Category Archives: Advocacy

What I told the California Medical Board about home VBAC

california state seal

A little backstory

Back in October, I attended my first Interested Parties Meeting held by the Medical Board of California regarding new midwifery regulations as required by AB1308. (Read more about AB1308 here and here.)  Up for discussion was which conditions or histories among women seeking a home birth with a Licensed Midwife should be required to obtain physician approval.  A prior cesarean was on the list of over 60 conditions or histories and home VBAC was the one subject that generated the most comment and discussion that day.

What does AB1308 mean in terms of home VBAC in California?

There has been a lot of confusion regarding what AB1308 means in terms of home VBAC in California. In an effort to clear things up, Constance Rock-Stillman, LM, CPM, President, California Association of Midwives said this on January 23, 2014:

AB 1308 went into effect on 1/1/14, but there is nothing in the new legislation that says we [CPM/LMs] cannot do VBACs. We can do VBACs. We just need to define in our regulations what preexisting conditions will require physician consultation. [Which is what the October 15 and December 15th Interested Party meetings were about.] Until the new regulations are written we should continue to follow our current regulations and they only require us to provide certain disclosures and informed consent to clients.

Please let the community know that if they want to have a say in whether or not VBACs with Ca LMs require a physician consultation, they should come to the Interested Parties meeting that the medical board will be holding and tell the board how they feel about it. The medical board is a consumer protection agency, so they need to hear what consumers want to be protected from.

We will let you know as soon as the meeting is scheduled.

[Ms. Rock-Stillman responds when questioned by those who have not been involved it the creation of this legislation yet insist this legislation removes the option of home VBAC entirely:]

I’m in my third year as president of the California Association of Midwives, and I’m a practicing licensed midwife. I have been at every Midwifery Advisory Counsel meeting, at the Capitol 30 times last year, I’ve spoken in legislative committee hearings, I’ve sat in weekly meetings with CAM’s legal counsel who worked side-by-side with us on the legislation, I’ve been in Assemblywoman Susan Bonilla’s boardroom with ACOG and at every one of the public events where Susan Bonilla promised that the LMs would still be able to do VBACs. So I think I qualify as a knowledgeable stakeholder in this issue. Yes, we intentionally left VBAC out of the list of prohibited conditions, so at this point there is no question as to whether or not we can do VBACs. The only part that’s in question is whether or not all VBACs will require physician consultation. Regulations that clarify under what circumstances physician consultation will be required will be written by the California Medical Board.  This is a process that takes time. Maybe even a year or more. The regulations that will be adopted will be based on evidence and input from all the stakeholders. This is why I think it’s so important that midwives and consumers be at the meetings to insure their voices get heard. At the last Interested Parties meeting that the medical board held, I asked what we were suppose to do until the new regulations are written and we were told that we should follow our current regulations and our community standards until new regulations are adopted.

Why I attended

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My intention in attending the October 15, 2014 meeting was to amplify the voice of the consumer.  I think sometimes it’s difficult for OBs who attend VBACs, or for those who live in communities where they have access to hospitals that allow VBAC, to understand that not everyone lives in that world.

Some live in a world where if they want a VBAC in a hospital with a supportive midwife or doctor who takes their insurance, that means driving over 50 miles each way for prenatal care and delivery while they literally drive by other facilities that offer labor and delivery, but ban VBAC.  Or it means acquiescing to a unnecessary repeat cesarean whose risks compound with every surgery. Or it means planning an unassisted birth which comes with its own set of risks. This is a tremendous burden.

As VBAC and repeat cesarean both carry risks and benefits, and women are the ones who bear and endure those risks, they should be the ones who choose which mode of delivery is acceptable to them. I celebrate when women have access to supportive hospital-based practitioners.  But the reality is, many women do not enjoy that privilege and yet they still wish to avoid the serious complications that come with each cesarean surgery.

Who else was at the meeting?

Other people in the room included the Senior Staff Counsel of the Medical Board, an OB-GYN representing ACOG, an ACOG lobbyist, Constance Rock-Stillman along with many other CAM representatives and midwives, California Families for Access to Midwives, a few other consumers, and me. Senior Staff Counsel was tasked with writing these regulations and as the meeting progressed, items were reworded or removed from the list.

Below is the five minute presentation I prepared and presented to the Medical Board on October 15, 2014.  As there was a limited time to speak, I sent a follow-up letter to the Medical Board which goes into more depth. I’ll be posting that soon.

My statement

Today I’m speaking on behalf of consumers regarding the importance of out of hospital VBAC. I will be focusing on the impact of requiring women seeking out of hospital VBAC to obtain physician approval. This proves problematic because very few physicians, if any, would be willing to sign off on a home VBAC due to liability concerns. This would effectively cut off the option of a vaginal delivery for many women throughout our state.

I’m Jennifer Kamel, Founder of VBAC Facts, an organization which seeks to close the gap between what best practice guidelines and the evidence says about VBAC vs. repeat cesarean and what people generally believe.

Some people may think reducing access to out of hospital VBAC is not a big deal. But 44% of California hospitals ban VBAC (Barger, 2013) despite the American College of OBGYNs (2010) and the National Institutes of Health’s (2010) assertion that VBAC is a safe, reasonable, and appropriate option for most women.

ACOG (2010) is clear, “Respect for patient autonomy argues that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.” But this recommendation is simply ignored by many facilities.

Consumers report that many facilities provide incomplete or misleading informed consent, maintain a strict VBAC ban, and ignore ACOG’s comments denouncing forced cesareans.  These facilities led women to believe that a repeat cesarean is their only option.

As a Sacramento area OB-GYN resident recently shared, “There is the routine overplaying of the risks of VBAC, and failure to mention the risks of repeat cesareans, or that ACOG considers VBAC safe and reasonable.”

