“Hospitals Cannot Legally Enforce VBAC Bans” and Other Juicy Advocacy Tidbits with Barbara Stratton

Barbara Stratton: But I can say that along the way, I was able to get someone on the phone in National Medicaid, which was no small feat, trying to get through the bureaucracy of the 800 number to a live person. And I spoke to a, a gentleman who actually is one of the people that processes these kind of complaints through the Medicaid system, and his answer to me was, Ms. Stratton, you're going to fail at what you're trying to do.

He said, because a hospital can put up any policy it wants, and that's okay with Medicaid and Medicare, but if they try to enforce it on the individual level, then we would have an issue. I said, okay, so to summarize in my own words, a hospital could put up a sign that says, when you walk in our doors, you give up all your rights as a patient to determine your care, and you're okay with that as long as they don't enforce that on the individual level. He said That's correct.

So my next phone call was to George Anis, the author who writes about medical ethics. And I said, George, this is what Medicaid is saying to me. And he said, Barbara, off the top of my head, I think they may be correct that legally or according to those guidelines that they have to follow, they can have any policy they want as long as they don't enforce it on the individual level. And of course that's a very hard thing to hear because one, it's impossible for us in birth activism to reach every single person who wants to give birth and give them this information and two, that's very difficult information to explain to someone and to relate to them, like, okay, well they can say this, but you know...

Jen Kamel: Hello, hello. Welcome to The VBAC Facts® Podcast. I'm Jen Kamel, VBAC Facts® founder and today I am so excited to welcome Barbara Stratton to the podcast.

Upcoming Events & News

Jen Kamel: But first I want to talk about my next speaking engagement, share some reader feedback about our episodes on the VBAC calculator, as well as share some observations I've had after joining TikTok this past month.

So first, my next speaking engagement which will be a VBAC training for a team within the Los Angeles County Department of Public Health this June. Specifically the LA team and stakeholders for the California Abundant Birth Project. I am so thrilled to support this project as well as the Los Angeles County Department of Public Health in their VBAC education. If you want to learn more about the California Abundant Birth Project, I'll include a link in the show notes.

If you want to learn more about the trainings that we offer and the various ways we can serve your team, unit, conference, or community, go to VBACfacts.com/speaking.

We get so much feedback from readers about our episodes, and if you want to share feedback with us, you can go to VBACfacts.com/podcast and submit your questions, submit your thoughts, submit yourself if you want to be on the podcast, and if there's someone else you would like us to interview. Let us know. You can do that all at VBACfacts.com/podcast.

And you know what would give me a big smile today is if you could just quickly pause and go to wherever you're listening to this podcast and leave us a quick five star review. And if you wanted to accompany that with a quick sentence, that would be fantastic because every bit of interaction we get like that helps communicate to the algorithm when someone searches for VBAC, this is what we need to display to them. Okay? So help us get our message out there. Help us and our mission of ensuring that people have access to evidence-based and respectful healthcare. Leave a comment. Leave a rating. Help people find us.

Reader Katelyn's Experience with the VBAC Calculator

Jen Kamel: But right now I want to share with you Katelyn from Ohio's feedback about her experience with the VBAC calculator. You may recall we've had a couple different episodes on this topic. One where we reviewed the evidence on the VBAC calculator and the other one when we brought on Dr. Nicholas Rubashkin, a physician scientist who studies the VBAC calculator. So Caitlyn wanted to share her experience:

"Just wanted to send a note to say thank you for sharing about the VBAC calculator on the podcast.

Yesterday I had an appointment with a midwife and she ran the calculator and it said I had a 25% chance of success. My first birth, I was induced twice, first time failed, and then I never progressed past four centimeters. But my baby did not engage and was sunnyside up. I finally couldn't handle anything anymore and my water had broken, so they only gave me so much time. Needless to say, I ended up with a C-section.

If I had only known how it would've impacted future pregnancies, I wish I could have gone back and done things differently. I just switched practices actually, because the OB who had the final say, whether he would support my TOLAC or not, which I just met for the first time last week, since every previous visit was with a midwife, said I didn't have many things going for me. And the only positive thing was that my baby was two and a half years old.

He kept questioning, why he took me on as a patient. Even asking the office manager why I was a patient there. And she showed him where he signed and circled okay on intake paperwork. He wanted to induce me on a Sunday at a different hospital than I had chosen because he was going to be scheduled there.

He also told me to get the trauma of my last birth out of my head because whatever your mind thinks, your body follows. I'm sorry. But even though we work through trauma and fear, I don't think we can ever totally forget it.

He also told me that second and third C-sections are an easier recovery than first time ones. My first one wasn't that hard, honestly, so I wasn't sure how to take that comment. Also said that with my stature, I'm five foot one, he wasn't sure if I could push a baby out.

After that I ended up switching to a different practice where I can TOLAC with a midwife. The midwife I switched to was super supportive and said I was a great candidate and totally deserved the chance to try. But yesterday I saw a different midwife and going over the calculator, I felt some of that same fear of failing creeping up.

But after listening to The VBAC Facts® Podcast episode about the calculator, it gave me a ray of hope again. It just seems like it's used for fear-mongering and trying to get you to cave to a repeat C-section. Not that I wouldn't have had another one if there was something medically necessary, but I wish they would stop using it.

Thank you for the work you do. I really appreciate the information you share. Keep up the good work."

Well, thank you so much, Caitlyn, for sharing your story because I know it will make a difference to the parents in our audience.

TikTok: Listen to Your Doctor!

Jen Kamel: And Katelyn's story here reminds me of an ongoing conversation we're having over on TikTok regarding provider support for VBAC.

In case you didn't know. Yes, VBAC Facts® has recently joined TikTok. So in addition to catching up with us on Instagram, Facebook, and LinkedIn, you can now go to TikTok and learn more about VBAC.

What I noticed in these conversations is that there are some major themes, one of which is if your provider says you are not a good candidate for VBAC, that means you're not a good candidate for VBAC and it's unsafe to have a VBAC. There is this idea that the only reason why a provider would tell a patient that they are not a good candidate for VBAC is because they really aren't.

A concept that goes hand in hand with that is this idea that all OBs have the exact same assessment and would have the exact same response. And so their recommendation is not just their recommendation, it is the truth with a capital T.

One of the things that I would love for parents and professionals alike to learn about VBAC is that just because a provider says someone is not a good candidate for VBAC, that doesn't make it true. There are providers in the US who don't support VBAC. Period. For anyone. Regardless of the clinical scenario, regardless of their medical history, they are not a candidate per that physician.

There were many professionals and parents alike over on TikTok who were quite outraged at this idea that if a provider said, you are not a good candidate for VBAC, that that was now irresponsible. It was now dangerous. You know, women were stupid for not heeding that advice.

But the anger is really misplaced there because we shouldn't be pointing at women and saying, wow, you're being really reckless because your OB recommended a repeat cesarean and you're ignoring that. Instead, we should go to these OBs who are recommending repeat cesareans for women who do not want them and do not need them, who recommend repeat cesarean for everyone because that is how they practice, and say, why are you doing this? This is unethical. This is wrong. If you don't support VBAC, okay, be honest about that.

I get messages like this all the time, but just this morning I got this direct message from someone on Instagram and she said, "it took three OBs before I found one I felt confident with for my first VBAC. I was lucky to find her while still trying to conceive. Immediately I noticed the language she used around VBAC was different. With the other two, the way they talked about it was as if it was the unlikely outcome and we should be expecting a C-section. With her, it was like the VBAC was what was going to happen, and the repeat C-section was a far off hypothetical scenario.

I would describe the first OB I saw as VBAC tolerant, the second as VBAC friendly, but the OB I chose was a true VBAC advocate, and I feel very blessed to have worked with her for two pregnancies.

But as far as the first two OBs, if it wasn't for your page, I wouldn't have noticed the red flags with them." And right there, that is the point friends. That is the point. When we act like all OBs are the same, that is a disservice. When we act like all car mechanics are the same or all teachers are the same.

You know, there's this, there's this immediate response that anytime there is an opportunity for improvement identified, people come up and say, well, not all OBs are like that, and I'm not saying that, so that's something that you don't need to say here in this space. We are well aware.

And the other refrain that I was hearing a lot was that, well, if, if a physician doesn't support VBAC, they shouldn't have to attend that. They shouldn't have their hand forced. And I hear that. And also when we are in a scenario where the patient wants a VBAC and the clinician is pushing for a repeat cesarean, what should happen?

And while there were OBs who were saying, oh yeah, well no one can force you to have a C-section. They were also simultaneously saying, well, I can opt out of that if I want. Okay, but let's think this through. If everyone opts out, where does that leave that birthing woman? Where does that leave her?

Because if you're insisting, you can just drop her from care, you can transfer her out to someone else. Okay. That works as long as there is someone supportive to transfer her to. And that was the point I was trying to make is that, what happens when we come to this crossroads where the physician says, I'm not attending this, and the woman says, well, I don't want a repeat C-section.

Let's look at what ACOG says. Let's look at what is the ethical thing to do. You know, in episode five, we talked about ACOG's committee opinion on informed refusal, which very clearly states in circumstances like this, we want to make sure that patients understand the risks and benefits of their options. We want to make sure that's an informed decision, but then you document and you proceed with what the patient wants.

