29–4.16). After adjustment for a gestational-age cutoff of 37 weeks, these risks remained similar.

Nulliparous women, in particular, had a higher risk for prolonged labor (RR, 1.73; 95% CI, 1.28–2.34) and postpartum bleeding (RR, 2.76; 95% CI, 1.74–4.36).

The authors themselves point out a potential flaw in this study: the use of data from birth certificates. These data create “the potential for misclassifying unplanned home births as planned home births.” The difference in outcomes could be significant. For example, the neonatal death rate for unplanned home deliveries in North Carolina and Kentucky was 18 to 20 times higher than the rate for planned home births in these states.^19,20

A study from Missouri observes that neonatal mortality was elevated for both planned and unplanned home birth, compared with physician-attended hospital birth.²¹

Selection bias is a concern

Selection bias is an inherent difficulty in many of these studies. Except for one previously mentioned paper—a very small study—none of the investigations involve randomization. As a result, we cannot exclude the possibility that “women who choose to deliver at home or in a birth center are likely to be different in terms of expectations and approach from women choosing to deliver in hospitals.”²²

Risk level can escalate rapidly

What is potentially troubling about home birth is the fact that a low-risk pregnancy that was complication-free during antepartum care can become a high-risk pregnancy in a matter of minutes, necessitating urgent, appropriate obstetric care. Some classic examples of urgent events include cord prolapse, postpartum hemorrhage, bleeding from vasa previa, and shoulder dystocia.

Let’s focus on shoulder dystocia, which occurs in 1.4% of all vaginal deliveries. The authors of one study point out that “most of the traditional risk factors for shoulder dystocia have no predictive value, shoulder dystocia itself is an unpredictable event, and infants at risk for permanent injury are virtually impossible to predict.”²³ This may make delivery in the home a high-risk endeavor because of the inability to mobilize an obstetric team to assist with shoulder dystocia maneuvers or perform a Zavanelli delivery.

Another variable overlooked in most studies is the speed of transfer and the outcomes of pregnancies in which the women intended to deliver at home but ended up requiring urgent transfer. One study that did examine this scenario found that “women who had booked for a home birth, but later needed to transfer their care for a hospital birth, appeared to have the highest risk of intrapartum-related perinatal mortality.”²⁴

There is also some controversy regarding the delivery of women who are pregnant with twins, who have a fetus in breech presentation, or who have a history of cesarean delivery. One study examined outcomes for intended home delivery of 57 women who had a prior abdominal delivery.²⁵ Fifty of these women delivered vaginally in the home, and seven (12.3%) delivered in the hospital. One hospital transfer was urgent for fetal distress. One baby was stillborn, delivered at home.

A 10-year prospective study of vaginal birth after cesarean (VBAC) in birth centers found that more than 50% of uterine ruptures and 57% of perinatal deaths involved the 10% of women who had more than one prior cesarean delivery or who had reached a gestational age of more than 42 weeks.²⁶

Skill of the caregiver is important

The training and qualifications of the obstetric care provider are incredibly important. One study evaluated 4,361 home births attended by “apprentice-trained midwives from 1970 to 1985 and 4,107 home births attended by family physicians from 1969 to 1981.”²⁷ The perinatal mortality rate for the midwife-attended births was 14 for every 1,000 births, in contrast to the rate of 5 for every 1,000 physician-attended births.

Three types of midwife are credentialed in this country:

• certified nurse-midwife (CNM)
• certified midwife (CM)
• certified professional midwife (CPM).

The first two categories are certified by the American Midwifery Certification Board (AMCB). CNMs and CMs undergo rigorous training and examination, and this designation will require a graduate degree within the next few years. The CPM category, however, requires much less rigorous training. Its midwives are certified by the North American Registry of Midwives. The clinical requirements for certification as a CPM include:

• attending a “minimum of 20 births”
• managing at least 20 additional births, at least half of them in the home or another out-of-hospital setting
• performing a small number of prenatal, newborn, and postpartum exams.²⁸

A high school diploma is not required.

I suspect that concerns about this lax certification process contributed to ACOG’s decision to issue a statement from its executive board in 2006: “While ACOG supports women having a choice in determining their providers of care, ACOG does not support the provision of care by lay midwives or other midwives who are not certified by the American College of Nurse-Midwives (ACNM) or AMCB.”²⁹

A number of midwifery advocates have made a legislative push to expand licensure for CPMs in this country, and the debate continues on a state-by-state basis.³⁰

Economics and other variables affect delivery decision

Some advocates of home birth note that the “average uncomplicated vaginal birth costs 68% less in a home than in a hospital.”³¹ Others try to organize support for women who want to give birth at home, such as the Home Birth Hotline, a voluntary, UK-based organization.³²

Some articles suggest that patient satisfaction is of significant importance in the decision about where to deliver. One noted that women who delivered where they had planned had higher overall satisfaction when that place was in the home (P<.01).³³

A randomized, controlled trial (n=3,510) simulated home delivery in a hospital, with “home delivery” patients having midwifery care in a room “similar to one in one’s own home” and the others having “consultant-led care” in rooms in the delivery suite that contained equipment to resuscitate both mother and baby, as well as monitors and other technology.³⁴ This study found no significant differences in measured outcomes, but “generally higher levels of satisfaction” among the women who had simulated home delivery.

A study from “remote and rural Scotland” found that most women “expressed a preference to give birth in hospital and have consultant-led care because they felt safer.”³⁵

Does the rhetoric surrounding home birth “empower” women?

Another frequently overlooked issue is the passionate rhetoric used to describe home birth—and the effect of that passion on women whose birth plan doesn’t play out as expected. Words such as “choice” and “empowerment” are often used. Regrettably, there is considerable mistrust of the medical system.

