Should it be Illegal for Pregnant Women to Smoke?

Some time ago, the American College of Obstetricians and Gynecologists and the American Medical Association released statements decrying home birth, ostensibly for reasons of safety. This “safety” is typically quantified by mortality and morbidity, which is why the ever-vigilant Dr. Amy travels the blogosphere preaching her gospel of “home birth with a DEM has 2-3x the rate of mortality as low-risk hospital birth.” I’m planning another post in the near future on that, but here is one post in which I take on that statement, if you’re interested.

But, just for the sake of argument, let’s say that Dr. Amy is right (which she’s not). She consistently says that the Johnson & Daviss CPM home-birth study shows 2.6/1000 neonatal mortality (although it includes intrapartum deaths), compared to 0.9/1000 in the hospital for low-risk births (which she defines as births to white women at 37 or more weeks gestation and 2500 grams of birthweight, although that is not necessarily an accurate comparison). She also says that the CDC stats show that home birth with “other midwife” has a neonatal mortality rate of 1.15/1000 vs. a CNM rate of 0.37 (although she deliberately ignores the higher rate of babies that were born with lethal birth defects like anencephaly). She says, “The issue is safety.” Is it really?

Let’s pretend she’s right, though, and say that planned home birth has, say, a 1.5/1000 neonatal mortality vs. 0.6/1000 for a similar low-risk group who have planned hospital births (just picking a number in the middle of the above-mentioned numbers). This would mean that for every 1,000 babies born at home, 1 more would die in the planned home-birth group as opposed to the hospital-birth group. (Just to remind you, even though I don’t agree with this assessment, these numbers also don’t take into account serious morbidity — injury that the baby sustains during or after birth.) But let’s say that the 2.6 as opposed to 0.9 is correct — that would mean that the “excess mortality rate” would be 1.7. So, the worst-case scenario is 1.7/1000.

The U.S. government gathers statistics about births and deaths, and here is the link to the report on the year 2000. If you go to the 11th page of this PDF file, you’ll see infant mortality rates by maternal race and various characteristics (like gestational age at birth, birthweight, infant sex, etc.). I want to draw your attention to two different characteristics, near the bottom of the page: marital status and maternal smoking. While these data are separated by maternal race, they do have them combined into “all races.” If you look at “marital status,” you’ll see that unmarried women have an infant mortality rate 4.5/1000 more than married women (probably due to the higher socioeconomic status of married women vs. single mothers). If you look at maternal smoking, you will see that smokers’ infants die at 4.2/1000 more than babies born to non-smokers. A big factor in this is prematurity, which as everyone who has ever read a pack of cigarettes knows, the surgeon general warns that pregnant women who smoke increase the risk of preterm birth, low birthweight, and infant mortality.

So, if ACOG and the AMA want to outlaw home birth because of the “safety issues”, or as Dr. Amy puts it, 2-3x the neonatal mortality (which at most equals 1.7/1000), why not start with something more easily changed, which would affect a larger number of women and babies? Let’s say that 1.7 is accurate — heck, let’s even go all the way up to 2/1000; and there are at most 40,000 women who intentionally give birth at home with a midwife (although the CDC statistics only record about 15,000 women per year). That means that at most 80 babies would be affected. But (according to page 12 of the PDF), there are 1,347,069 babies born to unmarried women every year (at 4.5/1000 excess infant mortality), or 6,061 babies who die that would have lived had their mothers been married. Also on that page, are the numbers for smokers — 425,107 (at 4.2/1000 excess mortality), or 1785 dead babies because their mothers smoked. (If you look at just black women, you’ll see that smoking raises the rate from 12.7 to 19.8/1000!)

So, if ACOG and the AMA really have issues with safety, why do they not throw their powerful lobbying muscle behind reducing the number of women who smoke or who have children out of wedlock? When was the last time you saw anything on the national news from ACOG or the AMA decrying out-of-wedlock births? Oh, sure, they kick and scream and turn blue and foam at the mouth when Ricki Lake releases The Business of Being Born and is vocal about home birth; but when celebrity women like Camryn Manheim, Jessica Alba, Jodie Foster, Halle Berry, Susan Sarandon, and Madonna all have babies “without the benefit of marriage”, the only thing anybody talks about is “who’s the daddy?” When Dan Quayle took “Murphy Brown” to task for having a baby out of wedlock, he was roundly derided on all sides. Yet looking at the plain statistics, we see that “regular folks” have an increase in infant mortality, even if wealthy celebrities do not.