And ACOG has so many golden quotes in that committee opinion. We go through them all in episode five, but I just wanna share this one , "in these circumstances, as in all clinical encounters, the obstetrician gynecologist actions should be guided by the ethical principle that adult patients who are capable decision makers have the right to refused recommended medical treatment."

And it was really surprising to me how many clinicians I was engaging with who one, did not seem to be familiar with this concept that ACOG, I mean, they've been saying this for decades, this isn't new information. Their committee opinion on informed refusal is simply one of the most comprehensive documents they have published on this topic.

And it walks clinicians through how to manage these scenarios of informed refusal. What does that look like? What should you do? And they're very clear that in these circumstances, no one should be coerced. No one should be forced. We shouldn't be calling the courts. We shouldn't be calling CPS. We shouldn't be calling psychiatrists in and threatening patients with psychiatric evaluations trying to act like they are somehow mentally unstable or unwell or unfit to make medical decisions. ACOG says, you should not be doing any of that. Because of our inability to see into the future and our inability to say, for certain, this bad outcome is going to happen. Patients have the right to make these medical decisions.

So one, clinicians were acting like they were unfamiliar with this, and then two, they were acting like they really didn't care. They just didn't care. I don't care that you don't want a C-section. You can't make me do this. You can't force me to do this. And then there was even people who were saying how bodily autonomy goes both ways as if an OB refusing to attend a VBAC is the same exercise of bodily autonomy as someone who is declining a C-section. I mean that it didn't even make sense.

And it was such an interesting dynamic because the idea that they are being forced to attend a vaginal delivery, which is within the scope of practice of an obstetrician. As well as obstetricians have all the skills to perform an emergency cesarean and respond to emergencies if necessary.

So the idea that an OB would say, I'm uncomfortable attending a VBAC, what they're saying is, is that I'm uncomfortable attending a vaginal delivery and I'm uncomfortable responding to the emergencies that can occur during that vaginal delivery, even though that is inherent within the job description of being an OB.

Anonymous, Disrespectful, and Full of Disdain

Jen Kamel: So this is the battle that women are up against, and it's one thing for us to be having these conversations on TikTok. It's another thing entirely when you have a woman who's 26 years old and she's pregnant after a a c-section, and her OB or her nurse is talking to her like this.

Because if we have these anonymous clinicians on social media speaking to other people, so disrespectfully and with such disdain, and I ended up banning, uh, quite a few people over the last few days because while we can all disagree, the second that you start attacking people, the second you start being rude, I just have zero space for that plus do you think they're showing up in their clinic speaking with their patients with respect? I don't think so. I think the way that you do one thing is the way that you do anything. And when people show up on social media, when clinicians show up on social media and they behave this way and they belittle people.

You know, I shared the quote from a parent who used the term VBAC and an OB came on and said, basically, "who are you? You don't know anything. You are not even using the right terminology. You should be using TOLAC." And I said to him, I was sharing the quote from a parent. I think you understood what she was trying to say, even though she used VBAC. I like to use the phrases planned VBAC or labor after cesarean rather than TOLAC, and I'm really encouraged that I'm seeing that kind of language used in medical research.

But it was so interesting how he was trying to devalue the message of what this woman was saying by picking apart how she said it. And I just thought, I wonder how you engage with your patients. Is it with this same level of arrogance, the same level of don't you know? Where is the respect? Where is the kindness? Where is the humanity?

Showing Up on Social Media

Jen Kamel: So, you know, one of the things I share is that when I'm on social media, when I write something, I write it in such a way that if it is written up on a billboard, I would be proud of what I write. And I notice that a lot of people do not do that. A lot of people want to just rip each other apart. And if your objective is just to, you know, get clicks and be dramatic, then that is certainly successful because we know that people online love drama.

But if your objective is to actually communicate something in a way that the other person might receive it. Then thinking about how you communicate is important. I know that's what's going through my mind. So I'm not coming with insults. I'm not being rude or crass. I'm really trying to communicate in a way that I think, this is the way I would want someone to talk to me, so this is how I'm gonna talk to you.

And even if the person that I'm engaging with on social media dismisses what I say, my words will still hang there. And maybe someone else will come across it and they'll read it and they'll pause. That's what I'm looking for because change comes when we all work together and when we're communicating together.

Concerns About Litigation

Jen Kamel: And one of the things that I saw on TikTok again and again and again, was concern about litigation. Well, as I pointed out to the people who were bringing this up, litigation has nothing to do with the risks and benefits of a particular woman having a VBAC. Litigation has to do with your fear of there being a bad outcome and you being sued. But that should not inhibit the process of informed consent because the person that you're talking to, regardless of the fears that you have in your heart, they still have the right to hear the objective, accurate risks and benefits of VBAC and repeat cesarean so they can make an informed choice. And when providers carry this tremendous fear about being sued, that can interfere with their ability to provide good ethical informed consent, where they accurately convey the risks and benefits and create space for the patient to freely choose.

And people were repeatedly sharing stories of how, well, you know, I know someone who, or I had a patient who had a VBAC, had a uterine rupture, and they sued and they had this incredible informed consent and yada yada yada. And I, I know that that happens. And also I hear what informed consent looks like.

I have countless women who are constantly coming to me and sharing with me. This is what my OB said, and I can tell you the feeling that I get is that the informed consent that most women receive about VBAC and repeat cesarean is quite insufficient. And we know that proper informed consent is protective in litigation. We know that cultivating a relationship, a good provider patient relationship is protective from litigation.

And when I shared that one clinician's response was, well, we don't care about relationships and we don't care about reviews. That's not what we're talking about. And she just completely dismissed out of hand what I had said, which that's not a statement that like I just made up. That's a statement that's based on the research that we have on litigation, why people sue, when we look at research on plaintiffs, why did they sue? These are the reasons why when we look at the characteristics of OBs who are sued, we see that OBs who have a more authoritarian, um, my way or the highway mentality, that personality style, that communication style, is associated with more claims.

So. It is interesting when I show up in these spaces and I talk and OBs wanna argue, they wanna disagree. And it's like what I'm saying is tied to the research. And if this is how you're showing up here, I'm getting a sense of how you might be showing up in clinic with your patients. And then I'm getting a sense of, you know, when we talk about OBs that are sued. All of this kind of comes together, right? The way we treat each other, the way we talk about informed consent, what information you think is important, what information you don't think is important.

And all of this isn't to say that, you know, if you do X, Y, Z, no one is ever going to sue you. But we know from the research that there are specific actions that clinicians can take. There are certain behaviors that are associated with lower or higher rates of litigation, and by employing these various methods, we can decrease the chances of litigation. And wouldn't it be incredible if it was possible to not only improve VBAC access and outcomes, but decrease your litigation risk while you do that.

Well, that is exactly what I spoke about at the Minnesota ACNM conference last October. I just did a quick one hour session, and then, as many of you know, back in April, I went up to Washington State and presented a four hour version of that training to a midwifery state organization.

You can feel the heaviness in the air at the beginning of the training. It's a huge topic, right? And as we move through the content, as we have real, open, honest, responsible, vulnerable conversations, and as people learn, how can I do this even better? How can I provide even better informed consent? How can I cultivate that relationship with my client? What are the specific actions that I should be taking to protect myself in the event that litigation occurred? What kind of team should I hire in the event that I do have a claim filed against me? When clinicians have that, there is a sense of power.

And there's this real aha moment of I really can confidently attend VBAC and support VBAC and also reduce the odds of being sued. And if I am sued, I know exactly that I have done everything in my power to cover my bases, to behave in the way that is in line with ACOG's guidelines. That's the right thing to do. And then also knowing exactly what type of legal team to hire and what kind of arguments to make. So this is part of the training that I do. I would love to come out to your community and offer this training because I see a need for it. And when, I mean, there were so many times on TikTok, people are like, well, why aren't you doing this? Well, why aren't you doing that? Um, I am, that is what I do. I mean, being on TikTok, that's part of the education process that I do. But, you know, I'm here doing the podcast. I speak across the country. I'm doing policy consulting, I'm doing expert witness work. I am doing the things. And also I am one person. So, you know, I have my team, but we are a small but mighty group. And so this is not just about you do this, you do this, you do this. You know, one of the things we're going to hear from Barbara is the importance of physicians getting involved with fighting VBAC bans and the power that they hold with that.

We heard in episode 13 with Dr. Stroud about how experiencing a uterine rupture, having a baby die, going through a lawsuit. He shared how that was something that he has never quote, gotten over because that was such a huge event in his life and in the family's life, who lost not only their baby, but her uterus, and so she could not have any more children.

So it's a human reaction to carry that pain with you, but the trick is, is to not let it interfere with the ultimate goal, which is providing evidence-based and respectful care. And if you missed that episode with Dr. Stroud, if you are struggling with this concept yourself, I encourage you to go check out episode 13 because I think the way he communicates it, I really hope physicians can hear that and feel that in your heart because that is the kind of duality we need in healthcare.