With the cloud of legal liability hanging over our heads, I wonder about the culpability of the many facilities whose hospital policies mandate repeat cesareans and forbid VBACs yet who are also unprepared to manage the serious consequences of multiple repeat cesarean sections including placenta accreta, cesarean hysterectomies, and hemorrhage. (Heller, 2013)

VBAC is successful about 75% of the time, most women are candidates (ACOG, 2010), about half of women are interested in the option (Declercq E. R., Sakala, Corry, Applebaum, & Herrlick, 2013), and VBAC results in lower maternal morbidity and mortality rates in the current delivery as well as in future deliveries. Yet, VBAC is simply not occurring in many communities throughout the state of California resulting in a 9% VBAC rate statewide. (State of California Office of Statewide Health Planning and Development, 2013)

According to Barger (2013), a study looking at the prevalence of VBAC bans in California, “Among the 56% [of hospitals that offer trial of labor after cesarean or TOLAC], the median VBAC rate was 10.8% (range 0-37.3%)…According to the nurses surveyed, we found that about half of hospitals with continuous anesthesia coverage did not offer TOLAC, not because of an explicit hospital policy against it, but because physicians were unwilling to stay in the hospital with a woman attempting TOLAC.”  So even in facilities that offered VBAC, attaining one and avoiding surgery can be elusive.

It is within this climate that women choose out-of-hospital VBAC. For many women in the state, VBAC is simply not a viable option at their local facility. Barger (2013) found that “The mean distance from a non-TOLAC to a TOLAC hospital was 37 mi. [as the crow flies] with 25% of non-TOLAC hospitals more than 51 mi. from the closest TOLAC hospital. In 2012, 139 hospitals offered TOLAC, [which was] 16.6% fewer than in 2007.” So the trend is moving towards fewer hospitals offering VBAC.

For some women traveling to a hospital that offers VBAC and accepts their insurance is a huge burden consisting of coordinating work and school schedules, vacation and sick time, and the cost of travel and child care. We do not want to be in a position where state troopers are attending births on the side of the road.

As Dr. Elliott Main (2013), Medical Director of the California Maternal Quality Care Collaborative (CMQCC), has stressed, “In California, we are seeing a lot of hysterectomies, accretas, and significant blood loss due to multiple prior cesareans. Probably the biggest risk of the first cesarean is the repeat cesarean.”

Women should not feel like home VBAC is their only option, but for too many women their choice is limited to home VBAC or repeat cesarean. If a hospital VBAC is not a possibility and the choice of out-of-hospital birth is removed, that essentially forces women into either unwanted and unneeded repeat cesarean surgery, and the increasing risks that come with multiple prior cesareans, or into unassisted home births where they deliver without an midwife or doctor.

In light of the recommendations made by ACOG and the NIH and the realities of increasing maternal morbidity rates in the state of California due to multiple repeat cesarean sections, the objective should be making VBAC more accessible, not less.

Bibliography

American College of Obstetricians and Gynecologists. (2010, August). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116(2), 450-463.

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy Childbirth. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636061/pdf/1471-2393-13-83.pdf

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlick, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved from http://www.childbirthconnection.org/article.asp?ck=10450

Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44571/

Heller, D. S. (2013). Placenta accreta and percreta. Surgical Pathology, 6, 181-197.

Main, E. (2013). HQI Regional Quality Leader Network December Meeting. San Diego.

National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm

State of California Office of Statewide Health Planning and Development. (2013, December 17). Utilization Rates for Selected Medical Procedures in California Hospitals, 2012. Retrieved from http://www.oshpd.ca.gov/HID/Products/PatDischargeData/ResearchReports/Hospipqualind/vol-util_indicatorsrpt/

Home VBAC threatened for California families

There has been a lot of confusion regarding AB1308, the legislation that went through at the beginning of this year in the state of California. It said that LMs were no longer allowed to attend home births some situations (such as breech, beyond 42 weeks gestation, etc) and other situations required a physician to sign off on the home birth.

It’s these regulations that are currently being written by the Medical Board with input from ACOG, CAM, CFAM, and VBAC Facts. It is under discussion whether a prior cesarean should be included on this list of conditions that would necessitate a physician’s approval in order for the woman to plan a home VBAC.

On October 15, 2014, I flew to Sacramento and attended a Interested Parties Meeting at the California Medical Board.  I spoke on behalf of California women who want home VBAC to remain an option in our state. You can read a summary of that meeting here and listen to a partial recording of the meeting here.

There is going to be another meeting on December 15th from 1-4pm in Sacramento (agenda) and I will be there once again representing consumers.  I will be preparing a short testimony.  If you are a California resident and would like to attend the meeting, please do.  If you can’t, but want your voice to be heard, please email me the following information:

1. Why home VBAC is important to you

2. Your name

3. Your county

More information from the California Association of Midwives and California Families for Access to Midwives

 

Some people think I’m anti-this/ pro-that: My advocacy style

The way I do things

VBAC Facts communicates differently than many others who speak or write about birth. Rather than advocating for a specific decision, we advocate for access to information. Specifically, the mission of VBAC Facts is to close the gap between what the best practice guidelines from ACOG and the NIH say about VBAC and repeat cesarean and what people generally believe.

In meeting this goal, VBAC Facts makes hard-to-find, interesting, and pertinent information relative to post-cesarean birth options easily accessible to the people who seek it. VBAC Facts does not advocate for a specific mode of delivery, birth attendant or birth location. Because of this stance, sometimes people are a little confused. They are accustomed to outspoken advocates (arguing for either the pro or con) urging them to have a certain type of birth at a prescribed location with a specific type of birth attendant – or none at all.

VBAC Facts is occasionally labeled as pro-this/ anti-that because I periodically will not agree with someone, even if we have made similar birth choices.  If someone supplies incorrect statistics, uses faulty logic,  or uses the dreaded terms “always/never,” I pipe up and give my perspective and a source corroborating my stance.  You may (or may not) be surprised how often this interjection is interpreted as anti- or pro-[insert method of birth, place of birth or type of birth attendant here.]

