Category Archives: Advocacy

worth-the-trade-post

Why I’m feeling conflicted about AB 1306: CNM Physician Supervision vs. Home VBAC Hurdle

Update September 2, 2016

This bill was not passed.

Update August 25, 2016 1:32pm

The Senate floor vote for this bill has been postponed until Monday.


Update August 25, 2016 9:57am

For those of you watching this issue closely, this bill will be up for a Senate floor vote today. You can watch the California Senate live here.


Update August 24, 2016 10:06pm

The Senate floor vote for AB 1306 is scheduled to happen tomorrow, August 25th. (Click here to see the current status of the bill.)

The California capital opens at 9am, so if you haven’t already called your state Senator to tell them how you feel about AB 1306, tomorrow is the time.

All you have to say is, “I’m calling to voice my support of [or opposition to] AB 1306.”

Click here to receive a reminder email tomorrow at 9am.

All my thoughts on AB 1306 can be found below.


Update August 24, 2016 11:06am 

I have thought about AB 1306 for so many hours since I initially opposed it last Friday and I’m feeling really conflicted about it.  Let me share with you why.

Removing physician supervision will improve the ability of CNMs to practice autonomously including offering VBAC in the hospital setting (where hospital policy permits) and in birth centers (provided the CNM opts to offer VBAC). This could be a good thing for VBAC families and a great thing for all the other people CNMs serve.

And so it’s really tough because it could negatively impact the small number of women who plan home VBACs by requiring them to have a VBAC consult with an OB.

So, what is the right decision?

Support this bill so CNMs can have a greater reach?

Or oppose this bill because of this requirement?

My mission is to increase access to VBAC in all birth settings. Is it enough that this may increase hospital VBAC access – where most women birth – as well as birth center VBAC while possibly making home VBAC harder to achieve?

Here is the specific language from AB 1306 (Sec 6, 2746.5(B)):

If a woman wants a home VBAC and she ‘still desires to be a client of the certified nurse-midwife, the certified nurse-midwife shall provide the woman with a referral for an examination by a physician and surgeon trained in obstetrics and gynecology. A certified nurse-midwife may assist the woman in pregnancy and childbirth only if an examination by a physician and surgeon trained in obstetrics and gynecology is obtained and, based upon review of the client’s medical file, the certified nurse-midwife determines that the risk factors presented by the woman’s condition do not increase the woman’s risk beyond that of a normal, low-risk pregnancy and birth. The certified nurse-midwife may continue care of the client during a reasonable interval between the referral and the initial appointment with the physician and surgeon.’

This is why I’m conflicted:

44% of CA hospitals outright ban it. They do not “allow” their physicians to attend VBAC. What happens if those hospitals decide, they will not “allow” their physicians to even consult with families seeking out-of-hospital (OOH) VBAC? Or physicians say that their malpractice insurance will not “allow” them to consult with OOH VBAC families? Where does that leave OOH VBAC families?

Right now, the VBAC rate in the state of California is only 9%. This bill could increase VBAC access in birth centers and hospitals assuming that hospital policy “allows” CNMs to attend VBAC.

As it stands, 91% of California families have repeat cesareans and the overwhelming majority of those are due to VBAC bans, misinformation and being unable to find a supportive provider.

But here’s the tough part: OBs who are staunch supporters of VBAC have told me that they would never have a consultation with a woman planning a home VBAC because they don’t, in any way, want to be connected with something that could be construed as validating, okaying, or approving home VBAC.

Even though the legislation isn’t asking OBs to approve of home VBAC, that is what OBs see. And the overwhelming majority of OBs – who support hospital VBAC and may even philosophically agree with OOH VBAC – would not participate in VBAC consults for women planning home VBACs.

This is mitigated a bit by the fact that women can have these consults via a chart review and Skype. So regardless of where they live in the state, they could reach the handful of OBs willing to participate in a VBAC consult.

But having the VBAC consult in the legislation means that as OB allies die, or as hospital policies tighten, or malpractice insurance fears increase, the legislation holds firm. That is not a good thing. It leaves women standing out in the cold on their own. And forces them to go back to the hospital system, where, as we see from the current California VBAC rates, they will likely acquiesce to a cesarean or be forced into a cesarean per hospital policy that is presented as equivalent to law unless CNMs are able to measurably increase VBAC access in the hospital setting.

CNMs can tell families that the prior cesarean is “unlikely to impact this pregnancy” and then talk about the unlikely though possibly dire consequences if a uterine rupture occurs out of the hospital. And talk about transfer protocols as you would with any other patient. Women don’t need to talk to an OB in order to get that information.

So while this bill does include home VBAC in the language, access to home VBAC is assuming that the pregnant person can find a OB who is willing to provide them with this consult. While the option is there, the ability to exercise that option is based on the kindness and ethics of a few OBs. And when they are gone, or the climate changes, women bare the brunt of their absence.

A VBAC consult does not make pregnancies safer. It will not improve outcomes. It only undermines the professional training of CNMs and the autonomy of patients.

And all the while, this bill also removes physician supervision from CNMs. And that is a very good thing.