The Bait & Switch

Jen Kamel: And the third theme that was repeated continuously and even with a very healthy dose of hostility from nurses and doctors who were commenting was just the very quick and casual, find a supportive provider. Why are you having such a hard time finding a provider? You shouldn't be pushing VBAC onto doctors. This isn't something that you should be deciding late in pregnancy.

And it made me think, how can we have such a disconnect between what parents are experiencing and the perception that nurses and physicians have? I think it's very interesting because parents want a supportive provider and they go through quite a bit of effort to find the names of providers and interview providers.

But as I explained in one of the many comments was that there is this phenomenon called bait and switch. And that's where patients find a provider who seems very supportive and they settle in. And their pregnancy progresses. And then as their pregnancy gets further and further along, their provider starts to withdraw support. And now instead of saying, oh yeah, we're gonna have a VBAC, that's, that's the intention, that's what we're doing. Now comes the pressure to schedule a C-section. Reasons like, if you wanna go through the whole list, go check out, not only our episodes about ACOG's VBAC guidelines, but we have an entire episode about VBAC myths. But essentially the bait and switch, they are supportive and then they're suddenly not.

And one of the things that providers were saying in response to this was, well, this isn't a bait and switch. This is that the conditions change and now they're no longer a candidate for VBAC. And what I would love for physicians to do is to talk about how they practice. Rather than assuming that everyone practices like them, because I'm telling you, this is what is happening. So when people are telling you this is what is happening and you respond with, this is not happening, that's, that's called not listening.

So the response is not to blame women for the shortage of providers who attend VBAC. To act as if women are somehow the problem because they don't want elective repeat cesarean sections. The solution to this problem is increasing the number of providers who are supportive of VBAC.

And one of the comments I got was, well, the problem is, you know, liability concerns. That's why obs don't wanna support VBAC. Why aren't you dealing with that? At which point I brought up the fact that I do deal with that. And also, again, it's this idea of, well, why don't you do this? Why aren't you doing this? And to which I would respond, I am doing the work. What are you doing? Because see, this isn't, this isn't going around and pointing it like everyone else and you all need to do this. This is saying, what can I do? And then do it.

And so that would be something I would encourage to clinicians listening to and parents who are listening right now, if you want to create change. Think about how you can do that. There are so many opportunities for improvement. There are so many opportunities to have wonderful informed conversations.

Of course one of the first things I would say is whether you are a parent or a professional, come do VBAC education with VBAC Facts®. I mean, having solid information is the very foundation to advocacy, right? Because then when a situation presents. You know exactly what to say and you can take that right moment, that right time.

You could leverage that relationship you have and you can interject some key information that would be pivotal to that conversation whether it's VBAC bans or the risks and benefits of VBAC or long-term risks, or you know, the myriad of topics that we talk about.

Why "Find Another Hospital" Is So Hard

Jen Kamel: But back to this topic of find another hospital. Just find another provider I want to share with you, I think It is so easy to say, just go somewhere else. Just go to another hospital. But we know that for many women, that is not an option. And you might wonder why.

Well, there's a variety of different barriers. First and foremost, we have insurance. Not every hospital takes every form of insurance, and then you have issues around transportation. Say someone lives in a rural community or even an urban area. In rural communities, the issue is distance, right? In urban communities, the issue is traffic.

I mean, maybe there's a VBAC supportive hospital 50 miles away, but in an urban community, that might be a two hour drive. And what if you don't have a car? What if you're taking the bus? What if you're in a rural community and you are expected to take a bus 300 miles? Do you think that's going to impact access to care?

Absolutely, because then we look at how much time people have to take off for work. We look at the cost of childcare or having their children in tow with them. There are so many factors when we think about looking for another provider. What about the time of year? Traveling over snowy passes, traveling long distances in labor.

I really hope people see how what is possible in their community may not be possible elsewhere. And this is why we're here talking about the evidence on VBAC and how important it is to increase access. Because when we are all in our own little world, and we sometimes people tend to think, well, my experience is the experience, right? So if I live in a community and there's lots of VBAC options, certainly that must be the same everywhere. And I'm here to tell you, we know not only from the research, we know from patient stories, that VBAC is not equally accessible.

Now, we have interviewed practitioners who are very supportive of VBAC and in those communities that they serve, they are lucky to have providers like that. But don't take that to mean that there are providers like that in every community. So I think one of the messages here is that when people tell you that they are having challenges, believe them. Believe them. People are not coming into hospitals trying to like make a point with their VBAC. They're not trying to cause a problem. They're not trying to cause drama. They are literally trying to access evidence-based and respectful healthcare and your understanding of the larger issues around VBAC, the various factors that can inhibit access, will enable you to have more compassion towards people who might be having an entirely different experience than you. Okay, let's jump into our interview with Barbara.

Meet Barbara Stratton

Jen Kamel: Let me tell you a little bit about Barbara. Barbara is a mother birth activist, humor writer, and former doula. She founded the Baltimore chapter of the International Cesarean Awareness Network and was the National ICAN VBAC Ban Chair.

Her activism has included reversing two hospital VBAC bans, legalizing domestic partnership health insurance for gay Marylanders, before legal gay marriage, and helping to open a Baltimore City public charter school. And today she is going to talk to us about reversing VBAC bans. Welcome Barbara. I am so excited for you to be here.

Birth Words Poetry Magnet Set

Barbara Stratton: You very much, and we can add to the bio that I'm now also the creator of the world's only set of birth themed poetry magnets. It's a project I had wanted to do for a long time. I felt the birth community needed its own set of poetry magnets, and so I've created one and I now sell them on my Etsy Shop baltimoresoaps.etsy.com.

Jen Kamel: Can you tell us more? What are poetry words?

Barbara Stratton: So if you've ever been at someone's house and they had little rectangular magnet tiles with words on them that you could create poetry, that's the kind of set this is. There's 220 words. My set is queer inclusive, and it has hopefully all the words you would want and need to create poems about birth.

Jen Kamel: I love that. You know, that reminds me of when I homeschooled my kids many, many years ago. And I bought those same, not those same magnets, but that concept of magnets. And we would have that up on our fridge. And in fact, I bought little magnetic dry erase boards for them to practice their writing on.

And I still have one of those boards with all of my magnets on in my bedroom. 'cause it was such a sweet little memory and I love that. That's such a great idea.

Barbara Stratton: When people have traumatic births, I myself wrote a poem called "My Cesarean Poem" after my birth, and I often will suggest to women that they, make their own cesarean poem as a therapeutic step in dealing with what happened. And some people just really have trouble putting word to paper. So I'll say, well, here's a magnet set is a starting point. You can just push these words around. There's no need to try to, you know, create the wheel for yourself. Uh, so I think it'd

Jen Kamel: Yeah.

Barbara Stratton: tool for that.

Her Cesarean Poem

Jen Kamel: You know, you mentioned your poem. Barbara, would you be willing to share your poem with us

Barbara Stratton: Yes.

Jen Kamel: That you wrote about your C-section?

Barbara Stratton: So this is the poem I wrote when I was postpartum from my own cesarean, and I wrote it for one reason to be able to give it to people close to me, to help explain to them how I was feeling. My partner, when I had my first baby, felt like possibly I was the only person in the world that cared so much about how her birth had gone. So I, you know, I created this poem so I can hand it to them and say, this is what I'm feeling.

So it's called my cesarean poem.

I had a cesarean. I didn't want one. a baby. All wet and messy, onto my bare chest to comfort in his first moment by the stroke of my hand and a nuzzle at my breast. I had a cesarean, all Betadine and beeping machines and anonymous blue masks, seeing my insides and me numb to my toes with no feeling. Heartbreak, my plans and my dreams were betrayed by the orange attached to my chart for high risk. I didn't feel high risk. I hated that label. Who are these people? Did you start? here. I'm here. Why is no one talking to me? I hear my baby cry. My baby cry, but can't see my baby. My baby, my baby. Someone bring me my baby. No answers, no explanation. Am alone. Except for the blue masks putting my insides back in. He was brought to me already clean and wrapped and frantic. I couldn't even hold him. I'm sure it's not what he expected either. Then the blood, then the pain. belly no longer full of baby grew distended with air. It doesn't matter now. Woman number one said. I had three Cesarean. They're no big deal. Bitch number two said, your sister sprang right back. My mother said sister was 19. I have flashbacks, like a war vet. A sadness that no one wants to hear about and pain. It does matter. It is a big deal. It is a mourning. I had a cesarean. didn't want one.

Jen Kamel: Wow, that is really beautiful,

Barbara Stratton: Thank you,

Jen Kamel: beautiful

Barbara Stratton: heartbreaking.

Jen Kamel: and I'm sure resonates with many of the people listening. And if it doesn't resonate with you, remember that this is the experience of a lot of people, not all people, but a lot of people who have a c-section. And so we've got to keep that in mind when we interact with someone who's just had a C-section. This could very well be their experience.

Her Journey to Birth Activism

Jen Kamel: So one of the things we were going to open with was why did you become a birth activist? And I think we already got a little bit of insight into that, but can you share that a little bit more?