Balanced Rock

“Error, error Will Robinson!”

Let me give you the most recent example. The other day on Facebook, someone posted this:

A Canadian study has found that homebirth is safer …. yes EVEN FOR VBAC!
http://www.cmaj.ca/content/181/6-7/377.full.pdf

Naturally I was curious to read it as the number of studies on out-of-hospital (home or birth center) VBAC is really limited. So I did and noticed two key points which I shared because in her country, and mine, this study would not be applicable in all situations:

“It should add confidence to the safety of home birth in a context such as ours in which registered midwives have a baccalaureate degree or equivalent and are an integral part of the health care system. Our findings do not extend to settings where midwives do not have extensive academic and clinical training.24”

HBAC [home birth after cesarean] sample was too small to make any conclusions about HBAC: 88 women.

Questioning my personal choices

Then she basically accused me of being anti-home birth.

I had a home VBAC, but my personal choices are pretty irrelevant in terms of my work, since I’m not advocating for all moms to choose home birth or VBAC. But this fellow home birthing mom, since I questioned how she interpreted this study, came to the conclusion that I must be against home birth. What other reason could there be? So I replied,

This is an interesting study, but I think it’s important to be clear about it’s findings and how it was conducted. 88 HBAC moms is not a significant sample size because it’s simply too small to accurately measure complications/ outcomes.

This study also intentionally excluded any TOLAC [trial of labor moms] moms from the hospital comparison group. So this is not so much a HBAC vs. hospital VBAC study as it is a study on home vs. hospital birth among unscarred moms.

“Lots of your posts come off as opposed to homebirth.”

Her response is telling:

Thank you for clarifying that. I can’t tell you how many times I’ve been asked if you’re against homebirth and I say you aren’t and in fact you ARE a homebirther. Lots of your posts come off as opposed to homebirth.

And there it is.  You don’t tow the party line, you don’t appear to be in constant agreement with those who make similar birth choices, and people don’t know what to make of you.  It’s as if life has become so polarized that people can’t imagine someone who really isn’t on one end of the spectrum or the other advocating for everyone to make the same decision as them.  I am an advocate for information.  Plain and simple.  I reply:

Perhaps people interpret my realistic/ practical approach to things as anti-homebirth. And because I like to debunk myths and this frustrates people because these myths give them (misplaced) confidence. I acknowledge the various risks and benefits that come with our birth choices.

I do this because I think that women are intelligent enough to hear “these are the risks and benefits of XYZ” rather me dictating “make XYZ choice” or giving the (often hollow sounding) “it will all be fine” or “I had an HBAC, so should every woman!!!”  To some people, that comes off as anti-this/pro-that… but for me, it’s a fair look at our choices.

I think sometimes people start to look at a specific mode of birth/ birth location/ type of birth attendant with rose-colored glasses.  They try to minimize the risks associated with their “choice of choice” in an attempt to advocate for others to make similar decisions whether that is VBAC, repeat cesarean, home or hospital birth.  (Everyone has an agenda!!)

But minimizing risks deprives women of their right to informed consent and that is really no different than individuals who exaggerate risk. I don’t advocate for women to birth a certain way in a certain location.

My frank discussion of the risks sometimes angers people because they think it’s scare tactics anytime someone brings up a bad outcome or risks. I write about the difference between scare tactics and informed consent here after I received a comment from an OB saying I’m anti-OB/anti-hospital.

A big part of my philosophy is based on the fact that I have a website and a large readership.  I don’t want anyone to ever come back to me after a bad outcome and say, “You misled me.”  I feel an obligation to be honest and truthful about the pros and cons of options as well as the quality and quantity of research available to us.  Women often feel misled by their HCPs [health care providers].  I don’t want to be part of that misinformation machine.

My mission is simple: to make hard-to-find, interesting, and pertinent information relative to post-cesarean birth options easily accessible to the people who seek it.

I do this because I think the information speaks for itself.  It doesn’t need a cheerleader!  It doesn’t need someone to stretch the truth!  Just someone to say, “Read this!”

My tips for birth advocates

Later that same day, someone posted in the VBAC Facts Community asking how they can get involved with birth advocacy. Other VFC members and myself directed them to a variety of organizations like ICAN, Improving Birth, the National Advocates for Pregnant Women, the ACLU, Legal Advocates for Birth Options and Rights (LABOR), and Human Rights in Childbirth. I also supplied a few tips for anyone interested in becoming a birth advocate based on my own journey:

  1. Share info, don’t persuade.
  2. Offer options, risks, benefits.
  3. Be OK with people making different choices than you.
  4. Point to reputable sources so it’s clear that you are the conduit of information, not the source.
  5. Always verify “facts” before forwarding.
  6. Don’t get emotional, swear, belittle, insult, name call, bully, etc. I know that may sound obvious, but I’ve met many people whose aggressive and angry passion totally turns people off. If you isolate, insult, antagonize, or annoy people, they are not going to listen to you and what could have been a teaching moment, is gone. And once they write you off as a crazy, hysterical loon, it will be unlikely you will be able to change their perception.

There are many roads to the same destination. You can advocate right now by going on message boards and simply pointing people to accurate information when they ask questions. Sometimes all they need is to see a little bit that suggests what they have accepted as “truth” is the opposite of what major medical organizations, public health professionals, and medical researchers support and recommend.

Take home message

VBAC Facts advocates for access to information, not a specific decision.

Yes, I had a home VBAC. But just because I made that choice doesn’t mean:

  • I believe home birth has zero risk (it doesn’t)
  • I think everyone should have a home birth (they shouldn’t)
  • I think everyone should have a VBAC (they shouldn’t)

I have said many times, “Birth is not one size fits all.” As ACOG says, two women can look at the exact same information and make very different choices. And I’m ok with that because there is not a Right or Wrong decision for all women, just a right or wrong decision for that specific woman, and that is hers to make based on information, not bullying or hysteria.

