Women they really believe that if they are good patients, if they are friendly, if they don’t question to much, if they are good-natured, their OB will treat them with the same courtesy by reading their birth plan, respecting their wishes, supporting their desire for a vaginal birth, and creating an environment where VBAC is the goal.  In short, the woman believes that she will receive a genuine opportunity to VBAC. 

However, as we read below, it is not enough to like your OB.  It’s not enough that you feel comfortable with them.  They need to support VBAC.  They need to see the value in vaginal birth.

As I read this letter again, it really breaks my heart to share with you.  This woman is fresh from her repeat cesarean and she is still mourning.  I thank her deeply for sharing her pain and regret with the readers of this site.  I hope that this woman’s pain can be transformed into greater knowledge and understanding for you.  I hope if you are considering staying with your OB/midwife just because you like them, and not because their standard of care is in favor of vaginal birth, that you reconsider your decision.

To learn more about “bait & switch” OBs, read: The Three Types of Care Providers Amongst OBs and Midwives. 

To read more birth stories of women who received less than stellar care in the hospital, please read: Hospital VBAC turned CS due to constant scare tactics and VBACing against the odds.

To support an OB who is currently being targeted by his hospital for attending VBACs, please read: VBAC supportive OB asked to stop attending VBACs by his hospital.

Dear Dr. XYZ:

It is with great reluctance that I submit payment to you for services rendered. 

I hired you for an intervention free VBAC.  Instead I had EVERY intervention I told you I did not want.  Under your care, I failed in the most basic way a woman can fail – I failed to birth my children.   You ignored each and every point on my birth plan.  I cannot help but wonder if you even read it, or if you ever had any intention of following it. 

I needed time for my body to do what it was designed to do.  I needed support from my doctor, from my nurses, and from my hospital.  What I did NOT need was to be pumped full of drugs, have multiple interventions that I specifically stated I did not want and pushed into a surgical procedure.  I am especially struck by our final interaction prior to consent.  Never, for the rest of my life, will I forget how you made your speech, and then stalked out of the room.  I recall thinking “I’m actually paying to be treated like this?  To be verbally bereted and physically tortured?” 

I have no joy when recalling my children’s births.

I have regrets. 

I regret coming in for an appointment that day when labor was in the early stages.  I regret listening to you that I should go to the hospital “just for some monitoring.”  I regret not leaving when labor stalled.  I regret agreeing to pitocin.  I regret allowing you to turn up the pitocin to a point where I could not stand it without pain relief.  I regret getting the epidural instead of just screaming my lungs out until it was over.  I regret letting you artificially rupture my membranes.  I regret allowing the monitoring – internal and external.  I regret not telling you that this was my baby, my birth experience, and I wasn’t having a C-section without a court order.

But what I regret most is choosing you as my provider.  I knew going in that you had a high C-section rate, that you had already given me most of those interventions with my first child.  But I liked you, and allowed that to influence my decision. 

How I wished I had chosen someone I loathed who would have worked with me to get the natural birth I desired.  In the end, liking you got me nothing that I REALLY wanted.

So, here is your money.  I don’t particularly think you have earned it, but I want to be free of this one last reminder of the worst experience of my life. 

Sincerely,

Jenn in St. Louis

Wow is this article amazing for being published in the post-2004 “anti-VBAC per ACOG” era, by two MDs no less! If your OB gives you the third degree about VBAC, you might want to give him a copy of this article. The tide against VBAC might be turning!

Dated February 2008, not only does it openly and explicitly encourage VBAC, but it also:

• declares VBAC as the “safest option”
• encourages efforts to “minimize the primary cesarean delivery rate”
• asserts that cesareans increase the risk of “placenta accreta, increta and percreta” which “may be particularly difficult to address in a rural community hospital setting”
• puts the high cesarean rate squarely on the shoulders of OBs: “Physician specific practices influence cesarean delivery rates”
• notes that OB attitudes towards cesareans is the “largest stumbling block” in lowering the rate
• concludes that, “An important ingredient in reducing cesarean delivery, either in nulliparous or parous women, is to place value on vaginal delivery”
• supports “labor management strategies to reduce cesarean rates in the Native American population in the Oklahoma Area and nationwide”
• questions why smaller hospitals state they can’t accommodate VBAC, yet offer maternity services, when there are other emergencies that occur during non-VBAC labors at a greater rate than uterine rupture
• encourages hospitals to revaluate their policies and support VBAC
• asserts that VBAC is successful 75% of the time
• reaffirms that spontaneous VBAC labors are more successful (80.6%) than VBAC labors that are induced (67.4%) or augmented (73.9%)
• reaffirms that women who are more than 4 centimeters dilated upon admission have greater VBAC success (83.8% vs. 66.8%)
• found VBAC success can be had among women with “larger babies” (over 4000 grams or 8 lb, 12 oz) (62%) and women who are ‘overdue’ as defined as 41 weeks or more (64.8%).  I would personally take these odds over the 0% chance of VBAC success if you have a scheduled repeat cesarean!