Barbara Stratton: So I think that my journey to birth activism started before I had even given birth. Freshman year of college, I took a woman's studies class and part of the assigned reading was to have a copy of the book, Our Bodies, Ourselves. And I remember reading the chapters on pregnancy and birth. With interest. And there was a photo in that book of a woman having a home birth surrounded by a small group of women who were there to support her in that journey. And I think it was at that point that that became my vision for my birth.

So where some people, some women, you know, say, well, I planned my wedding since I was a little girl. Birth became important to me years before I was pregnant for the first time. So when I did get pregnant for the first time years later, I knew I wanted a midwifery birth. What I didn't know was that there are different types of midwives and I didn't know about the dynamic and the politics between a birth center. And their midwives with their backup OBs and with their backup hospital. And I particularly didn't know that in the case of the birth center I chose that was attached to the backup hospital, that that is perhaps even a stronger issue and that they are very beholden to that backup hospital in their policies.

And then I specially didn't know that this particular midwifery practice was known for having a more medicalized approach, which we call medwives, and that they were known for having a high transfer rate, meaning they risk you out of midwifery care and you end up with their backup OB. So I developed a case of gestational diabetes, risked me out into their backup OB care. I still wanted a midwifery centered birth. The OB was willing to co-manage the birth with the midwives, the midwives were worried about getting paid, so they said no.

So because of the gestational diabetes, my son was estimated to be 95th percentile for size and weight. He was, encouraged to come out before he was ready, and as those things often go, I, I ended up with a cesarean. By the way, he was only eight pounds, seven ounces. And seven years later I had a VBAC of a baby a full pound larger, nine pounds, seven ounces. So within four months of my cesarean, I started my first activism. That was in the form of calling around the Maryland State government- I lived in Maryland -to try to find who was the keeper of the hospital cesarean rates. And I found them and they released them to me. And I became the first person in the state to ever have these cesarean rates released to the public. And then for many years after that, I would get fresh data most years, print them out and just hand them out like candy to anyone who would accept a copy.

Because I believe, you were looking at our hospital in Maryland that had many years the highest cesarean rate, and I don't remember exactly the numbers. It was somewhere in the low forties. I believe that if you're going to walk into this hospital that is sectioning 42% of the people that walk through the doors, that you have a right to know that. And so that was my first step of activism and that's how I got into the whole journey to reverse VBAC bans and other things.

Jen Kamel: Wow. Wow. Can you share with us why you became a doula? So what was the next step that made you think, okay, now I'm going to become a doula?

Barbara Stratton: Yeah, and that was the next step. So first I got the hospital cesarean rates, and then by the time my baby was two years old, I had completed training to be a labor doula. And my thought was that, I wanted to help other birthing people avoid the same fate of what had happened to me.

So I started attending births. It was a mixed bag for me though. One, when you're dealing with your own birth trauma, ending up in a birth where the birthing person ends up with a cesarean and seeing firsthand, particularly how sick she looked after the surgery when she was in recovery, was very hard. And seeing how birthing people are treated in a hospital setting, it was very, very hard on me. It dredged up a lot of things. On the other hand, you have one, the thrill of being part of someone's birth. It's a wonderful thing, you know, it's, it's just so special. And then you do have the cases where you did help this person have it empowered birth and you can carry that with you forever. You will be in their memory forever that you help them. So that was my next step.

Finding Post-Cesarean Support

Barbara Stratton: And then when my son was four years old, I had been, participating in the ICAN Listserv. This was back before Facebook groups. We had Listservs on Yahoo or another platform. And I had been participating with the International Cesarean Awareness Network Listserv for all of those years.

And by the way, it was an interesting story how I found ICAN. So I had my cesarean, I was devastated about what had happened I had never heard of ICAN. I called the hospitals in my city asked them, do you have a cesarean support group? And of course they all said no. And I think they kind of thought I had two heads. It wasn't until I think I called the Baltimore Birth Center I got referred to ICAN. I found them online and they became a lifesaver.

You know, when you have postpartum depression, sometimes you get insomnia. So there you are, up at two, three in the morning. There's no one in your support network you can call, ICAN Listserv was always there. And because of different time zones in the country, there might be someone online when you're on there at two or three in the morning. So I had used that Listserv to learn more about birth, to process what had happened to my birth and to move forward with education towards my VBAC.

Learns About VBAC Bans

Barbara Stratton: I started hearing from my involvement with the ICAN Listserv about the problem of hospital VBAC bans. And a VBAC ban means the hospital has decided that the birthing people do not have the right to choose to avoid a repeat cesarean. We call that a VBAC ban, and I was hearing that this was happening across the country. I had never heard that.

We had one in my state of Maryland, I had heard that in some areas it was so bad with so many VBAC bans that the people literally didn't have a choice in their region to get a vaginal birth.

And you and I had talked in our pre-session, it was Oklahoma where there was a complete VBAC shut down, we were hearing that there wasn't a single hospital in the entire state that was allowing VBAC, and it was because all the hospitals used the same malpractice insurance carrier, and that carrier wasn't covering VBAC. We did later learn that there was one teaching hospital in a major city, maybe Oklahoma City, that was doing VBAC.

Planning Her First VBAC Ban Rally

Barbara Stratton: So I've been hearing about these VBAC bans and I'm hearing that they're spreading across the country and becoming more prevalent. And then all of a sudden, in September of 2004, I hear that one has started an hour north of me at Frederick Maryland. And when I

Jen Kamel: What has started?

Barbara Stratton: VBAC ban at the hospital there.

Jen Kamel: Okay.

Barbara Stratton: And when I heard the news that they had launched a VBAC ban, immediately my thought to myself was, this is not going to happen in my state. So at the time, there was the birthing circle of Frederick, and I called up the president at the time, Robin O'Brien, and I said, you know, when Frederick Memorial Hospital fired their midwives, did the birth circle, have any response?

And she said, yeah, we wrote a few letters. I said, well, you know, now they've announced a VBAC ban. I said, do you have any response planned? And she said, no, not really. I said, would you like to co organize a rally? And I don't think Robin quite knew what she was getting into when she agreed. So we decide to plan a rally.

So we find out about the ban in September. We plan a rally for November. You have to check into permits and are you allowed to use amplification? And you know, where are you allowed to rally? And we plan a rally at a park in Frederick, and then we're going to march to the hospital. And, one fun part of the story was Robin and I, one evening were on the phone with each other, brainstorming sample signs that people could write to carry. My favorite one I came up with was Choosy Moms Choose VBAC. And so we created the sample rally sign slogans, which then later were shared with other VBAC rally planners. So it was fun to see them pop up in other media stories.

So we're planning this rally and the ICAN National Office had a PR director who taught me how to pitch stories to the media and how to speak to the media. So we're planning. And I start pitching the media. I pitch the Frederick News post. I pitch the Baltimore Sun. I pitch the AM radio news station. I pitch NPR in the Baltimore area, and I pitch the local TV stations. And when you're pitching the media, a particularly frustrating part is TV stations. These TV stations will give you kind of a lukewarm commitment that they'll cover your event, but then the day of the event, if there's other, any other big news story like a house fire or something, you're going to lose your coverage.

So I remember leading up the rally the week leading up to it, I was just calling these media places over and over and over again, trying to get commitments. And it got to Friday, Friday at 6:00 PM. I had not gotten out of my pajamas all day. I had not gotten my 4-year-old out of his pajamas all day. I was letting him watch cartoons, which was a treat for him, and I was so tired of calling the local media, I thought, I'm going to call the New York Times. So I get on the New York Times website and I search for a reporter who has covered other women's health topics, and I find Denise Grady. And there's her phone number. Six o'clock on a Friday night. Still in my pajamas. I have my media pitch in front of me, which is how I teach women now as well.

You have a two to three sentence pitch. Had it in front of me. I dial Denise's number, she answers her line, which was shocking to me. So I made my pitch there was a pause at the other end. And Denise said, well, we don't cover rallies, but why don't you send me an email with some information.

So I send Ms. Grady an email with a few bullet points, and one of them was, there are at least 300 hospitals in the United States that are currently having VBAC bans. And Denise shot back. Well, how do you know that number? And I said, because we called them because that's the year that volunteers with ICAN called every single birthing hospital in the United States and surveyed for VBAC bans.

I personally called all of Maryland, part of Pennsylvania and part of Delaware. And ICAN compiled the data into the ICAN VBAC Ban database, which they then put up on their website. It was the only source of that information in the country. No one else had looked into this. So that one phone call to Denise Grady became the front page article with photos in New York Times that broke the story in our country of the problem of the VBAC bans.

Jen Kamel: Uh, amazing. Amazing.

Barbara Stratton: And let me tell you, when you get in the New York Times, it goes everywhere. Everyone picks up the stuff. You would open your Yahoo email and there would be the story. It was reprinted with the LA Times. It just went everywhere. The day after the story hit, the Today Show with Katie Couric, trained up the chief OB from the Frederick Hospital to New York City to have him debate the president ICAN.

So after that story hit, after it ended up on the Today Show, eventually all the major news outlets covered the story: today, cnn.com, Newsweek Magazine, Time Magazine, LA Times, Washington Post. Everyone covered, and it was all because Denise Grady broke the story for us in the New York Times.