One woman describes how her planned home delivery, “influenced by the feminist literature,” went awry.³⁸ After a long labor, she wrote, she “just wanted the baby out, safe and healthy. It no longer mattered how it happened….I couldn’t get rid of the underlying feeling that I had ‘failed’ in some way….”³⁸

Because of her strong desire for home delivery, this woman was deeply affected when the delivery became difficult: “I did not have the authority to proclaim whether or not various medical interventions were necessary, or whether my case actually did constitute a medical emergency….Faced with these ‘options’—safe birth or potential death—how could I be said to be making a ‘choice’?…The obstetrician has more power than the woman because s/he has more knowledge.”³⁸

Despite having come to this realization, and delivering a healthy baby, she still experienced “a sense of disappointment and anger” and “traumatic flashbacks.”

I worry that patients may become so caught up in the rhetoric of their own power and choice that, when uncontrollable events occur, the happiness of a healthy delivery is overshadowed by deep disappointment.

Heated debate isn’t helpful

An unfortunate rift seems to have developed between some members of the midwifery community and some physicians. ACOG and the ACNM have a longstanding policy that: “In those circumstances in which obstetrician/gynecologists and certified nurse-midwives/certified midwives collaborate in the care of women, the quality of those practices is enhanced by a working relationship characterized by mutual respect and trust.”³⁹

Whether individual physicians agree with the practice of planned home birth or not, the health and welfare of the patient must be paramount. The American Public Health Association and the ACNM support home birth.^40,41

When obstetric emergencies do arise in the home setting, necessitating emergent transfer, it is critical that the transfer be managed in a way that ensures the best outcome.

One disturbing article describes both “disarticulations” that occur “when there is no correspondence of information or action between the midwife and the hospital staff” and “fractured articulations” that arise from “partial and incomplete correspondence.”⁴² A number of midwives were interviewed who no longer feel comfortable bringing patients to certain hospitals because of the negative response they received from health-care providers, sometimes to the detriment of the patient.

Can we improve the situation?

First, we need to choose our words carefully when we counsel women about labor and delivery, in recognition of the buzzwords used by advocates of home birth (“empowerment,” “choice”) and the sense of failure and distress some women feel when they eventually require heightened medical intervention.

Perhaps we should dispense with the term “failure,” as in failure to progress, failure to dilate, and so on, to avoid implying that this “failure” is the woman’s fault. And instead of saying that a patient’s pelvis is “adequate,” implying that another woman’s pelvis isn’t, we could use a term that sounds less judgmental.

We can also make the hospital environment more nurturing and supportive of women’s choices for labor, as long as safety isn’t compromised. And when we receive a transfer of a patient whose home delivery has gone awry, we should openly, efficiently, and professionally communicate with the home-delivery provider to best benefit the patient, regardless of our feelings on the subject.

Home birth isn’t going away

That’s my take on the literature. There are certainly data supporting the safety of home birth for the vast majority of women who choose it, but there is also a significant number of women who will experience unpredictable events that could be fatal if blood products or surgery isn’t rapidly available. For that reason, and in light of the very high stakes involved, I wonder: Why take that chance?

The author reports no financial relationships relevant to this article.

Few issues in obstetrics spark as much controversy as home birth—and where controversy rages, media attention follows.

Press reports of a 2008 policy statement on home birth issued by the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) highlight the rift between the formal medical establishment and advocates of home birth.^1-3

On one side, the AMA and ACOG assert that the hospital or an accredited birthing center “is the safest setting for labor, delivery, and the immediate postpartum period.”¹ On the other side, advocates of home birth argue that having the option adds to women’s empowerment and choice.

Some people have accused the medical community of trying to corner the “baby birthing industry.”⁴ The title of a recent Baltimore Sun article sums up this sentiment: “Home birth battle: Doctors strong-arm women away from healthy alternative to hospital care.”⁵

Neither ACOG nor the AMA advocates criminalization of home deliveries, but their statements on home birth have generated considerable fear that they will.

This article explores the controversy, focusing on the literature on home birth, gaps in knowledge, the state of regulation, liaison with midwives, and other issues. It also offers suggestions on how to discuss labor and delivery with patients so that they clearly understand the risks involved and do not feel that they have “failed” at meaningful childbirth when they choose hospital delivery.

Did a rise in hospital births reduce maternal mortality?

Obstetric care changed dramatically in the mid-20th century. In 1940, 55.8% of deliveries occurred in the hospital, but that percentage rose to 99.4 by 1970 and hasn’t changed appreciably since.⁶

Some proponents of hospital delivery note that, in 1940, when 44% of births occurred outside the hospital, the maternal mortality rate was 608 deaths for every 100,000 live births, compared with 37 deaths for every 100,000 live births in 1960, when fewer than 4% of deliveries occurred outside the hospital.⁶ And in 2003, with only 1% of deliveries occurring in a home setting, the maternal mortality rate was even lower: 12 deaths for every 100,000 live births.⁷

Others argue that this sharp decrease in maternal mortality cannot be attributed solely to the change in location of the delivery (and subsequent availability of services and personnel), but reflects universal advancement in safe practices such as aseptic technique.⁸

What do the data show? All studies of home birth have serious methodologic flaws, thanks largely to the nature of the subject matter. A recent Cochrane review observes that there is only one randomized, controlled trial—with a sample size of only 11 women—from which to draw conclusions.⁹ The review concludes that “there is no strong evidence to favour either home or hospital birth for selected, low-risk pregnant women.”¹⁰

Most data come from abroad

Much of the literature on home birth comes from international sites because of the higher prevalence of home delivery in other countries. These data reveal that:

• Two percent of deliveries in the United Kingdom occur in the home.¹¹ The British National Institute for Health and Clinical Excellence recommended that all women be offered the option to have their baby at home or in the hospital, although, depending on the “trust” (a geographically based public-system cooperative that provides care), 8% to 76% of women weren’t given this choice formally.¹²
• One study conducted in Switzerland involved 489 women who opted for home birth and 385 who chose hospital birth. Of the former, 37 were referred to a specialist during pregnancy, and 70 were referred during labor. The groups had similar birth weights, gestational ages, and clinical conditions.¹³
• In the Netherlands, 30% of infants are born at home.¹⁴ If a woman has an uncomplicated pregnancy, she remains under midwifery care and can decide where to deliver. A study of 280,000 “low-risk” women under primary midwifery care found that 68.1% completed childbirth under that care, 3.6% were referred urgently, and 28.3% were referred without urgency.¹⁴ When referrals were considered as a whole, 11.2% involved urgency, primarily for fetal distress (50.2%) and postpartum hemorrhage (33%). Adverse neonatal outcomes were most common in urgently referred cases, followed by nonurgent referrals. The authors acknowledge the importance of transport time once a referral is initiated, stating that, “The Netherlands is a very densely populated country where the average distance to the hospital is relatively short.” (The same cannot be said of many parts of rural America.)
• A study involving home deliveries in Australia from 1985 to 1990 identified 50 perinatal deaths out of 7,002 planned home births.¹⁵ The perinatal death rate of infants weighing more than 2,500 g exceeded the national average (5.7 versus 3.6 for every 1,000 deliveries), with a relative risk (RR) of 1.6 (95% confidence interval [CI], 1.1–1.4). Intrapartum death not attributable to prematurity or fetal malformation was also higher (2.7 versus 0.9 for every 1,000 deliveries), with a RR of 3.0 (95% CI, 1.9–4.8). According to the authors, the main contributors to excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy, and breech presentation, and a lack of response to fetal distress.

Is the evidence on water birth just too murky?

In the summer of 1999, a woman delivered a 7.7-lb infant after 42 weeks of gestation. The birth took place in the woman’s home in Japan, and the baby was delivered in a bathtub of warm water. The woman had had an uneventful pregnancy, and the baby appeared to be perfectly normal.

Four days later, the infant developed fever and jaundice and was admitted to the hospital, where she was treated with phototherapy. She improved, but her symptoms recurred 3 days later, and she began to vomit. Eight days after birth, she suffered cardiopulmonary arrest and died. An autopsy revealed the cause of death to be legionellosis—infection with Legionella pneumonia. The most likely source was the bathtub in which she was born.⁴³

Other case reports describe similar tragedies associated with water birth (among them, drowning, infection, and a snapped umbilical cord), but no randomized, clinical trial has systematically compared delivery in water with conventional land-based birth.

The death, morbidity, and lack of data so troubled members of the American Academy of Pediatrics that the Committee on Fetus and Newborn issued an advisory in 2005:

• The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed randomized clinical trial after informed parental consent.⁴⁴

This statement contrasts the conclusion of the most recent Cochrane review of the subject, which found that, “Immersion in water during the first stage of labour significantly reduces women’s perception of pain and use of epidural/spinal analgesia.”⁴⁵ The review also noted, however, that, “No trials could be located that assessed the immersion of women in water during the third stage of labour.”⁴⁵

No studies have explored immersion in water during the third stage of labor.

What’s in that water?

Amy Tuteur, MD, an ObGyn who publishes a popular blog (“The Skeptical OB”), focused on the topic of water birth earlier this year. “What’s in the water at waterbirth?” she asks.⁴⁶

To answer the question, Dr. Tuteur cites a 1999 study of 4,030 deliveries in water, which found that 35 infants suffered serious morbidity and three died—although it is unclear if any of the deaths were a direct result of water birth. “However, of the 32 survivors who were admitted to the NICU,” writes Dr. Tuteur, “13 had significant respiratory problems, including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include five babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth.”⁴⁷

Dr. Tuteur also points to the poor quality of the water in birthing pools, arguing that it is “essentially toilet water.”⁴⁶ “The water in a birth pool, conveniently heated to body temperature, the optimum temperature for bacterial growth, is a microbial paradise,” she writes.⁴⁶ She cites a study of 1,500 water births that included analysis of the water found in the birthing pools (before anyone entered the water) and identified:

• coliforms in 21% of samples
• enterococcus in 19% of samples
• Escherichia coli in 10% of samples
• Legionella pneumophila in 12% of samples
• Pseudomonas aeruginosa in 11% of samples.⁴⁸

After a special water filter was installed, contamination diminished but did not disappear completely.

Pools in the home setting were not the only ones implicated in contamination; some hospital pools also were affected.

What’s the bottom line?

The American College of Obstetricians and Gynecologists has yet to weigh in on the matter. Until it does, ObGyns may be wise to heed the words of Ruth Gilbert, MD, of the Centre for Paediatric Epidemiology and Biostatistics at the Institute of Child Health in London.

“Can delivery in water cause serious adverse outcomes?” she asks, rhetorically, it turns out.

“Undoubtedly, the answer is ‘yes.’”⁴⁹ —JANELLE YATES, SENIOR EDITOR

The data we do have are difficult to interpret

Among the limitations of studies of home birth are:

• lack of follow-up after the delivery
• varying definitions of perinatal mortality internationally
• lack of clarity regarding the identity and education of delivering providers
• the fact that there are often “too few neonatal deaths from which to extrapolate reliable rate calculations.”¹⁶

One meta-analysis found a rate of intrapartum transfer ranging from 7.4% to 16.5%, and a rate of primary cesarean delivery of 1.4% to 17.7% (it was 13.8% to 28.25% in the “comparison group”).¹⁶

A challenge inherent in many of these studies is identifying exactly what the comparison group is. In addition, some of the data are obtained from discharge summary records, which don’t always reflect the level of risk or acuity.

Oft-cited study has weaknesses

The study that many advocates of home birth cite was conducted in the United States and Canada and published in 2005.¹⁷ It evaluated “all 5,418 women expecting to deliver in 2000 supported by midwives with a common certification [certified professional midwives] and who planned to deliver at home when labour began.” The hospital transfer rate was 12.1%, in line with other studies. The risk of adverse outcomes was lower in the group that planned to have home delivery, compared with a “relatively low-risk hospital group.”