Maybe the pendulum is finally swinging the other way and this will be the beginning of VBAC support for all women.

The emphasis below is mine.  Note that VBAC is referred to as ‘trial of labor after cesarean’ or TOLAC.

Leeman, Larry, MD, MPH and Eve Espey, MD, MPH. “Concern for rising Cesarean rates in Native American populations.” CCC Corner 6.2 (February 2008)

Concern for rising Cesarean rates in Native American populations

By Larry Leeman MD, MPH and Eve Espey MD, MPH

Editorial Note : The following is in response to a Point / Counterpoint discussion of trial of labor after cesarean (TOLAC) in rural hospitals, December CCC Corner*

We appreciate the willingness to engage in discussion about trial of labor after cesarean (TOLAC) availability and the approach to cesarean delivery at W. W. Hastings Hospital. Every facility faces unique factors in the decision to offer TOLAC services. However, we fear that the high total cesarean rate and lack of TOLAC services will ultimately result in worse perinatal outcomes considered from a population level.

Not only is vaginal birth after cesarean (VBAC) highly desired by many women, but it is preferable to a repeat cesarean delivery in certain women, including those with a single cesarean delivery who have had a successful vaginal birth before or after their cesarean delivery. Evidence suggests that such women should be encouraged to have a TOLAC particularly if they plan to have additional children. Given these data, anesthesia staff should be strongly encouraged to change their policy and offer 1 VBAC services in accordance with guidelines similar to those developed in the Northern New England Perinatal Quality Improvement Network (NNEPQIN). Ethically, it is difficult to justify withholding TOLAC when it is the safest option. If services were offered to this group of women, obstetrical and anesthesia staff could develop greater comfort with TOLAC and expand the local eligibility criteria.

Annual cesarean rates at some Indian Health facilities in Oklahoma are > 37% and short term rates over 40%, hence are above the recently published 2006 national rates for the total U.S population (31.1%), the Oklahoma state population (33.3%), and the US Native American population (27.5%) 2 We note that the Native American cesarean rate increased 1.5% from 2005 to 2006, almost double the 0.8% increase for the total US population. The rising cesarean rate is likely a reflection of both rising primary cesarean delivery rates and decreased vaginal birth after cesarean delivery.

Given the limited availability of TOLAC services for women in the Oklahoma service area, efforts should be made to minimize the primary cesarean delivery rate. The decision to lower the threshold for primary cesarean delivery as evidenced by an acceptance of the high rate and an unwillingness to look at physician specific factors will result in higher adverse outcomes in future pregnancies 3, particularly when combined with the lack of TOLAC services. Women in the Hastings area with primary cesareans can be anticipated to have cesareans in all future births placing them at increased risk for placenta accreta, increta and percreta 5. These complications of abnormal placentation may be particularly difficult to address in a rural community hospital setting.

Although Healthy People 2010 does not include a recommendation for the total cesarean rate due to varying patient factors, it recommends that efforts be made to decrease the primary cesarean rate to 15% in women who are giving birth for the first time 6. ACOG similarly recommends that comparative cesarean delivery rates for populations, hospitals, or physicians should be based on the subgroup of nulliparous women with term singleton vertex gestations 7. We would be interested in seeing the rate for this population at those affected facilities in Oklahoma Area.

We worked in at the Gallup Indian Medical Center (GIMC) and Zuni-Ramah Hospitals in the 1990s and continue to work with Native populations in Albuquerque and New Mexico. Our study of the population based CS rate in Zuni-Ramah in the 1990s demonstrated a 7.3% cesarean rate despite an incidence of diabetes and hypertensive disorders well above national rates 8. Physician specific practices influence cesarean delivery rates 9. We believe that the cesarean delivery review initiated at GIMC in the early 1990s was important in identifying factors in patient management that can result in a high cesarean rate.

An important ingredient in reducing cesarean delivery, either in nulliparous or parous women, is to place value on vaginal delivery. The attitude that “None of the physicians in our department are concerned with our cesarean delivery rate” may prove the largest stumbling block in developing strategies more consistent with national goals.

We suggest that the maternity care providers in Hastings present the evidence for improved maternal outcomes in women with prior vaginal delivery to their anesthesia colleagues and make TOLAC available at least for this group of women. Addressing the high total (and presumably) primary cesarean rates will require analysis of the indications and physician specific patterns. Given the increasing evidence for adverse outcomes with multiple repeat cesareans and the limited ability of community hospitals to address problems with placenta accreta, increta and percreta, we support labor management strategies to reduce cesarean rates in the Native American population in the Oklahoma Area and nationwide.