What happened after the article hit is for the next two weeks, the Frederick Memorial Hospital had media on their doorstep them up against walls with cameras in their faces, with microphones pointed at them, asking "Why would you force women to have surgery who don't want to have it?" And for two weeks this went on.

So we had our rally and it was a very cold day in November. And kudos to the people who brought their bundle up babies. It was, it was not a pleasant day for a rally. And to get the head count to 50 people, we had to add in the babies. So it was not a huge crowd. We did get our TV coverage. I love the TV station because when they put together the story for the evening news that night when we were marching, they clipped together various shots, various angles of us marching, and it made us look like we went on forever

Fighting the VBAC Ban

Jen Kamel: Oh

Barbara Stratton: it was just 50 people, including babies, that showed up for this cause. So you would think Frederick reversed their ban right away. They didn't.

It took a year and a half for them to finally reverse. And what I did in the year and a half intervening was every time I could think of a way apply pressure again, I did.

So when the state issued new hospital cesarean rates, and I could show that their cesarean rate had gone up since they invoked the ban, I called the reporter at the Frederick News Post and she ran a story. At one point I called the commission for women in that county and I said, do you have any idea that this is going on?

And they said, no, that's awful, we're going to call over there. And so anything I could think of in that intervening time I did.

First VBAC Ban Reversed!

Barbara Stratton: And so finally in August of 2006, they reversed the ban and immediately three out of four OB practices said that they were interested in offering VBAC there.

Jen Kamel: Amazing. Amazing. Yeah, that's incredible. The ban was reversed and immediately you have 75% of OBs saying, yeah, we'll offer VBAC.

Barbara Stratton: yes.

Woman Wants VBA2C, Declines Third Cesarean

Jen Kamel: So at one point, the Maryland Attorney General issued an opinion on this topic. Can you share with us what they said?

Barbara Stratton: So that came about because even though we reversed the ban at Frederick Memorial Hospital, I still became aware of an issue at some point after that where a woman named Laura was planning a VBAC after two cesareans, and she had been very clear with her OB practice in that area that she planned on having a VBAC after two.

But late in pregnancy, very close to her due date, they said, well, we need to schedule your cesarean. And she said, I'm not having a cesarean, I'm going to have a VBAC. And they fired her as a patient. With no notice they terminated her care. My understanding of patient abandonment is that it's not based on a statute, but rather what case history has shown in the courts, and that if a person is near their due date, they're considered to have a medical condition that requires ongoing care and that you can't just drop them like a hot potato with no notice. That likely you should probably give them 30 days of promise continuing care and make sure you follow up with them to make sure they find a new provider. And this didn't happen. She was just dropped with no notice and left floundering to find new care. So I decided to bring in the media on that one as well.

Maryland Attorney General: "Generally it is not legal to section a woman against her consent"

Barbara Stratton: And while I was starting to work with the media about her case, I reached out to my local elected official. 'cause in Maryland, you're not allowed to just call up the Attorney General's office yourself. It has to go through your elected official. So I called up my elected official and I said, Hey. I'm wondering if you could ask the Attorney General's office to issue an opinion on whether it's legal to section a woman who doesn't want to have a cesarean. So So she sent the inquiry out and the Maryland Attorney General's office issued an official opinion on their letterhead that quote, generally it is not legal to section a woman against her consent. So I provided the copy of that Attorney General opinion to the reporter for Laura's case and usefully they flashed it up on the screen right during their coverage of what was happening to her. We ended up relocating Laura to a different hospital. The story on the TV station had gone viral in the medical community, so when she landed at the different hospital, they definitely were treating her with kid gloves. Like, we don't want to end up on the TV news.

Laura did get her VBAC. It was not a super easy labor. And in fact, in the middle of the night, Laura had not hired a doula, birthing people should hire a doula, in my opinion, and she was struggling with her labor. And in the middle of the night, I found an angel doula who dropped everything and went to help Laura and helped her finish her labor and Laura got her VBAC. So that's how we got an attorney general opinion in Maryland.

Jen Kamel: Wow. Wow. So I want to back up a little bit.

Resources for Fighting VBAC Bans

Jen Kamel: So during this process of reversing the VBAC ban at Frederick Memorial, you created a Yahoo Group, which you used as a repository for resources for other people who wanted to reverse VBAC bans. Can you tell us a little bit about the kind of materials you had at this Yahoo Group?

Barbara Stratton: Sure. So I think it was along the way while I was working on that Frederick ban for a year and a half that I became the National ICAN VBAC Ban chair, and my role was to respond to inquiries for people that were fighting bans. My personal goal was to find a way to try to reverse all the VBAC bans in the country with one effort. Part of the role with the VBAC ban chair was I created this Yahoo group and I didn't want people who were fighting VBAC bans to have to reinvent the wheel. There's just no reason for that. So I loaded in the files, a sample rally press release, the sample rally sign slogans. I wrote up what I had learned from the national PR director, tips for pitching the media, and tips for speaking to the media.

Goal: To Reverse All VBAC Bans

Barbara Stratton: And then the list was also a way that people who were working on various VBAC bans could communicate each with each other about successes and challenges. So I ran that for a while. Then my overall goal, that goal of finding a way to try to reverse, just a small goal of finding a way to reverse all the VBAC bans in the country at once, led to a few different approaches.

When I first started it, activist Katie Prown and I, and an activist named Steve, I don't remember Steve's last name, used to meet by phone and strategize. Literally, what could we try to fix all the VBAC bans. What is the legal grounding for them? What can we use to challenge them? And we, we would have these phone calls and Katie ended up writing a document called a VBAC Primer, and I can put it up on their website. And she listed just everything that she could find in the research about the legality and how we might challenge these bans.

So one of the things that I ended up trying was what I call the Medicaid approach. The idea is, is that Katie pointed out that any hospital that receives Medicaid or Medicare funds, most do have to adhere to something called the Medicare Conditions of Participation. And they have to adhere to these for all patients, not just patients who are using Medicaid or Medicare. And part of those guidelines they have to follow include clear patient rights language. You know, that you have a right to make your own decision about your medical care and refuse unwanted treatment.

So I tried to implement this idea by having people file complaints at their hospital. And the point person that we started with is called, the Chief Compliance Officer for Medicaid and Medicare. So they would file these first level complaints, and the idea was that if the complaints were turned down, which in every case they were, the person would then appeal that complaint. It was a bit tricky through Medicaid to find out who you would appeal those to, but we learned that you would appeal to the Chief Compliance Officer for Medicaid, and then you would appeal to the office of the Inspector General at the Department of Health and Human Services. And then if that appeal failed, you would go to the Department of Justice. So this was our goal.

Where that project got, I couldn't follow through, is I wanted to write an appeal template for these people to use. I felt like it was important to put in that template, everything we could think of. I didn't want that template to be used and have the people that receive it have just one point and be able to refute that one point and turn down the appeal. So I went about doing the research to try to put every single thing we could think of in this template. And it was a huge project and I had a young family one point I asked one of the lawyers who helped with things in birth activism to write part of it for me, and she did.

But when she provided to me her section, hers was all written in legalese, in lawyer language, and the rest of it was written in "Barb the activist" language. And I remember thinking it was very hard to merge these two and I never finished the template. And so that's where we left off with that project.

Hospitals Cannot Legally Enforce VBAC Bans

Barbara Stratton: But I can say that along the way, I was able to get someone on the phone in National Medicaid, which was no small feat, trying to get through the bureaucracy of the 800 number to a live person. And I spoke to a, a gentleman who actually is one of the people that processes these kind of complaints through the Medicaid system, and his answer to me was, Ms. Stratton, you're going to fail at what you're trying to do.

He said, because a hospital can put up any policy it wants, and that's okay with Medicaid and Medicare, but if they try to enforce it on the individual level, then we would have an issue. I said, okay, so to summarize in my own words, a hospital could put up a sign that says, when you walk in our doors, you give up all your rights as a patient to determine your care, and you're okay with that as long as they don't enforce that on the individual level. He said That's correct.

So my next phone call was to George Anis, the author who writes about medical ethics. And I said, George, this is what Medicaid is saying to me. And he said, Barbara, off the top of my head, I think they may be correct that legally or according to those guidelines that they have to follow, they can have any policy they want as long as they don't enforce it on the individual level. And of course that's a very hard thing to hear because one, it's impossible for us in birth activism to reach every single person who wants to give birth and give them this information and two, that's very difficult information to explain to someone and to relate to them, like, okay, well they can say this, but you know... and I know you talk a lot in your work about the, the rights that individuals have, but it was just super frustrating to have that come out, you know, through Medicaid's own words.

Jen Kamel: Yeah, absolutely. But, and also I'm so glad that you're sharing that here because I have often said, you know, hospitals can have whatever policies they want, but you still have the right to say no, I don't want that to happen. But like you said, it's communicating that to people because people often think, well, the hospital says I have to do this, or I can't do this, and that means I have to follow whatever the hospital says. But it's so important for people to hear that is not the truth. So do not comply in advance.