So, I ask again, as I did in my title — if home birth should be outlawed or warned against on every corner, with ACOG and the AMA issuing seriously-worded press releases about the risks of home birth because Ricki Lake made a movie about it (except they forgot to put in any data supporting their claims….) — where is the foaming at the mouth when higher-profile celebrities — world-famous celebrities, in fact, like Madonna — flaunt their single motherhood, and do everything shy of making a movie about it? Where is the outrage by the doctors for the “attention in the media by celebrities having” out-of-wedlock births which are statistically at least twice as risky as even the direst home-birth predictions, and are also have some 33x the rate of occurrence of home-births throughout the United States every year? Where are the press conferences deriding maternal smoking, and the press releases by these organizations announcing an attempt at legislation making maternal smoking illegal?

Until these doctors begin to attack real and serious risks, I cannot take them seriously when they scream that they do not support home birth because of potential safety reasons. And I wonder how anybody can take them seriously, when they put forth so much effort to stop home birth which is already so rare (less than 1% of all the births in the United States, although making home-birth midwifery illegal is the #2 legislative priority for ACOG), and do so little to stop maternal smoking (12% of all births, with a 10.7/1000 overall infant mortality rate) and unwed motherhood (1/3 of all births, with a 9.9/1000 overall infant mortality rate).

Open letter to ACOG and the AMA: GET REAL!


9 Responses

  1. Right on!!!!
    But you of cource my dear are talking COMMON SENSE and the fact is that smoking dramaticly increases complication which of course means mothers need OB interventions more thus increasing their bottom line.
    I run a prenatal smoking cessation program as part of my childbirth services and I have to say I have had a hard time getting refferals from local Dr, luckliy for me I have great relationships with their nurses and they refer moms to me.
    I had one doctor say that smoking during pregnancy is not a big issue.
    But then again this Dr has a 57% c section rate in his practice, so what does that tell ya?

  2. PS

  3. Great post, Kathy! I heard someone refer to it in person at our Orgasmic Birth screening this afternoon (as in, “I recently read a blog post that making smoking illegal is more logical than going after homebirth…” and I thought, “That sounds like Kathy’s post! So…you’re being read and discussed around the country 😉

    I love how thought-provoking, well thought out, and well reasoned you are!

    Best wishes,


  4. […] am This blogger writes an excellent post which goes hand-in-hand with what my main point is in this post. Namely, if your organization (be it ACOG or McDonald’s) doesn’t like what the […]

  5. So, the obvious reasons why ACOG goes after home births and not after other causes of increased mortality are…control…power…authority…

    And then there is another even bigger reason: home birth makes them look bad. If it is possible for some women to give birth without all that supervision and intervention that makes them look bad. And if the outcomes in the escapee cohort are better than in the supervised, controlled and intervened cohort they look even worse.

    I don’t think protecting women and babies is really their first priority, do you?

  6. No, I don’t think it’s their first priority. To me, being so against home-birth (even if their worst predictions are accurate, the number of women choosing a home birth is incredibly small) while being silent on the tremendous death toll associated with maternal smoking and unwed marriage, is like trying to lose weight, so cutting out salads (because of the fattening dressing) while still eating dessert all the time. Either hypocritical or idiotic. Either way, nonsensical.

  7. making it illegal for pregnant woemen to smoke ciggarettes would be stupid and useless. The number of people who smoke is very high and nicotine is more addictive than heroine. Before people start blabbering about how its harmful to the fetus and all of that fairly obvious but still meaningless jabber, consider this: What would we gain from making smoking while pregnant illegal? think it would help something? To me it looks like there are many women who would simply be prosecuted and made EVEN MORE unfit to care for their chidren because of legal costs/probems, and then we’d a be complaining about the extra burden on the system. Guess what people just cause you can prove that soemthing’s not perfect doesn’t mean youll be fixing anything by taking legal measures to punish someone for it. We dont prosecute people because they make us mad. We do it to protect society. So prove how we coud possiby protect fetus’s by punishing their mothers in a way that woud only make it even harder for them to care for them properly? and dont say if they just dont do it then they wont have to worry about being punished, because as addictive and LEGAL as ciggarettes are, that is next to impossible. If we realy want to tak about solving the problem or at least starting to solve it why not make ciggarette smoking illega period? It’s not helping anyone anyway. To say that we should only make it illegal for a pregnant woman is basically just a cry for women to be controled more and more just for the natural and necessary effects of womanhood, with the guise of protecting the fetus. What about all of us who drive cars? we are SERIOUSY polluting the air and babies breathe that air just like everybody else. Should we make it illegal to drive now too? If you realy want to tak about the things that are harmful to fetus’s the list is extremely long. To single out ciggarette smoking is a pure cop out.

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