OB/GYN CCC Editorial comment:

An argument for better teamwork: Trial of labor after cesarean in Indian Country

First, I want to thank the leaders of the Indian Health Midwives listserv for raising these important issues, as this discussion was originally begun in the Midwives Corner feature. Though the current discussion revolves around Indian Health facilities, it is reflective of most small rural hospitals and increasingly some larger urban facilities.

Next, the availability of the trial of labor after cesarean option is really a ‘systems’ issue not just a problem confined to midwives or physicians. To decrease the long term morbidity and mortality associated with cesarean rates that now exceed 40%, we need to approach this issue systematically. Specifically, how can we engage our Indian Health administrative staff to foster an environment whereby anesthesia, pediatric, and nursing services work together with the provider staff to decrease excess morbidity in Native women.

Should you offer vaginal birth after cesarean delivery at your facility?

Should your referral facility be offering VBAC?

Let’s put some of the above issues into perspective.

What are just a few of the risks that you should currently handle very well:

In all but one of the above cases the incidence of these obstetric emergencies is actually increasing each year.

If you can’t provide VBAC because of the 0.5% risk of uterine rupture, then should your facility be offering intrapartum care at all? [emphasis theirs]

If you work at a facility that can not develop a rapid response for a clinical issue like symptomatic uterine rupture in a VBAC setting, which happens ~0.5 percent of the time, then your facility, should re-evaluate its ability to manage obstetric intrapartum care.

Taken on their own individual merit, most of the above common urgencies and emergencies occur more frequently than 0.5 percent. Taken as an aggregate, the risks above far outweigh the risks of VBAC. Now seeing the above risks, if you feel you need to re-evaluate offering obstetric intrapartum care because the above risks, then please contact me as soon as possible.

For those facilities that feel they are able to continue to offer obstetric intrapartum care within the risk environment above, then I would suggest a program of emergency obstetric drills, pan-ALSO** certification for all nurses and providers, and an ongoing quality assurance.

Each of the last three national Indian Women’s Health and MCH Conferences has devoted significant blocks of lecture time and workshops to improve systems of care and specific content updates. (Link to Meeting Lecture notes below)

Lastly, there seems to be some confusion as some providers at times combine the risk of a TOLAC sequela vs the relative success of a vaginal birth in TOLAC. These are two separate issues that need to be discussed with our patients separately for a fully informed consent.

1.) Success of vaginal delivery

Overall the rate of successful vaginal delivery in TOLAC is actually quite high, often in the range of 75% in the general population, and much higher success rate in the AI/AN population at 85-90% over the years.

A previous successful VBAC is probably the best predictor of future success; about 90 percent of such women deliver vaginally with trial of labor. By comparison, women delivered abdominally for dystocia are least successful, although approximately two-thirds are delivered vaginally.

Among the previous dystocia group, the success rate is higher if cesarean delivery was performed in the latent phase of labor and lower if performed after full dilatation. Within the former group, 79% of women who originally had surgery while still in the latent phase of labor had a successful trial of labor, compared with 61% of patients who had an arrest of dilation in the active phase of labor and 65% of those who had an arrest of descent. (Duff et al Obstet Gynecol 1988 Mar;71 (3 Pt 1):380-4.)

Multivariate logistic regression analysis identified as predictive of TOL success: previous vaginal delivery (OR 3.9; 95% CI 3.6-4.3), previous indication not being dystocia (CPD/FTP) (OR 1.7; 95% CI 1.5-1.8), spontaneous labor (OR 1.6; 95% CI 1.5-1.8), birth weight <4000 g (OR 2.0; 95% CI 1.8-2.3), and Caucasian race (OR 1.8, 95% CI 1.6-1.9) (all P < .001).

The overall TOL success rate in obese women (BMI > or = 30) was lower (68.4%) than in nonobese women (79.6%) (P < .001), and when combined with induction and lack of previous vaginal delivery, successful VBAC occurred in only 44.2% of cases. (Landon et al The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol. 2005 Sep;193(3 Pt 2):1016-23. )

The combination of previous cesarean for dystocia, no previous vaginal delivery, and induced labor had a particularly poor prognosis in the Flamm system, e. g., fewer than 50 percent of such women achieved a successful TOL.

A decision analysis model favored TOL if the chance of success was >50 percent and if the desire for additional pregnancies was 10 to 20 percent. (Mankuta et al Am J Obstet Gynecol 2003 Sep;189(3):714-9.)