Barbara Stratton: So I reversed the VBAC ban, they reversed August, 2006. I then gave birth to my VBAC baby, my nine pound, seven ounce VBAC baby in December of that year. So there I am in the postpartum period and within the first couple of months of having my new baby, a VBAC ban surfaced one county over from Frederick, and I thought, have these people learned nothing? You know, we stuck Frederick in the New York Times and on the Today Show and all this other negative media exposure, what is going on? And I was often the only ICAN chapter in the state of Maryland. And so I would end up helping people and sometimes in parts of Delaware and Pennsylvania as well, when there wasn't coverage.

And I started hearing from women in Washington County, Maryland that they were being told they could only VBAC between the hours of 7:00 AM and 3:00 PM that VBAC was safe from seven to 3, 3 0 5, not so much. And I thought, well, I can't wait to go to the media with that. So I start working on that. I was cranky about it.

I had a newborn baby. I remember sitting at my office desk and pulling out my, my drawer in front of me and setting my baby's Boppy on it and laying him across it and nursing him and reaching around type I. While I was working on this, I was not happy about it, not good timing, but I was not going to let it stand again in my state.

So that one only took four months to reverse. And it reversed in the way that the hospital said in the media that they denied that that had ever existed. They had said this to multiple people that had

Jen Kamel: Wait, so the hospital said they never actually had a ban.

Barbara Stratton: That they said, we never said that. Seven to three to people. And

Jen Kamel: Wow.

Barbara Stratton: that one. And by the way, a fun side note. Again, I only knew of the Frederick Ban at first. It turns out in Maryland, we had had a long standing ban on the eastern shore. I didn't know about several hours away from Baltimore at Eastern Memorial Hospital, and I had, I learned about that along the way. So when Frederick reversed their ban, you bet the first call I made was to the newspaper in the Eastern Maryland community. And I said in my pitch, your hospital, there is the only one in the state that is taking this choice away from women, bingo, they ran a story on it

Jen Kamel: Wow.

Barbara Stratton: That was fun.

The Secret to Activism

Jen Kamel: So I have so many questions. So first, what are your top tips about reversing VBAC bans? If someone wants to get started, and you've shared a lot about your own experience, but if someone wants to get started, what are the first couple things they should do?

Barbara Stratton: So along the way, I wrote an article called 50 Ways to Protest: A VBAC Denial, and it's still up on the Midwifery Today Magazine website. Give that a read through. Some of it is still relevant and it would kinda give you some ideas. I think my Yahoo list is still up, so they can also reach out to me and I could connect them with the resources I put up there. My general tip for activism is I always say the secret to activism is you pick up your phone and you open your computer and you just get started and you have to not be afraid to talk to people. You know?

One of the problems we have in the world of birth is that the medical community knows that overwhelmingly people giving birth tend to be young women and they take advantage of that. Often women that have not yet found their voices, and so I will tell people, you know, if you need something from your hospital that they're not, say you're doing your, your birth planning and you want X, Y, Z, and they're not allowing you, they're not giving that to you. Just call up the chief OB. They're just a person like you are.

And like with media pitches, you flub that call, or if I flub a media pitch, or if my voice is shaking, which it often is, the only person that's going to know is you and the person at the other end of that line. No news story's going to go out that Barbara called and her voice was shaking and she sounded like an idiot, right? So don't be afraid to call people and if you are a paying customer through your insurance, that hospital, they want your business, right? It's in their best interest to make you happy. I say, pick up the phone, open your computer, and do it. So I would read my article on how to reverse VBAC bans, and you don't have to start with a rally.

And I always say start with being polite. Asking. You know, sometimes people will say, well, I need a bunch of data to bring to these people so that they'll know, VBAC is a safe choice and that they don't need the 24 hour anesthesia. I get a little cranky about that 'cause one, these are providers, they should already know the data. Two, they probably do know the data.

You know, Frederick attributed their ban to safety. But really it came down to the cost of malpractice insurance and that there had been some, some large payouts in VBAC uterine rupture cases, but "it's all about patient safety." They would follow that with. And so I would start nice, and I suggest that you gather some other people who are affected by that ban, either in the past, the present, or will be in the future. Gather them together as a group that's willing to work on it. Doesn't need to be a huge group.

When you speak to the hospital administrators use the word "we." Use the phrase women in the community or birthing people in the community. We, we feel, what I'm hearing from people in the community, what women in the community have told me, make it sound like you have an army behind you. There may be just a group of five of you. They don't know that. I would speak to them in that way and I would ask nicely and I would give them some time to mull it over. In my mind, I would know how much time I was going to give them.

And then at the end of that time, if they don't agree to remove the VBAC ban, then I would move ahead with more aggressive things, maybe the rally, maybe the media. As you can hear from my stories, the media is a very, very effective tool and I can help people. With these guidelines, I wrote how to pitch the media and how to speak to the media so I would do that. And petitions, not a super fan of petitions. I am a fan of approaching the hospital from every angle possible. So you heard me say I called the local commission for women in that county and made an inquiry.

Years Katie Prown and I got the National Organization for Women now to issue a resolution in opposition to the VBAC bans. So we could call the local NOW chapter and maybe they'd make an inquiry. I even called the police in that county where Frederick Memorial is located and said to the police, if we called you from a labor room with a person being forced to have a cesarean they didn't want, would you come? Unfortunately, their answer was no, we'd consider that a civil matter. But I just reached out to anything I could think of, anything I could think of to apply pressure from any angle.

Go ahead and file that first level Medicaid patient rights complaint. They will have to respond to it. They're required to respond to it. Make them feel like you're coming at them from all angles because you are, and hopefully they will see, you know, that their correct way out is to remove that ban.

Jen Kamel: When you think about engaging the media, what are the top things that people need to keep in mind?

Barbara Stratton: Not to be afraid to do it. And in the very brief, simple, easy to understand guidelines that I wrote based on what I learned from the ICAN PR person, there's just a certain way to pitch. There's a certain time of day that's best to pitch print reporters. There's a certain time of day that's best to pitch TV reporters. And then when speaking to the media, there's just a certain way to speak to them and have your pitch written out. Just two or three sentences. Practice it. Literally, you can read it when they pick up their phone.

It's not rocket science. Sometimes you need to be a little persistent, like with those darn TV stations. But you can pitch the media. I have since then pitched the media a multitude of times. Often with success. Not always with success, but you know, you want to have a good pitch. You know, the community hospital telling people that they can only be back from 7:00 AM to 3:00 PM that's a real good pitch. A woman who is being fired from her practice right near her due date. That's a good pitch.

Work with Barbara 1:1

Jen Kamel: You know, as I hear you talking, I can envision advocates wanting to have a call with you to talk about their individual situation. Do you offer consulting for this kind of work?

Barbara Stratton: I do, and I haven't put my website up. I actually have to do it to earn a living now. So if they're willing to pay a consult fee, I would be glad to talk to them. I wanted to add in another example of activism for people that are on the fence about whether to take something like this on and to stress.

As you hear from my story, the difference that that one rally, 50 people, including babies, and that one phone call to the New York Times, the difference that that made in the birth activism on VBACs. 'cause I can tell you that that first story that Denise Grady put up for us, the beginning of the media pressure on ACOG to reverse those VBAC, to revise those VBAC guidelines.

Speaking Even When Your Voice Shakes at the NIH VBAC Conference

Barbara Stratton: 'Cause you remember, this is back in 2004, in the VBAC guidelines, we still had the immediately available anesthesia requirement, and that was being used to justify a lot of the bans. That article started the media pressure and then all those follow up stories that later happened applied pressure to ACOG to revise those ending, in my opinion, you and I were both at the NIH VBAC consensus hearing in 2010. Gathers experts on a topic, they have a panel, they have presentations of research, and at the end they issue an opinion on that topic. So 2010, it was VBAC. You and I both went, you and I both spoke at the microphone. Here is an example of speaking, even if your voice shakes

Jen Kamel: Yeah.

Barbara Stratton: audience was very intimidating. We were on camera broadcast across the world. We had in the audience there, the president of ACOG. We had the midwives, we had our peers. And there are these microphones in the audience that you can go up and stand in line to speak. And when NIH gave its proposed document that they were going to issue about VBACs, we all went to the microphone to provide our feedback. And I went up to that microphone, my voice was shaking and I said in these guidelines, you have said that the decision on whether to VBAC should be made between a woman and her provider, then I am here to tell you that you need to add into that document, but ultimately, the decision rests with the woman because those of us who work in this field regularly have forced cesareans dropping in our inbox, and if you don't include that language, we'll continue to have this problem.

And behold, August of that year, just a couple months later, ACOG revised their guidelines and they started emphasizing that you should not be forcing birthing people to have cesarean that don't want them. That all to me started because we had a rally of 50 people in Frederick, Maryland.

Changing Hospital Placenta Policy

Barbara Stratton: Another example I give of my activism is on placentas. A woman came to ICAN who was not a previous cesarean, but she was a woman that probably normally would've birthed at home, but she had a failing heart valve, and she, because of that, had to birth at baltimore's high risk hospital, Johns Hopkins downtown, and then after giving birth, was going to have to get a new heart valve.