So, do we say to home VBAC families, “Best of luck to you?” and, “Removing physician supervision for CNMs is worth this trade?” and then hope and pray that these women can find an OB willing to provide them with this consult?

I’m sharing with you the pros and cons as I see them so you can make your own decision.

It’s not too late to contact your state Senator and tell them, “I’m calling to voice my support of [or opposition to] AB 1306.”

Does your state require families planning home VBACs to have a consultation with an obstetrician? If yes, I’d like to ask you a few short questions.


Update Friday August 19, 2016 10:21pm

Thank you to those that contacted your Assembly Member today! The deadline to amend the bill to exclude the VBAC consult was Friday.

The next step is to oppose the Senate floor vote which is expected to happen next week (the week of Aug 22nd).

Please contact your state Senator on Monday, August 22nd, and tell them, “I’m calling to voice my opposition to AB 1306.” That’s it.

If you click the yellow button below, I’ll send you a reminder email Monday morning when the capital opens at 9am.

Be notified when legislation threatens VBAC access!


August 18, 2016 by Jen Kamel

Yesterday I was in Sacramento attending the Midwifery Advisory Council meeting at the California Medical Board.

At that meeting, I learned about a piece of legislation that will decrease VBAC access in California.

TODAY IS THE LAST DAY TO VOICE YOUR OPINION!

If access to midwifery care for women who have had a prior cesarean section is important to you, then please register your opposition to AB 1306 unless amended to exclude VBAC consult with your Assembly Member or with it’s author – Assembly Member Autumn Burke.

AB 1306 would remove physician supervision for Certified Nurse Midwives (CNMs).

This is a good thing.

But here’s the bad part: it puts into statute (law) a requirement that any woman seeking to deliver with a CNM outside a hospital AND who has had a prior cesarean delivery must first have a consultation with a physician (AB1306 Sec 6, 2746.5(B)).

Be notified when legislation threatens VBAC access!

It is this requirement for consultation that is at issue for the following reasons:

• All women are capable of determining for themselves and their families, together with their midwife or health care provider, what measure of risk is appropriate for them. Requiring a physician consultation before they are able to continue midwifery care undermines patient autonomy.

• Certified Nurse Midwives (CNMs) are highly trained health care professionals. They are quite able to determine, together with their client, when a particular woman would benefit from a consultation with a physician.

Requiring a physician consultation for every woman with a prior cesarean delivery does nothing to increase her safety in the current pregnancy. There is no way for a physician (or anyone else) to predict which pregnant woman is going to have difficulty with her current birth because she had a cesarean delivery in a prior pregnancy.

Requiring a physician consultation puts an increased burden on women. It may delay prenatal care, a known risk factor for prematurity, low birth weight and poor outcomes. It is costly and time consuming in the absence of evidence for benefit.

While collaboration between care providers is the ideal, in many areas of California midwife/physician collaboration is not possible because there are no physicians willing to form this relationship. This reduces access to midwifery care and in many instances it also reduces access to successful vaginal birth after a prior cesarean.

Putting precise wording, regarding any medical condition, into statute disallows health care providers the use of the most recent research when helping clients make decisions regarding their care. Putting into law, the requirement for a physician consultation when a woman has had a prior cesarean delivery, will not allow women and their midwives to take into account the growing body of evidence surrounding the practice of a trial of labor after a previous cesarean (TOLAC), prior to determining the need for a physician consultation.

I fully support CNMs and the important care that they provide to California families. But this bill is problematic because of how it will impact VBAC access for those who want an out-of-hospital VBAC with a CNM.

Once again, call your Assembly Member or AB 1306’s author – Assembly Member Autumn Burke – TODAY and say, “I’m calling to voice my opposition to AB 1306 unless amended to exclude VBAC consult.” That’s it.

If you want to say more, you can add, “…because it restricts a woman’s right to choose her care provider and mode of delivery.”

I already called my Assembly Member and it took me exactly 36 seconds.

I hope you do the same.

If you live outside of California, please leave a comment on the author’s Facebook page so others who are learning about the bill realize the implications it will have on VBAC access unless amended.

Be notified when legislation threatens VBAC access!

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

VBAC-relic

Click to share on Facebook

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

 

balance-rock-bridge-grass

When all people can see is black or white

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, I 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. 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.]

Perhaps people interpret my realistic/ practical approach to things as anti-_________.  I like to debunk myths. I like to question the conventional wisdom. This can frustrate people because these myths give them (misplaced) confidence. Conventional wisdom can be confused for evidence because “everyone knows _____ is true.”

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.”

I also tend to avoid the often hollow sounding, “It will all be fine” or “I had a VBAC, 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.

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

Someone recently posted in a group asking how they can get involved with birth advocacy. Other members and myself directed them to a variety of organizations like ICAN, Improving Birth, the National Advocates for Pregnant Women, the ACLU, and Human Rights in Childbirth.

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

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. There is not a Right or Wrong decision for all women, just a right or wrong decision for a specific woman. That is her decision to make based on information, not bullying or hysteria.

 

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.

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