Trial of labor success rates: obstetrical and historical factors

All overall P values are <.001; for categorical characteristics, only the comparison of birth weight <2500 g to 2500 to 3999 is not significant (P=.33).
CI: confidence interval; CD: cesarean delivery; VBAC: vaginal birth after CD; NRFWB: nonreassuring fetal well-being.
* Women with this characteristic served as the reference group.
Modified from: Landon, MB, Leindecker, S, Spong, CY, et al. Am J Obstet Gynecol 2005; 193:1016.

Flamm scoring system tool

FTP: failure to progress.
Data from: Flamm, BL, Geiger, AM. Obstet Gynecol 1997; 90:907.

2.) Risks:

Numerous risk factors have been cited for uterine rupture during labor in women with a previous CD. However, these risk factors are not consistent across studies, which are generally hampered by small numbers of patients with uterine rupture. Unfortunately, no single factor or combination of risk factors is sufficiently reliable to be clinically useful for prediction of uterine rupture.

Purported risk factors include maternal age greater than 30 years, induction of labor, more than one prior CD, postpartum fever, interdelivery interval less than 18 to 24 months, dysfunctional labor, and one layer uterine closure. Within this framework of incomplete data the New England Perinatal Quality Improvement Network (NNEPQIN) has developed a system to appropriately manage the risks.

Low Risk Patient:

• 1 prior low transverse cesarean delivery
• Spontaneous onset labor
• No need for augmentation
• No repetitive FHR abnormalities
• Patients with a prior successful VBAC are especially low risk.
  (However, their risk status escalates the same as other low risk patients)

Medium Risk Patient:

• Induction of labor
• Pitocin augmentation
• 2 or more prior low transverse cesarean deliveries*
• < 18 months between prior cesarean delivery and current delivery

High Risk Patient:

• Repetitive non-reassuring FHR abnormalities not responsive to clinical intervention. /li>
• Bleeding suggestive of abruption
• 2 hours without cervical change in the active phase despite adequate labor

* NB: ‘Two prior uterine scars and no vaginal deliveries’ is listed as a circumstance under which trial of labor should not be attempted by the American College of Obstetricians and Gynecologists ACOG Practice Bulletin No. 54, ‘Vaginal birth after previous cesarean delivery’.

Here is a suggested management system per NNEPQIN

Low risk

Notify Pediatrics, Anesthesia, and operating room crew of admission
OB/GYN on campus during active phase
Perinatal Guidelines of Care, ACOG, observed

Medium risk

Notify Pediatrics, Anesthesia, and operating room crew of admission
Operating room on campus in active phase or other plan if crew is busy

High risk

OB/GYN, Anesthesia, and Pediatrics available
No other acute care responsibilities
Rapid decision to incision

Please see the Midwives Corner and Oklahoma Perspective, below, for further discussion on this topic. A complete discussion of risk, benefits, and systems issues is available in the Perinatology Corner module: Vaginal Birth after cesarean http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/VB01.cfm

Other Resources:

Vaginal birth after cesarean (VBAC) in rural hospitals Counterpoint: David Gahn, M.D.

http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#MidWives

New England Perinatal Quality Improvement Network (NNEPQIN)

http://www.nnepqin.org/

Indian Health Meeting lecture notes

http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm

OB Emergency Drills in Indian Country

http://www.ihs.gov/medicalprograms/mch/F/documents/OBEmergDrills.ppt

2007 Indian Health Data Summary (Deliveries, VBAC rates, etc…)

http://www.ihs.gov/MedicalPrograms/MCH/F/documents/DataTally81107.doc

** ALSO = Advanced Life Support in Obstetrics

http://www.aafp.org/online/en/home/cme/aafpcourses/clinicalcourses/also.html

Leeman and Espey References:

1 Cahill AG, Stamilio DM, ADibo AO, Pelpert JF, et al. Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol 2006; 195:1143-7.

2 Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2006. National vital statistics reports; vol 56 no 7. Hyattsville, MD: National Center for Health Statistics. 2007.

3 Kennare R, Tucker G, Heard A, Chan A. Risks of adverse outcomes in the next birth after a first cesarean delivery. Obstet Gynecol 2007; 109:270-6.

4 Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107:1226–32.

5 Getahun D, Oyelese Y, Salihu HM, Ananth CV. Previous cesarean delivery and risks of placenta previa and placental abruption. Obstet Gynecol 2006;107:771–8.

6 U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.

7 American College of Obstetricians and Gynecologists, Task Force on Cesarean Delivery Rates. Evaluation of cesarean delivery. Washington, DC: American College of Obstetricians and Gynecologists, 2000.

8 Leeman L, Leeman R. A Native American community with 7% cesarean delivery rate: Case mix analysis, risk factors and operative indications. Ann Fam Med. 2003;1:36-43.