So this woman had expressed to the hospital she wanted to bring her placenta home, and the hospital said, no, that violates the Maryland medical waste disposal law. And I said, well, would you like a little help with that? And she said, yes.

And I had a lawyer in my ICAN chapter and I said, Hey, could you find out what the Maryland code says about placenta? She digs out the code in the Maryland codes and says, hospitals can release placenta to families or funeral homes. So she said, Barbara, I think, I think we're okay. I think the woman has the right, she said, but, just to be clear, I would find the person in the Maryland State government who's in charge of enforcing the placenta code and just verify with them.

So this was a fun round of calls. Hi, I need to find the person who's in charge of enforcing the placenta. What need? What? What'd you say? It took so many phone calls and when I finally get the right person on the phone, you have to use humor. So I said, Hey, is it safe to say I'm your first placenta call today? He said, yes, you are my first placenta call today. And so I told him what our issue was and he says, I, I think you're under interpreting it correctly, but let me get back to you. He said, I might write you, get you an attorney general opinion on this. And I thought, I've already had one of those. He came back and he said, you're correct. The hospital has the right to release it. The woman has a right to receive it, and any hospital legal person that needs that clarified is welcome to call me at this number. So then I wrote up a little document, placenta versus Maryland Law. I listed the code, I listed his name and contact info and a few bullet points, and then I distributed it to the doula community so that they would know that for their clients.

Examples of In-Hospital Advocacy

Barbara Stratton: I can offer a story about how my activism has affected my relationship since then with the medical community for both

Jen Kamel: Yes.

Barbara Stratton: because I, it, I found my voice, right. I found my voice and I have an entirely different relationship with the medical community for myself and advocating for my family members.

Now, am I always perfect? No, I'm not always perfect, but you know, my second baby ended up needing to be briefly hospitalized for something and, you know, you're in the hospital, so they immediately wanted to do lots of invasive tests, and I didn't feel that all those invasive tests were necessary. it ended up where the chief of pediatrics for the hospital is in my room with my son and me, you know, I'm trying to breastfeed, I have a newborn baby.

And we discussed this one topic, and I start spewing the research. I'm like, well, I know that X, Y, Z and X, Y, Z and X, Y, Z and dah, dah, dah, dah, dah. He just looked at me. And said, well, how do you know that? Because I'm informed, you know? And

Jen Kamel: Yeah.

Barbara Stratton: what we're basing this decision on. And he was shocked that I knew those things and that the plan forward that they were proposing was not cut and dry because you know of these variables.

Biggest Issue in Birth Activism: The Elusive First Time Mother

Barbara Stratton: So my hope, you know, I say that one issue with birth activism is that most of the people giving birth are young women. The biggest issue probably in birth activism, is how to reach the elusive first time mother.

Jen Kamel: Hmm.

Barbara Stratton: How do you reach her? How do you reach the person who is not taking a quality non-hospital affiliated childbirth class? How do you reach the person who's not hiring a doula? How do you reach the person who's not finding your podcast, who's not finding ICAN? And

Jen Kamel: Yeah.

Barbara Stratton: It when first time parents found ICAN before they had their first baby, that we could get them informed about what birth is like in our country at this time. How do you reach the person who's not getting the library books, who's not buying the books online? That, to me, always been the biggest issue.

Now, one solution that I had for, that didn't solve the whole thing, but one idea I came up with was when I created the art exhibit, Cesarean Voices. My idea with the art exhibit. Was that in putting together an exhibit of artwork by people who were impacted by cesarean, we would be reaching new audiences. We would be reaching some people who were not looking for that information, partly because we'd have media coverage with the art show. So I got a volunteer curator who was part of the arts community.

We wrote up a call for entry. She sent it out in the art circles. Again, new people. Right. Hopefully reaching new people. And then I sent it out through the birth community. We received submissions. She juried the show. We ran it in Baltimore one weekend. Soon I hope that the artwork will be available online through a national museum.

So I think in birth activism, we have to think of more and more ways. To try to break through the noise to get to these people that aren't looking for the information. Because you know, I'm still on the ICAN support group. It's no longer a Listserv, it's now a Facebook group, and every day women join. I wish I had known, I wish I had known. If I had known, I would have done differently. So to me, that's our

Jen Kamel: Yeah.

Barbara Stratton: challenge.

Mothers: "I Wish I Had Known..."

Jen Kamel: Well, and when you hear from these women about what they would've done differently, what are the major themes that you hear from them? What are the things that upon reflection, they realize, oh, I really wish I would've known x.

Barbara Stratton: Definitely the things about big babies. That big babies need to be induced that the testing in late pregnancy with ultrasound to measure fetal baby size was done. That their baby was estimated, like mine was in my first pregnancy, estimated 95th percentile for size and weight. He ended up only being eight pounds, seven ounces. And again, I VBACed a baby who was nine pounds, seven ounces, and I would add a genetically large head.

So the the big baby, the fear mongering that comes along with that and the arbitrary end to their gestation through, you have to be induced because you haven't started labor. You know, what is the word on the street now? They shouldn't be doing that before 41 weeks. Is that the current guideline?

You know, when I was a doula, I had a client who was aggressively induced for really no medical reason. it was extremely painful. She was on high dose Pitocin, trying to do it with no epidural, which is almost cruelty. And after her surprise, cesarean, we're still stitching her up kind of thing, the OB's talking to the nurse about, remember the days we used to let women go to 42 weeks? No, we don't do that anymore. Right?

And I created something called a spectrum of care provider choices, and when I get the opportunity, I will offer it to people on that Listserve. The idea is the that type of care you're going to receive in your pregnancy and birth is dependent on the type of location and provider that you choose, and so I created a spectrum with all the way, at one end would be a home birth with a midwife, and all the way at the other end is OB in a hospital and then there's some steps along the way. The type of care you're going to receive is going to depend on where you land on that spectrum.

So for example, if you're using a home birth midwife, she may educate you prenatally about Spinning Babies, the way that we try to prevent malpresenting babies. Many of us were sectioned for babies who were sunny side up. So Spinning Babies. And then if in labor, your midwife determines, or your doula and midwife together, 'cause doulas sometimes can catch this, that you're having a posterior labor that the midwife may suggest positioning changes. They may whip out the traditional scarf called rebozo. If you're over at the far end with OB, I hate to simplify it, but if your labor does not come progressing naturally at a good pace, it's going to be, we're going to rupture your bag of water, we're going to administer Pitocin. You may end up with some forceps and then a cesarean. So look at the difference in the types of care. So every birthing person, 'cause there's no one right answer, but every birthing person needs to take a hard look at the model of care they've chosen and where they're landing on that spectrum.

So if you're a first time mom. Know that hiring an OB for a healthy normal pregnancy is overkill. And the analogy I give, it's like hiring an electrician to change your light bulbs, right? The electrician is not going to want to sit around and wait for your light bulbs to burn out. And they're going to get bored of changing light bulbs. You know, eventually they're going to want their good skills and training to go to good use. And OBs are trained surgeons, okay? So if you're hiring an OB, you're at complete overkill for a normal, healthy pregnancy, and you are removing those extra tools that help babies get born vaginally that you would've received. If you had gone further down that spectrum and bringing a doula to your birth, no matter who you hire is your provider, no matter what birth location brings that extra set of skills.

Jen Kamel: I really hope we are getting some first time parents who listen to the podcast because this is exactly the kind of information that they need in order to avoid that C-section so they're not in this new category of people who are trying to find access to care after a cesarean.

Barbara Stratton: Yeah. And I was just, you know, we shouldn't argue with people online, but just yesterday I was arguing with someone online. A study had gone up about VBAC and uterine rupture risk and an OB jumped on. And you know, one of the things I said to her was, well, you realize the primary cause of VBAC is the primary cesarean. Right. You know, we wouldn't be in this boat.

And you know, there was a point where two states in our country, Virginia and Florida, released OB specific cesarean rates. And they don't anymore, but they did at one point. And in Virginia it was the primary cesarean rate, meaning the cesarean rate among first time parents. Some of the numbers were stunningly high.

You know, wouldn't it be nice if all birthing families knew that they were walking into an office and hiring a provider that was sectioning a very high percentage of the first time parents, and as your readers know, once you've had that first cut, the rest of your reproductive career, you are labeled a VBAC. You know, even if you go on to

Jen Kamel: Yeah.

Barbara Stratton: your next birth, you're still a VBAC. So I know you emphasized the importance of avoiding that first cut, I thought I was educated enough. I was not educated enough. I thought picking just midwives was enough. It turned out I picked for my type of goals and values, the wrong kind of midwife, the wrong birthing environment. Information is key. Avoid that first cut.

Jen Kamel: Yeah, absolutely. So what were the most challenging parts of reversing that initial ban and even that subsequent ban?

Barbara Stratton: So the time it took to reverse Frederick was very, surprising to me because of how much negative media exposure they had on this topic. It was frustrating and you know, one of my favorite quotes that one of our marchers in the rally gave to the TV coverage the reporter probably asked this person, well, you know, the hospital is saying this has to do with liability insurance and the cost of liability insurance, and the woman responded well, then the physician should be fighting for the women too.

