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
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.
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.
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/