9 Luthy DA, Malmgren JA, Zingheim RW, Leininger C. Physician contribution to a cesarean delivery risk model. Am J Obstet Gynecol. 2003;188:1579-85

Cahill AG, Stamilio DM, ADibo AO, Pelpert JF, et al. Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol 2006; 195:1143-7.

******************************

February 18, 2008

Dear _________,

I am a mother of a toddler who was born by cesarean. I recently moved to the area and was disappointed to learn that in 2003, [Hospital] system banned vaginal birth after cesareans (VBACs). According to [a local newspaper] article that covered the decision,

The American College of Obstetricians and Gynecologists recommended in 1999 that physicians, including an anesthesiologist, be ‘immediately available’ 24 hours a day at any facility that sanctions a so-called VBAC [...] [Hospital] cannot meet the staffing standard…. ‘Very few hospitals outside of universities are going to be offering this.’ The prime concern is that during labor a woman’s uterus can rupture along her existing C-section scar line. Critics are quick to note what several sources report — that such tears happen less than 1 percent of the time. [...] ‘The problem is when things go awry, things change immediately and that could be a dramatic outcome for the mother or the baby.

Recent research shows the risk of uterine rupture among women with one prior low uterine segment cesarean in spontaneous, naturally occurring labors to be about 0.5%.

I have several concerns about this situation that I hope you will address:

• Women go to hospitals to give birth because they often feel that a hospital is best equipped to handle birth emergencies. According to the [Hospital] website, the hospital handles 2400 births a year. I am concerned that if [Hospital] can’t meet the staffing standard for VBACs, that means the hospital doesn’t have the ability to perform an emergency cesarean 24 hours a day/seven days a week. If the hospital cannot accommodate a medical emergency such as uterine rupture, how can they respond and treat other real, but rare, labor emergencies such as cord prolapse (approximately 0.14-0.62% of births) or placental abruption (approximately 0.65% of births), both of which require the baby to be born ASAP usually by immediate cesarean sections?
• The cesarean rate in this country has risen well above the World Health Organization’s recommended rate of 10-15%. According to [a newspaper] article from 2003, at that time approximately 28% of births at [Hospital] were cesareans. Add to that the approximately 4% that were VBACs but are now required repeat cesareans and you get a 32% cesarean section rate — more than twice that recommended by the WHO. Healthy People 2010 recommends a reduction in cesarean births in the US to 15% by 2010. I am concerned that the cesarean rate in [our city] is so high, because cesareans are not risk-free operations, and I would like to know what the hospital is doing to address the over use of cesareans.
• I am concerned that [Hospital] is understating the risks of primary or subsequent cesarean surgeries yet exaggerating the risks of VBAC. Cesareans pose serious risks to mothers, including two to four times a greater chance of maternal death, increased risk of emergency hysterectomy, injury to blood vessels and other organs, chronic pain due to internal scar tissue, increased chance of re-hospitalization and complications involving the placenta in subsequent pregnancies. Cesareans also pose risks to the infant, including an increased risk of respiratory distress syndrome, prematurity, the development of childhood asthma, and a 1-9% chance the baby will be cut during surgery. The recovery from a cesarean is much longer than for a vaginal birth, involving more pain, more difficulty establishing breastfeeding, and a longer hospital stay.

I understand that having an anesthesiologist at the hospital at all times is expensive, and cannot be billed to a patient’s insurance unless he or she ends up being needed. However, I am concerned that emergency anesthesia should be available at all times if [Hospital] is going to be a safe place for women to be in labor and deliver babies.

As suggested by the 2003 article, I understand that fear of litigation drives a decision to ban VBAC in many hospitals. However, many hospitals have women who want to attempt a VBAC sign a form stating that they understand the risks of VBAC. Could [Hospital] do this?

Giving birth is a life-changing event in the life of a woman. She needs to be able to work with her care provider to make decisions that are best for her so that she will feel good about the experience for the rest of her life. With the exception of the VBAC ban, I have heard good things about the birth centers in the [Hospital] system. I hope that you will re-examine this policy and give women who have had a previous cesarean and are candidates for VBAC the chance to choose between VBAC and repeat cesarean. Thank you for taking the time to consider my request. I would like to follow up with you with a phone conversation next week and I look forward to hearing your thoughts on this matter.

Sincerely,

___________________

More options for women

The front page of the Jan. 20 St. Louis Post-Dispatch featured women birthing at home with midwives. The legalization of home birth midwives is a hot topic around the nation. States like Missouri and Illinois are considering licensure of certified professional midwives.

The Post did a great job highlighting birth choices. I would like to see the Belleville News-Democrat report a similar story regarding local birth options as well as how choices are becoming limited.