The study focused on:

• electronic fetal monitoring, used in 9.6% of deliveries in the home-birth group, versus 84.3% of the hospital group
• episiotomy, performed in 2.1% of home deliveries, compared with 33% of hospital births
• cesarean delivery, 3.7% of planned home deliveries, versus 19% of hospital births
• vacuum-assisted vaginal delivery, performed in 0.6% of planned home deliveries, versus 5.5% of hospital births
• neonatal death, at a rate of 2.0 deaths for every 1,000 intended home births. No comparison figure was cited.

One of the weaknesses of this study, as of others, was identification of a comparison group as a “low-risk” population without data to back up that designation. In addition, this study derived its data from birth certificates for 3,360,868 singleton, vertex births at 37 weeks or more of gestation. Data from birth certificates are limited as a basis for accurate risk assessment. Moreover, although the authors of this study asserted that they had no conflict of interest, the investigation was funded by The Foundation for the Advancement of Midwifery.

Study cited by advocates of hospital birth is also flawed

One of the studies many hospital and birthing center advocates cite was published in 2002.¹⁸ It involved an analysis of birth registry information on uncomplicated singleton pregnancies at 34 weeks or more of gestation in Washington state between 1989 and 1996. These pregnancies were either:

• delivered at home by a health professional (n=5,854)
• transferred to medical facilities after attempted home delivery (n=279)
• planned to be delivered in the hospital (n=10,593).

Infants whose mothers planned to deliver at home had a higher risk of neonatal death (RR, 1.99; 95% CI, 1.06–3.73) and a higher risk of having a 5-minute Apgar score of less than 3 (RR, 2.31; 95% CI, 1.29–4.16). After adjustment for a gestational-age cutoff of 37 weeks, these risks remained similar.

Nulliparous women, in particular, had a higher risk for prolonged labor (RR, 1.73; 95% CI, 1.28–2.34) and postpartum bleeding (RR, 2.76; 95% CI, 1.74–4.36).

The authors themselves point out a potential flaw in this study: the use of data from birth certificates. These data create “the potential for misclassifying unplanned home births as planned home births.” The difference in outcomes could be significant. For example, the neonatal death rate for unplanned home deliveries in North Carolina and Kentucky was 18 to 20 times higher than the rate for planned home births in these states.^19,20

A study from Missouri observes that neonatal mortality was elevated for both planned and unplanned home birth, compared with physician-attended hospital birth.²¹

Selection bias is a concern

Selection bias is an inherent difficulty in many of these studies. Except for one previously mentioned paper—a very small study—none of the investigations involve randomization. As a result, we cannot exclude the possibility that “women who choose to deliver at home or in a birth center are likely to be different in terms of expectations and approach from women choosing to deliver in hospitals.”²²

Risk level can escalate rapidly

What is potentially troubling about home birth is the fact that a low-risk pregnancy that was complication-free during antepartum care can become a high-risk pregnancy in a matter of minutes, necessitating urgent, appropriate obstetric care. Some classic examples of urgent events include cord prolapse, postpartum hemorrhage, bleeding from vasa previa, and shoulder dystocia.

Let’s focus on shoulder dystocia, which occurs in 1.4% of all vaginal deliveries. The authors of one study point out that “most of the traditional risk factors for shoulder dystocia have no predictive value, shoulder dystocia itself is an unpredictable event, and infants at risk for permanent injury are virtually impossible to predict.”²³ This may make delivery in the home a high-risk endeavor because of the inability to mobilize an obstetric team to assist with shoulder dystocia maneuvers or perform a Zavanelli delivery.

Another variable overlooked in most studies is the speed of transfer and the outcomes of pregnancies in which the women intended to deliver at home but ended up requiring urgent transfer. One study that did examine this scenario found that “women who had booked for a home birth, but later needed to transfer their care for a hospital birth, appeared to have the highest risk of intrapartum-related perinatal mortality.”²⁴

There is also some controversy regarding the delivery of women who are pregnant with twins, who have a fetus in breech presentation, or who have a history of cesarean delivery. One study examined outcomes for intended home delivery of 57 women who had a prior abdominal delivery.²⁵ Fifty of these women delivered vaginally in the home, and seven (12.3%) delivered in the hospital. One hospital transfer was urgent for fetal distress. One baby was stillborn, delivered at home.

A 10-year prospective study of vaginal birth after cesarean (VBAC) in birth centers found that more than 50% of uterine ruptures and 57% of perinatal deaths involved the 10% of women who had more than one prior cesarean delivery or who had reached a gestational age of more than 42 weeks.²⁶

Skill of the caregiver is important

The training and qualifications of the obstetric care provider are incredibly important. One study evaluated 4,361 home births attended by “apprentice-trained midwives from 1970 to 1985 and 4,107 home births attended by family physicians from 1969 to 1981.”²⁷ The perinatal mortality rate for the midwife-attended births was 14 for every 1,000 births, in contrast to the rate of 5 for every 1,000 physician-attended births.

Three types of midwife are credentialed in this country:

• certified nurse-midwife (CNM)
• certified midwife (CM)
• certified professional midwife (CPM).

The first two categories are certified by the American Midwifery Certification Board (AMCB). CNMs and CMs undergo rigorous training and examination, and this designation will require a graduate degree within the next few years. The CPM category, however, requires much less rigorous training. Its midwives are certified by the North American Registry of Midwives. The clinical requirements for certification as a CPM include:

• attending a “minimum of 20 births”
• managing at least 20 additional births, at least half of them in the home or another out-of-hospital setting
• performing a small number of prenatal, newborn, and postpartum exams.²⁸

A high school diploma is not required.