Supporting the mission of VBAC Facts

If you like my style of advocacy, you might really enjoy:

  • the class I created and teach targeted to parents, health care providers, and birth professionals entitled, “The Truth About VBAC: History, Politics, & Stats” offered on-line as a webinar or in a city near you,
  • the VBAC Facts Micro Brochure, a folding business card to be used by professionals and advocates that provides a brief overview of post-cesarean statistics, or
  • the “VBAC Facts Community,” a Facebook group that I created in response to other groups that I found very polarizing.  Our whose membership includes post-cesarean moms, health care providers, and birth professionals.

 

“Maternally Yours” Radio Interview Show Notes 7/31/12

microphone-1007154_1280On July 31, 2012, I was interviewed by Maternally Yours, a radio program on WSLR 96.5 LPFM, a Community Radio station in Sarasota, Florida.  Below are the show notes with links to more information.  I went off my notes for a bit, so be sure to listen to the podcast to get the full interview.  Also check out Maternally Yours’ blog post about the show.

____________________________________

Which women at good candidates for VBAC? Which are not?

Per the American Congress of Obstetricians and Gynecologists’ aka ACOG’s latest VBAC recommendations released in 2010, VBAC is a “safe and appropriate choice for most women” with one prior low transverse cesarean and for “some women” with two prior cesareans. Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC per ACOG.

ACOG also says,

Conversely, those at high risk for complications (eg, those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated are not generally candidates for planned TOLAC [trial of labor after cesarean].

Reviewing your personal medical history with a VBAC supportive care provider is the best way to see if you are a good candidate.  I recommend getting a copy of your medical record(s) and operative report(s) from your prior cesarean(s), get the names of VBAC supportive providers, and ask the right questions.

It’s really important to qualify your care provider to ensure that they are supportive of VBAC, before you get their opinion on whether you are a good candidate.  There is a great range of practice styles from one care provider to another.

What are some of the risks and benefits of VBAC vs. repeat cesarean?

There are real risks and benefits to both VBAC and repeat cesarean. A mom can only make an informed choice when she is aware of the risks and benefits to herself, her baby, and her future fertility, pregnancies, and health.

According to the 2010 National Institutes of Health VBAC Conference, the risk of a mom dying during a elective repeat cesarean section (ERCS) is significantly increased in comparison to a trial of labor after cesarean (TOLAC).  However, the risk is still quite low in either scenario: 13.4 maternal deaths per 100,000 ERCS vs. 3.8 maternal deaths per 100,000 TOLAC.

The NIH also found that the rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCS.  The risk of uterine rupture during a TOL was 4.7 per 1,000 vs. 0.3 per 1,000 in a ERCS.

2.8% – 6.2% of uterine ruptures were associated with an infant death within 28 days of birth. However it’s important to note that “the strength of evidence on perinatal mortality [the number of babies who die during the first 28 days of life] was low to moderate” due to the wide range of rates reported by the studies included in the Guise 2010 Evidence Report.  (Guise was the basis for the NIH VBAC Conference. ) The NIH identified this topic as an area for future research.

It’s important for women to understand the long term implications of multiple repeat cesareans.  A 2006 study of 30,000 women (Silver, 2006) undergoing up to six total cesareans found,

The risks of placenta accreta, [surgical injury of the bladder, bowel, and ureters],… the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units,… significantly increased with increasing number of cesarean deliveries.

Unfortunately, many women don’t think about these future risks until they are pregnant again.  According to the CDC, 49% of pregnancies are unintentional, so women really need to consider the fact that how they birth their current baby has implications for their future pregnancies and health.

[Dr. John Sullivan Jr. of Sarasota Memorial Hospital, another guest on the show, made mention of how I lead with maternal morality.  I did so for two reasons.  One, the Guise 2010 Evidence Report, when discussing the risks and benefits of VBAC versus ERCS in it’s Structured Abstract (page v), also discussed maternal mortality first.  I think this is because it is one of the primary questions moms have: what is my risk of dying?  Second, one of the ways that unsupportive care providers coerce women into a repeat cesarean is by misleading them on the risks of VBAC including uterine rupture and mortality rates.  So, I wanted women to know from the get go what the risks were.]

If evidence shows (and ACOG supports) that most women with one or even two or more prior Cesareans should be allowed a trial of labor, why are so many hospitals and physicians still banning the practice?

This is primarily due to the 1999 and 2004 ACOG recommendation that a doctor be “immediately available” to perform a cesarean.  Yet ACOG did not clarify if they meant an obstetrician or an anesthesiologist nor did they provide a standard for where the obstetrician and/or anesthesiologist should be or what they could be doing.

As a result, hospitals developed their own definitions producing differing VBAC protocols and requirements.  The most severe variety was the institution of VBAC bans in one-third of all American hospitals per the International Cesarean Awareness Network’s 2009 survey.  These bans disproportionally affect women living in rural areas as they may have to drive hundreds of miles in order to birth at a VBAC supportive facility.  The 2010 ACOG guidelines acknowledged that the interpretation of the prior recommendations were limiting access to VBAC and clarified that was not their intention.  ACOG even says,

Importantly, however, none of the principles, options, or processes outlined here should be used by centers, health care providers, or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC as safe as possible for those who choose this option.  In settings where the staff needed for emergency delivery are not immediately available, the process for gathering needed staff when emergencies arise should be clear, and all centers should have a plan for managing uterine rupture.  Drills or other simulation may be useful in preparing for these rare emergencies.

These same policies and procedures would also enable hospitals to respond rapidly to the increasing complications we see with multiple prior cesareans including placenta accreta. Read more here.

If women want to learn more about how hospitals without 24/7 anesthesia can provide VBAC safely, they can watch Dr. David Birnbach’s presentation from the 2010 NIH VBAC Conference or read his presentation abstract.