Do newspaper readers know that three area hospitals have banned vaginal births after cesareans, essentially coercing women into surgery? In December, the Centers for Disease Control reported the 2006 figures for births by cesarean at a national high of 31.1 percent. In 2005, 32.4 percent of births in St. Clair and Madison counties were cesareans. Local VBAC bans contribute to increases.

Perhaps with mainstream media coverage of a variety of birthing environments, more consumers will request choices. Many obstetricians today do not follow the American College of Obstetricians and Gynecologists guidelines or practice evidence-based medicine with regard to labor induction or cesarean delivery for low-risk pregnancies. If malpractice concerns preclude Illinois obstetricians and hospitals from practicing evidence-based medicine, women should be referred elsewhere.

Julie Herr

Belleville

For Maryland residents: Just click on this link and look up who your Maryland state delegates are. This bill is before the House so you are only writing to your delegates and not your senators.

For those living outside of Maryland, send your letter to the
Committee Health and Government Operations Committee (HGO)
Room 241, House Office Building, Annapolis, MD 21401-1912
(410-841-3770 Annapolis/Baltimore or 301-858-3770 Washington, D.C.)
Chair: Peter A. Hammen

Then, write them a letter. I have copied mine below. Make it your own
using portions of mine if you want to.

Address them properly and mention HB 1407 in the letter. You can send your letter today and/or copy your letter and fax it or email it to Mairi Rothman, CNM at 240-485-1818 so she can mail a copy of all of the letters out at the recommended strategic moment, about 3-4 days before the hearing of the bill (tentatively scheduled for 3/14).

Thank you!

=======================================================

Email Subject Line: Letter regarding HB 1407

February 21, 2008

The Honorable Put Delegate’s Full Name Here
Lowe House Office Building
Annapolis, MD 21401-1991

Dear Delegate Last Name Here:

This letter is to inform you that for the sake of Maryland women’s health care, you must support House Bill 1407, the Birth Options Preservation Act. This bill opens access for women to care by
Certified Nurse Midwives (CNM). Evidence demonstrates equal to superior care is provided by midwives. Women are consistently more satisfied with the clinical and holistic approach of their midwives.

As a childbirth educator and mother, I have used midwifery care both for well-woman care and in childbirth. I have very safe, happy and healthy pregnancies and childbirth experiences at a birth center. When there was any doubt that my first pregnancy might need medical assistance, I was referred to a perinatologist (high risk OB) for co-management and care. Fortunately, in the end, I did not need medical assistance but was grateful that my midwife referred me for medical monitoring to be on the safe side. CNMs are experts in women’s health care through the childbearing years and beyond. They are professionally bound by the Standards of Practice of the American College of Nurse Midwives. They are ethically and clinically prepared and qualified to collaborate and refer to medical care when appropriate.

The Maryland Board of Nursing in its requirement for physician signature to obtain a license has been a barrier to women’s access to midwives. Please support and pass this bill for the good of Maryland families. Show CNMs the same respect for our profession that the women we care for already demonstrate. Give Maryland women access to the health care that they desire and deserve.

I still remember the day you handed out information asking for my vote on the streets of Hampstead one warm summer day. I hope you will listen to my voice and the voice of others and fight for women’s rights to the best health care which must include midwives and better access to them!

Thank you for your efforts and thank you for listening.

Yours in birth,
Jessica Groves
Hampstead, MD

Bradley Method Childbirth Educator & Birth Doula
Trusting Our Bodies

The strength of this letter lies in a few key pieces of information.  First, it cited state law.  Research the laws in your state as they relate to midwives as some states compel insurance companies to cover midwives.  Also, research your state laws to see how they handle gaps in insurance coverage.  If your insurance does not have a contracted home birth midwive within your area, you can argue that there is a gap of coverage and thus appeal to your insurance to cover the home birth midwife you hired.

Second, cost effectiveness.  Homebirths are less expensive than hospital births and since insurance companies are all about reducing costs, this should be compelling to them.  The typical hospital vaginal birth runs about $7,000 which is way more than the typical homebirth midwife who charges between $2,000 – $4,000. 

Third, homebirth is a healthier option by eliminating the elevated risk of cesarean section one faces simply by setting foot in a hospital, eliminating all the risk that routine hospital procedures introduce, as well as eliminating the chance of catching a hospital acquired infection such as MRSA.

**************************************8

December 7, 2007

CIGNA Health Care
National Appeals Unit
P.O. Box 5225
Scranton, PA 18505-5225

Dear Sir or Madam:

This letter is in response to the denial of coverage for the prenatal care, labor and delivery, and post partum care surrounding the birth of my daughter XYZ on MM/DD/YY.