I suspect that concerns about this lax certification process contributed to ACOG’s decision to issue a statement from its executive board in 2006: “While ACOG supports women having a choice in determining their providers of care, ACOG does not support the provision of care by lay midwives or other midwives who are not certified by the American College of Nurse-Midwives (ACNM) or AMCB.”²⁹

A number of midwifery advocates have made a legislative push to expand licensure for CPMs in this country, and the debate continues on a state-by-state basis.³⁰

Economics and other variables affect delivery decision

Some advocates of home birth note that the “average uncomplicated vaginal birth costs 68% less in a home than in a hospital.”³¹ Others try to organize support for women who want to give birth at home, such as the Home Birth Hotline, a voluntary, UK-based organization.³²

Some articles suggest that patient satisfaction is of significant importance in the decision about where to deliver. One noted that women who delivered where they had planned had higher overall satisfaction when that place was in the home (P<.01).³³

A randomized, controlled trial (n=3,510) simulated home delivery in a hospital, with “home delivery” patients having midwifery care in a room “similar to one in one’s own home” and the others having “consultant-led care” in rooms in the delivery suite that contained equipment to resuscitate both mother and baby, as well as monitors and other technology.³⁴ This study found no significant differences in measured outcomes, but “generally higher levels of satisfaction” among the women who had simulated home delivery.

A study from “remote and rural Scotland” found that most women “expressed a preference to give birth in hospital and have consultant-led care because they felt safer.”³⁵

Does the rhetoric surrounding home birth “empower” women?

Another frequently overlooked issue is the passionate rhetoric used to describe home birth—and the effect of that passion on women whose birth plan doesn’t play out as expected. Words such as “choice” and “empowerment” are often used. Regrettably, there is considerable mistrust of the medical system.

One woman describes how her planned home delivery, “influenced by the feminist literature,” went awry.³⁸ After a long labor, she wrote, she “just wanted the baby out, safe and healthy. It no longer mattered how it happened….I couldn’t get rid of the underlying feeling that I had ‘failed’ in some way….”³⁸

Because of her strong desire for home delivery, this woman was deeply affected when the delivery became difficult: “I did not have the authority to proclaim whether or not various medical interventions were necessary, or whether my case actually did constitute a medical emergency….Faced with these ‘options’—safe birth or potential death—how could I be said to be making a ‘choice’?…The obstetrician has more power than the woman because s/he has more knowledge.”³⁸

Despite having come to this realization, and delivering a healthy baby, she still experienced “a sense of disappointment and anger” and “traumatic flashbacks.”

I worry that patients may become so caught up in the rhetoric of their own power and choice that, when uncontrollable events occur, the happiness of a healthy delivery is overshadowed by deep disappointment.

Heated debate isn’t helpful

An unfortunate rift seems to have developed between some members of the midwifery community and some physicians. ACOG and the ACNM have a longstanding policy that: “In those circumstances in which obstetrician/gynecologists and certified nurse-midwives/certified midwives collaborate in the care of women, the quality of those practices is enhanced by a working relationship characterized by mutual respect and trust.”³⁹

Whether individual physicians agree with the practice of planned home birth or not, the health and welfare of the patient must be paramount. The American Public Health Association and the ACNM support home birth.^40,41

When obstetric emergencies do arise in the home setting, necessitating emergent transfer, it is critical that the transfer be managed in a way that ensures the best outcome.

One disturbing article describes both “disarticulations” that occur “when there is no correspondence of information or action between the midwife and the hospital staff” and “fractured articulations” that arise from “partial and incomplete correspondence.”⁴² A number of midwives were interviewed who no longer feel comfortable bringing patients to certain hospitals because of the negative response they received from health-care providers, sometimes to the detriment of the patient.

Can we improve the situation?

First, we need to choose our words carefully when we counsel women about labor and delivery, in recognition of the buzzwords used by advocates of home birth (“empowerment,” “choice”) and the sense of failure and distress some women feel when they eventually require heightened medical intervention.

Perhaps we should dispense with the term “failure,” as in failure to progress, failure to dilate, and so on, to avoid implying that this “failure” is the woman’s fault. And instead of saying that a patient’s pelvis is “adequate,” implying that another woman’s pelvis isn’t, we could use a term that sounds less judgmental.

We can also make the hospital environment more nurturing and supportive of women’s choices for labor, as long as safety isn’t compromised. And when we receive a transfer of a patient whose home delivery has gone awry, we should openly, efficiently, and professionally communicate with the home-delivery provider to best benefit the patient, regardless of our feelings on the subject.

Home birth isn’t going away

That’s my take on the literature. There are certainly data supporting the safety of home birth for the vast majority of women who choose it, but there is also a significant number of women who will experience unpredictable events that could be fatal if blood products or surgery isn’t rapidly available. For that reason, and in light of the very high stakes involved, I wonder: Why take that chance?

The author reports no financial relationships relevant to this article.

Few issues in obstetrics spark as much controversy as home birth—and where controversy rages, media attention follows.

Press reports of a 2008 policy statement on home birth issued by the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) highlight the rift between the formal medical establishment and advocates of home birth.^1-3

On one side, the AMA and ACOG assert that the hospital or an accredited birthing center “is the safest setting for labor, delivery, and the immediate postpartum period.”¹ On the other side, advocates of home birth argue that having the option adds to women’s empowerment and choice.

Some people have accused the medical community of trying to corner the “baby birthing industry.”⁴ The title of a recent Baltimore Sun article sums up this sentiment: “Home birth battle: Doctors strong-arm women away from healthy alternative to hospital care.”⁵

Neither ACOG nor the AMA advocates criminalization of home deliveries, but their statements on home birth have generated considerable fear that they will.

This article explores the controversy, focusing on the literature on home birth, gaps in knowledge, the state of regulation, liaison with midwives, and other issues. It also offers suggestions on how to discuss labor and delivery with patients so that they clearly understand the risks involved and do not feel that they have “failed” at meaningful childbirth when they choose hospital delivery.

Did a rise in hospital births reduce maternal mortality?