What can a mom do if she wants to birth at a VBAC ban hospital?

Dr. Stuart Fischbein, a Southern California OB, has talked extensively about his struggles as a VBAC supportive OB who worked at a VBAC ban hospital.  For a while, he told his patients that they could just show up in labor, refuse surgery, and he would attend their VBAC.  When hospital administrators got wind of this, they made him put in writing that he would not longer advise his patients of their legal right to refuse surgery.

Women have VBACed at ban hospitals. The problem is when an obstetrician is under tremendous pressure from hospital administrators to only perform repeat cesareans.  So with this pressure in mind, if a mom is told her baby is in distress, how does she know if her OB is telling the truth or succumbing to the pressure of hospital administrators?

Further resources:

Tell us about the legality of VBAC

Hospital-based VBAC is legal in all 50 states.  In some states, it is illegal for a midwife to attend a VBAC either at home or in a birth center.

What are some of the myths of VBAC?

So many persistent yet very false myths!  First, women should know that you can induce a VBAC.  Without medical indication, the increased risks are generally not worth it.  But for those women who have a medical reason, such as preeclampsia, severe fetal growth restriction, diabetes, chronic pulmonary disease, etc, an induction can be a nice alternative to a repeat cesarean.  Of course, every mom should review the risks and benefits of her options with her care provider.  ACOG says that Pitocin and Foley catheter induction is acceptable in a VBAC whereas Cytotec is contraindicated due to the high rates of uterine rupture with which it is associated.

Another myth is that your risk of uterine rupture doesn’t increase much after a cesarean or that your risk is the same or similar to an mom who has never had a cesarean.  One study from the Netherlands (Zwart, 2009) including over 350,000 births found the risk of uterine rupture in an unscarred uterus to be very, very small: about 1 in 14,000.  That same study found risk in a scarred uterus to be about 1 in 156 (this figured included induced and augmented TOLs).

Uterine rupture in a scarred uterus occurs at a rate similar to placenta abruption, post-partrum hemorrhage, and cord prolapse.  It’s not that the risk is so high in an scarred mom, it’s just that it’s so very, very, very low in an unscarred mom.

Another myth is that the risk of uterine rupture in a scarred uterus is similar to the risk in an induced, unscarred uterus.  This is also false.  The risk in an induced, unscarred uterus is still about 1 in 4,500.  It is very rare for an unscarred uterus to rupture induced or not.

Another myth is that you can compare the risk of birth to the risk of non-birth activities like dying in a car accident or choking on a pretzel.  However, you can’t accurately compare the risks of a daily activity like driving or eating because those risks are measured on a annual or lifetime basis.

Your annual or lifetime risk of something happening will often be higher than your risk of a birth related complication.  This is because one’s annual risk measures their risk over the course of 365 days.  A lifetime risk is often based on 80 years which is over 29,000 days.  You are likely to be in active labor for one day, maybe two.

To compare the risk of something that happens over 1-2 days to the aggregate risk of something that could happen any time over 365 days or 29,000 days is unfair and confusing.  I think it’s more helpful for post-cesarean women to focus on the choice they have, VBAC vs. ERCS, and compare those risks to each other.  Don’t get bogged down in comparing the risks of birth to the risks of non-birth activities.

Finally, a special myth for Floridans.  One mom told me that since Florida had the most lightning strikes hit the ground in the nation, she was more likely to be struck by lighting than have a uterine rupture.  This is false.  The National Weather Service says, based on the number of reported lightning strike deaths and injuries, your risk of being struck by lightning is about 1 in 700,000.  This is a lot lower than the risk of uterine rupture in a scarred or unscarred uterus.

American Women Speak About VBAC

I’m here at the NIH VBAC conference and my brain is swimming!  I want to write a separate article later on the conference itself, but for now I want to share with you a piece I put together for the benefit of the panel who will be writing the Consensus Statement.

I received many requests to share it online, not only from conference attendees but by the women themselves who contributed their stories for this piece.  You can download a PDF copy of this document here.

I’m especially excited that I had the opportunity to share the comments provided by Wendy S. from California, Kristen K. of Nebraska, and Rachel R. of Oregon during the public discussion time which you can view via the Day 2 Webcast.  (You can also view the Day 1 Webcast, download a PDF of the Program and Abstracts, as well as pre-order the consensus statement.  The more people who order the consensus statement, the more powerful the message that people are interested in the option of VBAC.)

While the contributors gave permission for their full names to be used on the  handout I distributed at the NIH, not everyone is comfortable with their name on the internet.

American Women Speak About VBAC

In an effort to bring the consumer perspective to the 2010 NIH VBAC Conference,  Jennifer Kamel, Founder of VBAC Facts, asked women across America, “Why is the option of VBAC important to you?”  This is what they said.

Alabama – To avoid not being able to carry your baby because he’s dead from the placental abruption (or uterine rupture) as a result of those damn previous cesareans. – Amanda M.

Arizona – VBAC is important to me because I don’t want to continue to have increased risks with each major surgery. – Amanda McM.

Arkansas – Personally, VBAC is stellar important to me because I wanted to give birth to my babies, not have them cut out and handed to me.  On a soul-deep level, I believe it was necessary to validate my purpose in existing.  – Jer W.

California – It is important to me because I have the right to experience the complex passage of vaginal birth and the positive cascade of effects for mom and baby.  I want the right to experience VBAC without driving 90 minutes or more with traffic. Successful or not, VBAC empowers women for choice and a chance to fill an emotional void that is unmatched.  The whole “readily available” lawyer talk certainly is not protecting our other high risk patients.  – Wendy S., L&D RN

Because when a woman experiences a VBAC, she reclaims her body and gets to see that she is in fact perfectly capable of giving birth without surgery.  She is no longer broken.  Her body and spirit heal. – Layla M.