At the time that my wife and I started attempting to conceive in mid 2006, CIGNA was contracted with an out of hospital group of midwifes called ABC. This was the group that we used when my son was born and we found them to be an excellent alternative to the costly hospital birth. We found out later in the year, after my wife was four months pregnant, that ABC would be closing at the beginning of the year, more than four months prior to my daughter’s birth. At this point I contacted CIGNA to determine what other non hospital birth option would take their place. I was told that whatever contract changes would be made would probably not be in place in time for our birth.

This gap in coverage in our area (since there are non hospital midwife options outside our area) forced us to decide weather the healthiest option would be a hospital birth or out of network midwife. Due to the many health issues surrounding a stay in the hospital, from sleeplessness to super bugs like MRSA, we determined that the healthiest and most cost effective birth option was homebirth with an attendant midwife.

I understand that in contracting with ABC CIGNA was trying to provide an in network provider in Orlando that was commensurate with the in network providers in other areas of Central Florida. I also understand that the gap in coverage created by the closing of ABC was unforeseen by CIGNA. I do believe that this kind of gap in coverage is covered here in Florida under Florida Statute 627.6471 which states:
“If any service or treatment is not within the scope of services provided by the network of preferred providers, but is within the scope of services or treatment covered by the policy, the service or treatment shall be reimbursed at a rate not less than 10 percentage points lower than the percentage rate paid to preferred providers. The reimbursement rate must be applied to the usual and customary charges in the area.”

Here in Florida, the desire to have a more natural birth, either using a birthing center or a Certified Nurse Midwife, is clearly evidenced by other Florida Statutes like 627.6406 which states that:
(1) Any policy of health insurance that provides coverage for maternity care must also cover the services of certified nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed under ss. 383.30-383.335.

Clearly it is in the best interest of my company to keep costs low for health insurance. The cost for an OB/GYN to do the prenatal care, a hospital birth with attending physicians, and the following
stay in the hospital, would clearly have cost 3 times the $3100 I had to pay for the care and delivery of my daughter. And that’s if nothing went wrong.

It seems that it would be in the companies best interest to facilitate this less expensive option any time it is medically feasible to do so. I don’t know how the delivery would have gone if we had acted solely on financial decisions and gone to a hospital. I’m sure it would not have been anything like the birth we experienced. With a 33% rate of cesarean births here in Florida there is a very good chance it would have involved surgery. What I do know is that at one week shy of six month old, my daughter has pulled herself up to standing for the first time. I could not ask for a healthier, happier baby or a quicker more complete recovery for my wife. These are the reasons that this option is so important to the people here in Florida and to us specifically.

Thank you for reconsidering coverage of the birth of my daughter.
Sincerely,

Cc: (name removed), Human Resources
Enc: Midwifes notes

In California, you can have a home VBAC with a midwife if you exercise your right of informed refusal.  Simply write a letter stating that you understand the risks of VBAC/HBAC and then your midwife puts it in your file.  This process is even made more simple because you can use the letter I wrote below as a template.

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May 15, 2007

To Whom It May Concern:

This is a letter expressing my desire to evoke my right of informed refusal and have a homebirth midwife, L, attend my VBAC (vaginal birth after cesarean) this coming November/December 2007.

I understand the risk of uterine rupture and that I could be statistic. I also understand I have over a 99% chance of not experiencing uterine rupture.

I understand that the risk of rupture among women with one prior low uterine segment (”bikini cut”) cesarean in spontaneous, naturally occurring labors to be about 0.4%. (Landon 2004) Some studies have found the risk to be even smaller at 0.12%. (Gonen 2006)

I understand that labors induced or augmented with Pitocin or Cervidil have rupture rates two to three times higher. (Landon 2004)

I question a medical system that simultaneously discourages women from VBAC by warning them how risky VBACs are, yet voluntarily increases the risk by inducing VBAC women.

I question a medical system where obstetricians can induce VBACing women with Cytotec, with no evidence showing that it is safe, resulting in rupture rates 28 times higher than rupture rates in labors without Cytotec inductions (Plaut 1999) resulting in unnecessary and unfortunate ruptures and infant deaths.

I believe that uterine rupture will be diagnosed faster by having a midwife’s eyes, ears, and hands focused on me rather than an L&D nurse’s attention divided amongst several EFM machines.