Obstetric care changed dramatically in the mid-20th century. In 1940, 55.8% of deliveries occurred in the hospital, but that percentage rose to 99.4 by 1970 and hasn’t changed appreciably since.⁶

Some proponents of hospital delivery note that, in 1940, when 44% of births occurred outside the hospital, the maternal mortality rate was 608 deaths for every 100,000 live births, compared with 37 deaths for every 100,000 live births in 1960, when fewer than 4% of deliveries occurred outside the hospital.⁶ And in 2003, with only 1% of deliveries occurring in a home setting, the maternal mortality rate was even lower: 12 deaths for every 100,000 live births.⁷

Others argue that this sharp decrease in maternal mortality cannot be attributed solely to the change in location of the delivery (and subsequent availability of services and personnel), but reflects universal advancement in safe practices such as aseptic technique.⁸

What do the data show? All studies of home birth have serious methodologic flaws, thanks largely to the nature of the subject matter. A recent Cochrane review observes that there is only one randomized, controlled trial—with a sample size of only 11 women—from which to draw conclusions.⁹ The review concludes that “there is no strong evidence to favour either home or hospital birth for selected, low-risk pregnant women.”¹⁰

Most data come from abroad

Much of the literature on home birth comes from international sites because of the higher prevalence of home delivery in other countries. These data reveal that:

• Two percent of deliveries in the United Kingdom occur in the home.¹¹ The British National Institute for Health and Clinical Excellence recommended that all women be offered the option to have their baby at home or in the hospital, although, depending on the “trust” (a geographically based public-system cooperative that provides care), 8% to 76% of women weren’t given this choice formally.¹²
• One study conducted in Switzerland involved 489 women who opted for home birth and 385 who chose hospital birth. Of the former, 37 were referred to a specialist during pregnancy, and 70 were referred during labor. The groups had similar birth weights, gestational ages, and clinical conditions.¹³
• In the Netherlands, 30% of infants are born at home.¹⁴ If a woman has an uncomplicated pregnancy, she remains under midwifery care and can decide where to deliver. A study of 280,000 “low-risk” women under primary midwifery care found that 68.1% completed childbirth under that care, 3.6% were referred urgently, and 28.3% were referred without urgency.¹⁴ When referrals were considered as a whole, 11.2% involved urgency, primarily for fetal distress (50.2%) and postpartum hemorrhage (33%). Adverse neonatal outcomes were most common in urgently referred cases, followed by nonurgent referrals. The authors acknowledge the importance of transport time once a referral is initiated, stating that, “The Netherlands is a very densely populated country where the average distance to the hospital is relatively short.” (The same cannot be said of many parts of rural America.)
• A study involving home deliveries in Australia from 1985 to 1990 identified 50 perinatal deaths out of 7,002 planned home births.¹⁵ The perinatal death rate of infants weighing more than 2,500 g exceeded the national average (5.7 versus 3.6 for every 1,000 deliveries), with a relative risk (RR) of 1.6 (95% confidence interval [CI], 1.1–1.4). Intrapartum death not attributable to prematurity or fetal malformation was also higher (2.7 versus 0.9 for every 1,000 deliveries), with a RR of 3.0 (95% CI, 1.9–4.8). According to the authors, the main contributors to excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy, and breech presentation, and a lack of response to fetal distress.

Is the evidence on water birth just too murky?

In the summer of 1999, a woman delivered a 7.7-lb infant after 42 weeks of gestation. The birth took place in the woman’s home in Japan, and the baby was delivered in a bathtub of warm water. The woman had had an uneventful pregnancy, and the baby appeared to be perfectly normal.

Four days later, the infant developed fever and jaundice and was admitted to the hospital, where she was treated with phototherapy. She improved, but her symptoms recurred 3 days later, and she began to vomit. Eight days after birth, she suffered cardiopulmonary arrest and died. An autopsy revealed the cause of death to be legionellosis—infection with Legionella pneumonia. The most likely source was the bathtub in which she was born.⁴³

Other case reports describe similar tragedies associated with water birth (among them, drowning, infection, and a snapped umbilical cord), but no randomized, clinical trial has systematically compared delivery in water with conventional land-based birth.

The death, morbidity, and lack of data so troubled members of the American Academy of Pediatrics that the Committee on Fetus and Newborn issued an advisory in 2005:

• The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed randomized clinical trial after informed parental consent.⁴⁴

This statement contrasts the conclusion of the most recent Cochrane review of the subject, which found that, “Immersion in water during the first stage of labour significantly reduces women’s perception of pain and use of epidural/spinal analgesia.”⁴⁵ The review also noted, however, that, “No trials could be located that assessed the immersion of women in water during the third stage of labour.”⁴⁵

No studies have explored immersion in water during the third stage of labor.

What’s in that water?

Amy Tuteur, MD, an ObGyn who publishes a popular blog (“The Skeptical OB”), focused on the topic of water birth earlier this year. “What’s in the water at waterbirth?” she asks.⁴⁶

To answer the question, Dr. Tuteur cites a 1999 study of 4,030 deliveries in water, which found that 35 infants suffered serious morbidity and three died—although it is unclear if any of the deaths were a direct result of water birth. “However, of the 32 survivors who were admitted to the NICU,” writes Dr. Tuteur, “13 had significant respiratory problems, including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include five babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth.”⁴⁷

Dr. Tuteur also points to the poor quality of the water in birthing pools, arguing that it is “essentially toilet water.”⁴⁶ “The water in a birth pool, conveniently heated to body temperature, the optimum temperature for bacterial growth, is a microbial paradise,” she writes.⁴⁶ She cites a study of 1,500 water births that included analysis of the water found in the birthing pools (before anyone entered the water) and identified:

• coliforms in 21% of samples
• enterococcus in 19% of samples
• Escherichia coli in 10% of samples
• Legionella pneumophila in 12% of samples
• Pseudomonas aeruginosa in 11% of samples.⁴⁸

After a special water filter was installed, contamination diminished but did not disappear completely.

Pools in the home setting were not the only ones implicated in contamination; some hospital pools also were affected.

What’s the bottom line?

The American College of Obstetricians and Gynecologists has yet to weigh in on the matter. Until it does, ObGyns may be wise to heed the words of Ruth Gilbert, MD, of the Centre for Paediatric Epidemiology and Biostatistics at the Institute of Child Health in London.