To me it is like saying someone should be required to have open heart surgery, even though a laparoscope would be safer, just because doctors/ hospitals/ insurance companies, prefer it that way.  It is so much bigger than our desires to experience a vaginal birth or even to be some kind of hippie earth mother. It is about our right to safe and respectful medical care. Courtney Stange-Tregear

I wanted a VBAC to heal my raw emotions and psychological trauma caused by not having a vaginal birth the first time and because I believe it’s safer. Unfortunately, I had to travel 3 hours to get to the closest facility that allowed VBACs. But having the chance to VBAC was great! – Andrea O.

Because I love women and love babies and have spent 20 years investigating what affords the best possible beginning for them both and that is a vaginal birth. – Joni Nichols BS MS CCE CD(DONA) (CBI)

It is wrong that I have to travel to another county and fight for a normal, safe, healthy birth for my baby.  Hospitals and doctors need to get their priorities straight and practice true informed consent. – Kathleen S.

My VBAC proved to me that I was not as broken as I felt after receiving so many labels [FTP, etc] regarding my cesarean. – Alexandra R.

Colorado – VBAC allowed me to trust in my body and let it do what it needed to do.  My midwife and her assistant viewed my “long labor” as simply a variation of normal.  I was finally able to deliver my 10 lb baby, with a nuchal hand, in an amazing waterbirth.  My body is amazing and strong and did not let me down. Jill K., Ph.D. (Clinical Psychologist and Professor)

Connecticut – Without VBAC, women have no choice and are forced into dangerous births. – Danielle M.

Florida – VBAC matters because it is lifelong; it is forever; it is not short term.  The effects of a VBAC never wear off. – Shannon M.

My VBAC offered me a better recovery without worrying about an incision site. – Meredith S., HBA2C mom

Hawaii – The fact that the possibility of a malpractice suit dictates what most obstetricians offer and results in them pushing the birth option that is more likely to end in a mother’s death is totally incomprehensible to me. Evidence-based care is what our standard should be.  Every single obstetrician should be pushing the safest option for mother and baby, not the safest option for avoiding a lawsuit. – Naomi S.

Idaho – My VBAC was validation of my womanhood. It has made me a better mother and spouse. – Bonnie M.

Indiana – I wanted to have a large family and I think VBAC is the best option instead of repeat c-sections!!  I have had 6 VBACs so far and hope to be able to have as many more! – Stacy G.

Kentucky – Because having my baby cut out of my abdomen was very traumatic for me.  The bonding was more difficult [than my three previous vaginal births] and PPD followed. – Denise H.

Massachusetts – When my son was born by (unnecessary) cesarean, I felt like someone had deflated my belly and handed me a baby. He was mine, but a part of me felt like they could have handed me any baby. But when I look at my daughter’s head and stroke it while I am nursing her, I can say I gave birth to that head. I gave birth to that head! This is my baby. And no one can take that away from me. – Catie Ladd

Michigan – There are all sorts of “soft” reasons why VBAC is great but when it really comes down to the bottom line, what keeps me working for ICAN, what brings tears to my eyes, is the fact that women and babies are dying who shouldn’t, because VBAC is no longer a real option for most women in the U.S. – Gretchen Humphries, MS DVM

Mississippi. After my first baby’s labor ended with a cesarean, I felt that I really hadn’t been given a chance.  I felt bullied and pushed into a cesarean I didn’t want because it was more convenient for the doctor than letting me continue at a ‘slower than normal’ dilation rate. – Nancy W.

Nebraska – If VBAC was not an option, my daughter would have been an only child.  I could never willingly conceive knowing my child would be cut out of me via a completely unnecessary surgery. – Kristen K.

New Jersey – VBAC is certainly safe for both mom and baby as long as the original incision in the uterus was a low segment transverse incision. Evidence based medicine reports approximately 75% of women can successfully VBAC. As long as the mom is aware of the risks (minimal) and the benefits (MANY) they should have the right to VBAC. – JoAnn McQueen Yates, CNM

New York – Because I didn’t want to go through surgery if it wasn’t necessary.   Doctors take little stock in the emotional and psychological factors of giving birth – it’s not just about pushing out a baby!! – Carrie Moyer Howe

Ohio – Delivering vaginally for me was a “rite of passage.” I was finally able to cast off the numerous doubts and my sense of failure I experienced. I really was “adequate.” – Ellen B., Nurse Manager & VBAC mom X2

Oregon – After my c-section with my daughter, laughing was extremely painful for weeks.  I would think, how awful that during a time that should be filled with joy, I’m unable to laugh.  – Rachel R., HBAC mom

I think it’s important for the operating room space and staff to be available for a true emergency cesarean, rather than have me taking up their space and time for convenience. – Rebecca C.

Pennsylvania – If I had to plan a pregnancy to end in surgery, I would not have another child, period.  – Judy P., DVM, PhD (molecular biology)

VBAC is important to me because it has the capacity of healing my broken Self. – Monica R., PhD.

South Carolina – VBAC is a natural conclusion to a natural process.  Not to mention, how many babies with true emergencies, would be saved by not having operating rooms tied up with elective cesareans? – Raechel Fredrickson

West Virginia – Aside from the fact that offering VBACs is practicing Evidence Based Medicine and should be offered without question, I would like for other women to experience the joy and self-assurance that comes from working with her body as well as the indescribable feeling of pulling her fresh, warm baby up to her chest as I experienced with my HBA3C. – Teresa S.

Please share your stories of insurance discrimination!

I’m forwarding this from ICAN.  Please forward far and wide.  We have the government’s attention.  They are ready to hear our stories.  Let’s turn the frustration, anger, and pain into real change!

If you have have discriminated against due to your prior cesarean, our government needs to hear about it!