I believe that within the midwifery model of care, a women’s experience and intuition is given more respect than a machine that goes ping.[1]

I question a medical system that does not distinguish between true uterine rupture and uterine dehiscence when discussing the risk and outcomes of uterine rupture.[2]

I question a medical system that minimizes the risks of primary or subsequent cesarean surgeries yet exaggerates the risk of VBAC. Few women who undergo an elective cesarean section understand the variety of risks or know that they have a 3.6 greater risk of dying over vaginal birth (Deneux-Tharaux 2006) or that their baby’s chances of being admitted to the NICU or developing a pulmonary disorder doubles with a cesarean section. Babies born by elective cesarean section have a 10% chance of being admitted to the NICU or a 1.6% chance of developing a pulmonary disorder. (Kolas 2006)

I question a medical system that minimizes the risk of amniocentesis yet exaggerates the risk of VBAC. The risk of miscarriage from amniocentesis is 0.5%.[3] Miscarriage is death of a baby.  Compare that to the approximate 0.5% risk of uterine rupture in a one-prior bikini cut cesarean section in an non induced/ augmented VBAC.[4] Rupture does not equal death, but miscarriage does.  Yet the March of Dimes describes the risk of miscarriage vis-à-vis aminos as “small” while the number of VBAC-friendly hospitals decrease.

I question a medical system that changes policy solely based on the non-scientific or tested recommendations provided by the professional organization ACOG.[5] ACOG has recommended that hospitals attending VBACs be “equipped to respond to emergencies with physicians immediately available to provide emergency care”[6] which has resulted in many hospitals “banning” VBACs. If hospitals cannot accommodate a medical emergency such as uterine rupture, how could they possibly respond and treat other real, but rare, labor emergencies such as cord prolapse or placental abruption, both of which require the baby being born ASAP usually by immediate cesarean sections?  How could any mother labor in confidence knowing that if something went drastically wrong, that hospital could not quickly respond?

I understand that if “things go downhill fast,” I may be out of luck. I also understand that if I or MIDWIFE sense or determine any trouble at any time I can transfer to HOSPITAL which is 4 miles from my residence.

I understand that “while ACOG has recommended in the past that the ‘decision to incision’ time be no more than 30 minutes, in one study at a university hospital in the United States, (Chauhan 1997) 52 percent of the emergency cesarean sections for fetal distress had a decision to incision time that exceeded 30 minutes.”[7]

I understand that despite the fact the USA has the best technology and spends the most money in the world on medical care, we have the second highest infant mortality rate in the developed world[8] and rank 40^th in maternal mortality rates.

I understand that the countries with the lowest infant and maternal mortality rates utilize midwives for normal, healthy pregnancies and only engage the services of an obstetrician when a pregnancy becomes high-risk. (Born in the USA by Marsden Wagner, MD)

I understand the risks of birthing in the hospital by becoming part of the “birthing machine” through submitting to hospital protocols and “standard of care” procedures that introduce more risk than benefit when routinely performed on all women regardless of medical necessity.

I would rather open myself to the risks present in homebirth in order to reap the benefits of birthing at home, than expose myself to the risks present in the hospital.

Sincerely,

VBAC Mom

[2] “To accurately asses the risk of VBAC, it is necessary to differentiate between complete or true uterine rupture and incomplete rupture, often termed occult rupture or uterine dehiscence.  True uterine rupture is often sudden and associated with pain, blood loss and fetal morbidity.  It is most commonly seen in spontaneous or traumatic rupture of the unscarred uterus.  It also has been associated with classic uterine scars, often occurring without labor.  Conversely, uterine dehiscence is partial separation of the uterine wall that is usually asymptomatic and rarely contributes to fetal or maternal morbidity.  This is often the type of separation seen in lower segment scars, and usually occurs during labor.  Often asymptomatic windows are incidentally noted at the time of repeat cesarean section.” From OB/GYN Secrets by Wilkins-Haug & Fredrickson.  Section 77 VBAC by Robert Silver MD.

[3] March of Dimes. Amniocentesis. http://search.marchofdimes.com/cgi-bin/MsmGo.exe?grab_id=0&page_id=1061&query=amniocentesis&hiword=amniocentesis%20

[4] “True uterine rupture is typically distinguished from asymptomatic scar separation (dehiscence) by the need for emergency surgery, although some reports combine these separate processes and confuse the statistics.  The rate of true uterine rupture with one prior low-transverse scar has been reported by ACOG to be between 0.2 and 1.5 percent (one of 67 to 500 women).  Other studies involving more than 130,000 women undergoing a trial of labor for VBAC report rates that average 0.6 percent (approximately one of every 170 women).”  (Toppenberg 2002)

[5] What Every Midwife Should Know About ACOG and VBAC: Critique of ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section” by Marsden Wagner, MD, MSPH http://www.midwiferytoday.com/articles/acog.asp

[6] ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section” “Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”

[7] What Every Midwife Should Know About ACOG and VBAC: Critique of ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section” by Marsden Wagner, MD, MSPH http://www.midwiferytoday.com/articles/acog.asp

[8] Per study by Save the Children. http://www.cnn.com/2006/HEALTH/parenting/05/08/mothers.index/index.html