“Can delivery in water cause serious adverse outcomes?” she asks, rhetorically, it turns out.

“Undoubtedly, the answer is ‘yes.’”⁴⁹ —JANELLE YATES, SENIOR EDITOR

The data we do have are difficult to interpret

Among the limitations of studies of home birth are:

• lack of follow-up after the delivery
• varying definitions of perinatal mortality internationally
• lack of clarity regarding the identity and education of delivering providers
• the fact that there are often “too few neonatal deaths from which to extrapolate reliable rate calculations.”¹⁶

One meta-analysis found a rate of intrapartum transfer ranging from 7.4% to 16.5%, and a rate of primary cesarean delivery of 1.4% to 17.7% (it was 13.8% to 28.25% in the “comparison group”).¹⁶

A challenge inherent in many of these studies is identifying exactly what the comparison group is. In addition, some of the data are obtained from discharge summary records, which don’t always reflect the level of risk or acuity.

Oft-cited study has weaknesses

The study that many advocates of home birth cite was conducted in the United States and Canada and published in 2005.¹⁷ It evaluated “all 5,418 women expecting to deliver in 2000 supported by midwives with a common certification [certified professional midwives] and who planned to deliver at home when labour began.” The hospital transfer rate was 12.1%, in line with other studies. The risk of adverse outcomes was lower in the group that planned to have home delivery, compared with a “relatively low-risk hospital group.”

The study focused on:

• electronic fetal monitoring, used in 9.6% of deliveries in the home-birth group, versus 84.3% of the hospital group
• episiotomy, performed in 2.1% of home deliveries, compared with 33% of hospital births
• cesarean delivery, 3.7% of planned home deliveries, versus 19% of hospital births
• vacuum-assisted vaginal delivery, performed in 0.6% of planned home deliveries, versus 5.5% of hospital births
• neonatal death, at a rate of 2.0 deaths for every 1,000 intended home births. No comparison figure was cited.

One of the weaknesses of this study, as of others, was identification of a comparison group as a “low-risk” population without data to back up that designation. In addition, this study derived its data from birth certificates for 3,360,868 singleton, vertex births at 37 weeks or more of gestation. Data from birth certificates are limited as a basis for accurate risk assessment. Moreover, although the authors of this study asserted that they had no conflict of interest, the investigation was funded by The Foundation for the Advancement of Midwifery.

Study cited by advocates of hospital birth is also flawed

One of the studies many hospital and birthing center advocates cite was published in 2002.¹⁸ It involved an analysis of birth registry information on uncomplicated singleton pregnancies at 34 weeks or more of gestation in Washington state between 1989 and 1996. These pregnancies were either:

• delivered at home by a health professional (n=5,854)
• transferred to medical facilities after attempted home delivery (n=279)
• planned to be delivered in the hospital (n=10,593).

Infants whose mothers planned to deliver at home had a higher risk of neonatal death (RR, 1.99; 95% CI, 1.06–3.73) and a higher risk of having a 5-minute Apgar score of less than 3 (RR, 2.31; 95% CI, 1.29–4.16). After adjustment for a gestational-age cutoff of 37 weeks, these risks remained similar.

Nulliparous women, in particular, had a higher risk for prolonged labor (RR, 1.73; 95% CI, 1.28–2.34) and postpartum bleeding (RR, 2.76; 95% CI, 1.74–4.36).

The authors themselves point out a potential flaw in this study: the use of data from birth certificates. These data create “the potential for misclassifying unplanned home births as planned home births.” The difference in outcomes could be significant. For example, the neonatal death rate for unplanned home deliveries in North Carolina and Kentucky was 18 to 20 times higher than the rate for planned home births in these states.^19,20

A study from Missouri observes that neonatal mortality was elevated for both planned and unplanned home birth, compared with physician-attended hospital birth.²¹

Selection bias is a concern

Selection bias is an inherent difficulty in many of these studies. Except for one previously mentioned paper—a very small study—none of the investigations involve randomization. As a result, we cannot exclude the possibility that “women who choose to deliver at home or in a birth center are likely to be different in terms of expectations and approach from women choosing to deliver in hospitals.”²²

Risk level can escalate rapidly

What is potentially troubling about home birth is the fact that a low-risk pregnancy that was complication-free during antepartum care can become a high-risk pregnancy in a matter of minutes, necessitating urgent, appropriate obstetric care. Some classic examples of urgent events include cord prolapse, postpartum hemorrhage, bleeding from vasa previa, and shoulder dystocia.

Let’s focus on shoulder dystocia, which occurs in 1.4% of all vaginal deliveries. The authors of one study point out that “most of the traditional risk factors for shoulder dystocia have no predictive value, shoulder dystocia itself is an unpredictable event, and infants at risk for permanent injury are virtually impossible to predict.”²³ This may make delivery in the home a high-risk endeavor because of the inability to mobilize an obstetric team to assist with shoulder dystocia maneuvers or perform a Zavanelli delivery.

Another variable overlooked in most studies is the speed of transfer and the outcomes of pregnancies in which the women intended to deliver at home but ended up requiring urgent transfer. One study that did examine this scenario found that “women who had booked for a home birth, but later needed to transfer their care for a hospital birth, appeared to have the highest risk of intrapartum-related perinatal mortality.”²⁴

There is also some controversy regarding the delivery of women who are pregnant with twins, who have a fetus in breech presentation, or who have a history of cesarean delivery. One study examined outcomes for intended home delivery of 57 women who had a prior abdominal delivery.²⁵ Fifty of these women delivered vaginally in the home, and seven (12.3%) delivered in the hospital. One hospital transfer was urgent for fetal distress. One baby was stillborn, delivered at home.