ICAN needs stories about discriminatory insurance practices based on a previous cesarean.  This can include but is not limited to demands for sterilization, restrictions on how soon you can have another pregnancy and be covered, higher premiums, restrictions on the total amount of benefits they will pay, excessively high deductibles for maternity care.  Even if all you have is your name, state, contact information (email is fine) and a description of the circumstances (with the name of the relevant insurance company(ies) if possible) we can use it.  If you have written documentation, that would be pure gold.  There is interest about this at the highest levels of the Federal Govt. and we will use this to open the discussion on other areas of discrimination (like VBAC bans, lack of transparency, etc)….so please, take a moment and get the information to ICAN.  You can email me at advocacy@ican-online.org or you can snail mail to ICAN of Ann Arbor, PO Box 48, Stockbridge, MI  49285.

Your story could make a difference that would improve the care available for millions of women and their babies.

Below is a press release illustrating ICAN’s latest efforts.

ICAN Mother Provides Testimony on Capitol Hill Discriminatory Insurance Practices Investigated by Senate HELP Committee

REDONDO BEACH, CA, October 15, 2009 – Gretchen Humphries, Advocacy Director for the International Cesarean Awareness Network accompanied Peggy Robertson of Centennial, Colorado to a Senate hearing in the Health, Education, Labor and Pensions (HELP) Committee. Ms. Robertson testified about her experiences with discriminatory insurance practices based on her history of cesarean.

Ms. Robertson was featured in a New York Times article in July 2008 after she was declined insurance due to her previous cesarean. She was informed by the insurance company that her application would be accepted if she agreed to be sterilized.

As of 2007, 31.8% of childbearing women in the United States had a cesarean delivery and the rate continues to increase each year. These increases are due, in part, to the growing number of women who are denied the opportunity to have a vaginal birth after cesarean (VBAC) through similarly discriminatory VBAC bans. “The prospect of rendering a third of women uninsurable is frightening and unconscionable,” said Desirre Andrews, President of ICAN. “Many of these women are being pressured or bullied into first-time and repeat cesareans, and to doubly inflict them by leaving them without health insurance is offensive.” Clearly this type of practice potentially affects a very large number of women now and in the future as the cesarean rate continues to climb and the vaginal birth after cesarean rate continues to decline.

The practice of denying a woman health insurance because of a prior cesarean also indicts the medical community. Many of the cesareans performed today are unnecessary or the by-product of an over-interventive labor management process that is rooted in defensive medicine practices. “It is absolutely wrong to deny coverage to women either because of past cesareans or the risk of future cesareans, but it is also wrong to prop up a system where physicians can overuse surgery that both harms the health of women and babies, and forces insurance companies to take on excessive costs.” said Gretchen Humphries, ICAN’s Advocacy Director.

Cesarean section is associated with double to triple the cost of a normal vaginal birth. Cesarean also imposes the risks of medical complications in the short-term and long-term, which often carry high costs. “Insurance companies, in their actuarial pragmatism, are doing the math and recognizing that moms with a history of cesarean are high-cost beneficiaries and working to weed them out of the pool of people they cover. It’s discriminatory and lawmakers need to address this issue and determine a way to protect mothers, both from the practices of the insurance industry and the non-evidence based care from obstetricians,” said Humphries.

Maternity care is the number one most expensive line-item in the U.S. healthcare bill. From 1996 to 2006, the national cesarean rate rose by 50 percent, setting a new record each year from 2000 onward. The proportion of medically induced labors rose by 135 percent from 1990 to 2005, with strong suggestions that these official induction rates identify only roughly 50 percent of actual inductions. The burden on the health care system is staggering for maternity care as it is today. In 2005, the combined hospital charges for birthing women and newborns totaled $79,277,733,843 and exceeded charges for any other condition. Private insurers paid for 51 percent and Medicaid paid for 42 percent of these stays. “Pregnancy and delivery” was the most expensive condition, followed by “newborn infants” for both payers. Six of the ten most common procedures billed to Medicaid and to private insurers in 2005 were maternity related. Cesarean section was the most common operating room procedure for Medicaid, private payers and all payers combined.

As policymakers focus on healthcare reform and finding ways to improve outcomes while lowering costs, ICAN calls on policymakers to address the needs of pregnant women and make low-cost, optimal-outcome birth easier to access.

Currently: ·

Few women are given the information they need to navigate the pitfalls of the defensive medicine model of care that is rampant ·

Women are routinely coerced or pressured into expensive care that does nothing to improve outcomes, especially through the increasing practice of banning vaginal birth after cesarean (VBAC) ·

Access to low-intervention midwife-attended births are hampered by reimbursement issues, or onerous collaborative agreement requirements for practicing midwives

“The unique beauty of maternity care is that we can simultaneously improve quality and reduce costs,” said Andrews. “But we need to start by treating women fairly and equitably, and intelligently reserve medical technology and interventions for when they are appropriate.”

Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are more than 117 ICAN Chapters across North America, Canada , and various international locations which hold educational and support meetings for people interested in cesarean prevention and recovery.

Citation: C. Sakala & M. Corry. Evidence-Based Maternity Care: What It Is and What It Can Achieve. 2008.

Attorneys looking for VBAC ban victims

This was emailed out on the ICAN list:

__________________________________________________________

Dear Friends,

As you are likely aware, many women are denied access to VBAC (vaginal birth after cesarean) because of hospital policies and outright bans. Attorneys with the Northwest Women’s Law Center in Seattle are looking at this issue.

It requires that the woman is planning a hospital birth, in a hospital that bans VBAC, because she has no other options (not feeling comfortable with a homebirth is an acceptable reason to not have a homebirth for this purpose, so it doesn’t have to be in an area where there are also no midwives available). The reason for not having options can be geographic (no close hospitals to go to) or something like restrictions placed on her because of insurance or lack of insurance. But she definitely has to be planning a hospital birth.

__________________________________________________________

I’m a lawyer with the Northwest Women’s Law Center in Seattle. I’m investigating possible legal responses to bans on vaginal birth after cesarean at hospitals in the northwest states Alaska, Idaho, Montana, Washington and Oregon. If you are currently pregnant and want to have a VBAC, but are facing a hospital policy that would require you to have a c-section regardless of whether you want it and regardless of whether it is actually medically necessary, and you are willing to consider working with a lawyer on this, we’d like to talk with you. Please respond to
vbacbanhelp at ican-online dot org.

Even if you are not in one of the states listed, you can still help by emailing this out to any email lists you are on and asking everyone who receives it to email it to all the lists THEY are on as well so that it is distributed far and wide. Thanks.

Sincerely,
Susan Hodges, “gatekeeper”

Should we blame women or doctors?

This post on a pregnancy message board under the subject “Inducing at 38 weeks” was the catalyst of a discussion on the ICAN email list (emphasis mine):

I’m for it! There is NOTHING wrong with me, actually not even THAT uncomfortable (knock on wood!), and my Dr. is inducing me at 38 1/2 weeks! The group induces all of their patients! He said by 38 weeks the baby is ready – so why not get them out in the real world! I know it’s REALLY because they are 3 men, who just don’t want to get called out in the middle of the night all of the time, but they wouldn’t do it if there was a risk! I think it’s becoming more common these days – I’m just so anxious to meet her, they can take her whenever they want!! I trust them, they did go to med school and have been in practice for YEARS!

Whose fault is it that this woman doesn’t think there is any risk to inducing at 38.5 weeks?  Is it her fault since she didn’t educate herself?  Or is it her OB’s fault that they didn’t inform their patient on the risks, benefits, and options of induction?  Is it unreasonable to blame the OB since prenatals with an OB are typically 3 minutes after an hour wait?  Or is it unreasonable to blame the patient since she hires the OB for their expertise and education?  But what about the fact that we are dealing with this patient’s health as well as her baby’s?  Isn’t the OB’s oath to first “do no harm?”  But shouldn’t the mom have a vested interest in her health and shouldn’t she care more about her outcome than her OB?  This is a complicated topic…

But, in case you are reading and wondering, “What’s the big deal?  What are the risks of induction?”  A quick google search of “induction risks” lists a ton of sites, here is a quick run down:

What You Should Know: Risks of Labor Induction

  • Contractions are more painful because you are forcing your body to contract with drugs
  • Poor positioning of the baby = longer/more painful labor
  • Longer labor because your body isn’t ready for labor
  • “Longer and stronger contractions can interrupt blood flow and oxygen to the fetus, which can lead to drops in the heart rate.”
  • More bleeding and infection
  • Longer hospital stay and/or longer length of recovery
  • Higher levels of NICU admissions
  • Hyperstimulation of your uterus
  • Premature separate of the placenta (placental abruption)
  • Uterine rupture
  • Increased risk of abnormal fetal heart rate, shoulder dystocia and other problems with the baby in labor.
  • Increased risk of your baby being admitted to the neonatal intensive care unit (NICU).
  • Increased risk of forceps or vacuum extraction used for birth.
  • Increased risk of cesarean section.
  • Increased risks to the baby of prematurity and jaundice.

For a more complete discussion, and even more risks, please read Elective Induction of Labor by Henci Goer.  For a copy that you can easily print, go here.

I’m sharing with permission this post from the ICAN list that says there is plenty of blame to go around… (medpros = medical professionals)


I don’t think women exactly go out looking to hand the responsibility to
some one else. I think both women and doctors are to blame. Women think
(because no one tells them otherwise) that pregnancy has to be managed, that
they can’t do it on their own, and so they go on doing what they think they
are supposed to do, and right there waiting are the medpros waiting to offer
their “help”. Almost all women that walk into and Ob’s office think they are
doing the responsible thing. They think they ARE taking responsibility and
are getting the “care” they have been taught to get. The medpros gladly take
the responsibility from women more than I feel that women are looking to
hand it over.

It’s hard *because* women are not informed and they *don’t know* they are
missing information. They think they ARE informed. Once a person starts down
that path it’s hard to become truly informed because the new information
contradicts what they have always known AND it makes them feel like a fool
for not knowing before. I know we try to education women who just seem like
they don’t want to be educated, but it’s more than that. They have their
past decisions to protect. It’s not easy to realize you made mistakes. It’s
even harder when you made mistakes built on trust.

If women are failing we are failing each other more than we are failing our
individual selves. There is a reason there is such an emphasis on avoiding
that first cut. Women need to know BEFORE it’s too late, but those in “the
know” are not the majority and are certainly not the major influence on most
women today. Once you have been cut your further education is
forever limited by your experience and a women feels a need to rationalize,
justify, and remain in line with her former choices. (Some of us get past
it, many of us here, but we are a minority.) No one likes to hear that there
is a better way when they whole heartedly believed in the way they first
chose. It’d be like finding out you have been buying premium gas at a higher
price only to find out the cheaper gas is actually better for your
car. It would feel awful and your instinct would be to find a way that the
premium gas IS better so that you don’t feel as though you have wasted all
that money for nothing. However if when you get your first car some one
tells you the truth about what gas is best then you are just going to buy
the right gas and never make that mistake. And further more while you are
buying that premium gas and paying the higher price you might even brag to
your friends about how you can afford the better gas and how much better
your car is running, while there might be those around you thinking “you
idiot, that gas isn’t any better”, but NO one told you and if you are told
now, it’s too late, you’re invested. You might come around, but not everyone
would. Some people have to hold on to the bad decision they made being right
because if they admit they were wrong it would be devastating to them. Some
people can not handle that kind of truth or education. They have to remain
blind for their own sanity.

I know I learned nothing about pregnancy and birth from my mom. I know I
didn’t learn it from women I was friends with that were older than me and
had walked that path. I know I didn’t learn anything from my grandma or my
mother-in-law, or my sister-in-laws. What I learned was from movies and tv
where you go to an OB and they “help” you. Is it my fault that no one taught
me what I didn’t know I needed to know?

Sarah Taylor, New York