A 10-year prospective study of vaginal birth after cesarean (VBAC) in birth centers found that more than 50% of uterine ruptures and 57% of perinatal deaths involved the 10% of women who had more than one prior cesarean delivery or who had reached a gestational age of more than 42 weeks.²⁶

Skill of the caregiver is important

The training and qualifications of the obstetric care provider are incredibly important. One study evaluated 4,361 home births attended by “apprentice-trained midwives from 1970 to 1985 and 4,107 home births attended by family physicians from 1969 to 1981.”²⁷ The perinatal mortality rate for the midwife-attended births was 14 for every 1,000 births, in contrast to the rate of 5 for every 1,000 physician-attended births.

Three types of midwife are credentialed in this country:

• certified nurse-midwife (CNM)
• certified midwife (CM)
• certified professional midwife (CPM).

The first two categories are certified by the American Midwifery Certification Board (AMCB). CNMs and CMs undergo rigorous training and examination, and this designation will require a graduate degree within the next few years. The CPM category, however, requires much less rigorous training. Its midwives are certified by the North American Registry of Midwives. The clinical requirements for certification as a CPM include:

• attending a “minimum of 20 births”
• managing at least 20 additional births, at least half of them in the home or another out-of-hospital setting
• performing a small number of prenatal, newborn, and postpartum exams.²⁸

A high school diploma is not required.

I suspect that concerns about this lax certification process contributed to ACOG’s decision to issue a statement from its executive board in 2006: “While ACOG supports women having a choice in determining their providers of care, ACOG does not support the provision of care by lay midwives or other midwives who are not certified by the American College of Nurse-Midwives (ACNM) or AMCB.”²⁹

A number of midwifery advocates have made a legislative push to expand licensure for CPMs in this country, and the debate continues on a state-by-state basis.³⁰

Economics and other variables affect delivery decision

Some advocates of home birth note that the “average uncomplicated vaginal birth costs 68% less in a home than in a hospital.”³¹ Others try to organize support for women who want to give birth at home, such as the Home Birth Hotline, a voluntary, UK-based organization.³²

Some articles suggest that patient satisfaction is of significant importance in the decision about where to deliver. One noted that women who delivered where they had planned had higher overall satisfaction when that place was in the home (P<.01).³³

A randomized, controlled trial (n=3,510) simulated home delivery in a hospital, with “home delivery” patients having midwifery care in a room “similar to one in one’s own home” and the others having “consultant-led care” in rooms in the delivery suite that contained equipment to resuscitate both mother and baby, as well as monitors and other technology.³⁴ This study found no significant differences in measured outcomes, but “generally higher levels of satisfaction” among the women who had simulated home delivery.

A study from “remote and rural Scotland” found that most women “expressed a preference to give birth in hospital and have consultant-led care because they felt safer.”³⁵

Does the rhetoric surrounding home birth “empower” women?

Another frequently overlooked issue is the passionate rhetoric used to describe home birth—and the effect of that passion on women whose birth plan doesn’t play out as expected. Words such as “choice” and “empowerment” are often used. Regrettably, there is considerable mistrust of the medical system.

One woman describes how her planned home delivery, “influenced by the feminist literature,” went awry.³⁸ After a long labor, she wrote, she “just wanted the baby out, safe and healthy. It no longer mattered how it happened….I couldn’t get rid of the underlying feeling that I had ‘failed’ in some way….”³⁸

Because of her strong desire for home delivery, this woman was deeply affected when the delivery became difficult: “I did not have the authority to proclaim whether or not various medical interventions were necessary, or whether my case actually did constitute a medical emergency….Faced with these ‘options’—safe birth or potential death—how could I be said to be making a ‘choice’?…The obstetrician has more power than the woman because s/he has more knowledge.”³⁸

Despite having come to this realization, and delivering a healthy baby, she still experienced “a sense of disappointment and anger” and “traumatic flashbacks.”

I worry that patients may become so caught up in the rhetoric of their own power and choice that, when uncontrollable events occur, the happiness of a healthy delivery is overshadowed by deep disappointment.

Heated debate isn’t helpful

An unfortunate rift seems to have developed between some members of the midwifery community and some physicians. ACOG and the ACNM have a longstanding policy that: “In those circumstances in which obstetrician/gynecologists and certified nurse-midwives/certified midwives collaborate in the care of women, the quality of those practices is enhanced by a working relationship characterized by mutual respect and trust.”³⁹

Whether individual physicians agree with the practice of planned home birth or not, the health and welfare of the patient must be paramount. The American Public Health Association and the ACNM support home birth.^40,41

When obstetric emergencies do arise in the home setting, necessitating emergent transfer, it is critical that the transfer be managed in a way that ensures the best outcome.

One disturbing article describes both “disarticulations” that occur “when there is no correspondence of information or action between the midwife and the hospital staff” and “fractured articulations” that arise from “partial and incomplete correspondence.”⁴² A number of midwives were interviewed who no longer feel comfortable bringing patients to certain hospitals because of the negative response they received from health-care providers, sometimes to the detriment of the patient.

Can we improve the situation?

First, we need to choose our words carefully when we counsel women about labor and delivery, in recognition of the buzzwords used by advocates of home birth (“empowerment,” “choice”) and the sense of failure and distress some women feel when they eventually require heightened medical intervention.

Perhaps we should dispense with the term “failure,” as in failure to progress, failure to dilate, and so on, to avoid implying that this “failure” is the woman’s fault. And instead of saying that a patient’s pelvis is “adequate,” implying that another woman’s pelvis isn’t, we could use a term that sounds less judgmental.

We can also make the hospital environment more nurturing and supportive of women’s choices for labor, as long as safety isn’t compromised. And when we receive a transfer of a patient whose home delivery has gone awry, we should openly, efficiently, and professionally communicate with the home-delivery provider to best benefit the patient, regardless of our feelings on the subject.

Home birth isn’t going away

That’s my take on the literature. There are certainly data supporting the safety of home birth for the vast majority of women who choose it, but there is also a significant number of women who will experience unpredictable events that could be fatal if blood products or surgery isn’t rapidly available. For that reason, and in light of the very high stakes involved, I wonder: Why take that chance?