It's frustrating to me that myself and other people had to spend our time and our energy to reverse something that should have never been there to begin with. You know, in this case, in the case of the second ban, you know, when I have a new baby at home, it's very frustrating to me 'cause it's just so clear that those bans should not exist. So that would be a big frustration and certainly not having Frederick readily reverse their ban, you know, for a year and a half was frustrating.

Most Successful VBAC Ban Reversal Strategies

Jen Kamel: So I'd love to go back to the Frederick Memorial VBAC ban reversal, and can you share with us the most successful strategies you used as well as the ones that you tried and you thought, eh, I probably won't do that again.

Barbara Stratton: So as I was working to reverse that ban, of course I'd never done it before, and you don't know until you're done, you know, which things are going to work and which aren't. My approach was to just throw everything at it that I could think of. Just constant brainstorming, you know, to throw everything at it.

And, you know, I do think clearly the media is a very important component. These, you know, what I have heard about hospitals is they want business for their birthing services. And that one reason for that is if you enter the hospital through their birthing services, then throughout your life cycle, you tend to continue to use that hospital for other needs. So they want your business for this and they don't want to look bad in the community.

So when you say to them, women in the community are telling me you're only going to allow VBAC from 7:00 AM to 3:00 PM, I'm hoping they know how ridiculous that sounds. How ridiculous that is to be out in the world, that message. So I think the media is probably the most powerful tool if you start with the approach of asking nicely and they don't agree.

So definitely the media, I can't think of anything that I felt was not useful because again, when I inquired with the local Women's Commission and they made an inquiry to the hospital, that was just to me another way to apply pressure to that hospital. To let them know the people in the community are noticing what they're doing. So I would say probably the media is the strongest thing to use. And you know, I can't think of anything that, uh, that I felt was a failure.

You know, it's hard in activism. I know. I hear you say, you know you have a thousand or more women's birth stories in your heart that you keep dear. You know, when you're an ICAN chapter leader, you're exposed not just to the births in your own community, you're exposed to what's going on across the country and across the world. The positive of that is you, you know, you really have quite a grasp of what's happening in birth in our country. The negative of that is that you have those horrible stories in your heart.

A Forced Cesarean

Barbara Stratton: I'd love to say to you that after the ban was reversed, I had my finger on the pulse of that hospital and can give you a huge follow up on how things went from then on. I don't. The hospital is an hour north from where my ICAN chapter was. I was quite busy with my ICAN chapter. I led it for seven years. I can tell you though that later on we had a forced cesarean at that hospital. Not a coerced cesarean.

I got the phone call. It was one of those ones that it breaks your heart. When I say forced cesarean, I mean the kind of thing where they send the husband off to park the car. The woman has had an epidural, so she can't get off the hospital bed, and they gurney her down the hallway and they've tied her down and they section her without her permission. It is very hard to receive those phone calls. And I was very surprised to hear that that was happening at this hospital.

So getting one right from my own state, in Frederick, of one of these forced cesarean, and then women after these forced cesarean are recovering from surgery, taking care of newborn babies, and they're completely traumatized. You know, it's very hard for people in that condition to move forward to do something about what happened to them.

Jen Kamel: Yeah. Yeah. Well, and talking about lawsuits, it makes me think of how I'll be interviewing Hermine Hayes-Klein where she will share the story of a $1.73 million jury verdict she helped secure for her client. So, and we will dive into that whole topic a lot more. So thank you for bringing it up. You know, when you were working with Frederick Memorial, did you have the opportunity to speak with OBs or anesthesiologists that were there before or after the ban dropped?

Barbara Stratton: You know, it's an interesting question. I never spoke to the chief OB. I had spoken to their PR person. And he had my personal cell phone. And one day I'm at a Baltimore City animal shelter looking for a new pet, and my phone rings it's the chief anesthesiologist at Frederick Memorial. One, I was upset that the PR person who'd given out my personal phone number without asking me, and then two, to have this anesthesiologist call me. You know, and he just wanted to make some points about the cost of liability insurance and how it made it hard to practice in the state.

Not to sound cranky about that point, but you know, I live a modest lifestyle. Driving an old car, living in a ramshackle house, at that point, and I know someone who worked in the home of the chief OB and I, I spoke to her about that, you know, and all the time and energy we had to put into this fighting this ban and how they claim it's 'cause they just can't make a living because of these high costs of malpractice insurance. And her response was, well, he and his wife have a nice house and they drive two nice cars. And again, back to that point that they should be fighting for the women too. You know, if when someone says, well my hospital says they can't allow VBAC 'cause the malpractice insurance won't cover it, my response is tell 'em to call the next hospital over that is offering VBAC and ask them who's providing their coverage. And why don't you switch to them? You know, I mean, you're supposed to be as the, as the caregiver of women's health. know, let's, let's lift an activist's finger and take care of the women that you're supposed to be taking care of.

Jen Kamel: Well, and the other thing that comes to mind for me is that blaming malpractice insurance, it feels like a very firm response, like a very legitimate response, " well our malpractice insurance coverage doesn't allow VBAC", but it's the kind of reason that is very hard for people to verify, you know, people like you and me. How would you verify that? What is the coverage?

And I find that nine times out of 10, it is a misunderstanding or maybe a blatant misrepresentation of what the coverage includes or doesn't include. So I would push back on that, just like you said, because if there are hospitals who are offering VBAC, clearly there are policies that accommodate it or hospitals find a way. And that's the thing.

It's like when there is a barrier, you find a way around that barrier. You don't just say, well, the barrier's there. Oh, well. We need to keep fighting. And like you said, it shouldn't just be on the shoulders of the advocates.

And I think about how when Frederick reversed their VBAC ban, 75% of OBs supported VBAC and I think, where were they when this ban was enabled? Think of how easily 75% of OBs could have banded together and said, "Hey, we all want to support this. This is an evidence-based choice. This has major public health ramifications when we tell women their only option is a repeat C-section. Let's change this for the better." I think physicians also need to stand up and realize how much power they have within this system, to get together, to team up with advocates to create change. We can all do this if we all work together. That is within our power to work together and create change.

Barbara Stratton: Yeah, for sure. And you know, the cranky side of me. You know, we talk about what are the benefits to a provider for doing cesarean. Henci Goer has an article she wrote about the economics of medical care, I learned from that article that there are two ways in a medical environment to increase revenue. One is to charge more for a particular procedure, other is to do more of those same procedures in a given amount of time. so cesarean accomplishes that on both fronts. They do pay more, they do charge more, you can do more cesareans in a day than you can waiting for those pesky first time laboring people to proceed through normal labor.

You know, are all the OBs bad guys? Of course not. But there is that incentive. And then the real factors in their lives, they're often in their childbearing ages as well. Who wants to get woken up in the middle of the night? You know, a solution to that is change where you land on that spectrum of care provider choices. Our midwives are the gatekeepers of normal birth.

You know, compared to the analogy that hiring an OB is overkill, midwives are the gatekeepers. They're trained to get babies out without Pitocin, episiotomies, and cesarean, they're trained to think on their feet. Whipping out the rebozo, the traditional scarf to help sift a baby and change the baby's position and get it born vaginally. These are skills they had to develop over the years before there was a medical backup. They had to save lives. They had to have the skills. So let's take a hard look at the type of care that you're choosing right off the bat for your first pregnancy.

And, you know, women will often say, well, you know, I, I like, I like my OB. You know, I've been with 'em since I was 16. I'm like, great, take him or her out to lunch. You're not going to see them in your labor. You know, they're going to come in the last hour. You're not going to see them. Your labor's going to be managed by people in the hospital and are they really there to provide you the best skills, resources, knowledge to get that baby born vaginally? Whether you care like I did about your birth, whether it matters to you, whether you have a cesarean or not, I'm not here to pass judgment. You have the birth you want, but you have to come to that birth from an informed place.

The fact is that cesarean carry risks and like you've talked about on your podcast, how when OBGYNs are counseling patients about the risks and benefits of VBAC versus cesarean, that they just brush over the cesarean risk part.

And one of the things stuck in my head is the list of bad cesarean stories. I actually kept a file for a while for speaking in the media of horrible cesarean stories of people willing to speak out about them. You know, the 23-year-old mother in Baltimore City who was induced only because her partner had been a large baby at birth. That was the whole reason and the induction failed. She was given a cesarean and bled out. Had to have a hysterectomy. A first time mother and that ended her reproductive days right there, you know, heartbreaking stories. So would that have happened likely if she had been pursuing a non-interventionist vaginal birth? I am guessing not.

You know, another heartbreaking story. We had a woman in Maryland took her 10 years to conceive. Got pregnant, had a breech baby. Breech is one of those issues. You've gotta get your facts and make your own decision based on your own values and where you want to place the risk on the cesarean or the vaginal birth, she chose the cesarean. I'm sure that was what was recommended to her. And a week later, she had a deep vein thrombosis and died before she could get to the hospital. You know, first time mother, 10 years to conceive. I put her on Good Morning America. These are heartbreaking stories. And if I have this head full, that happened just in one state, just in the time that I was very active with my I can chapter. know these are multiplied across the country.

The Idea of Fault

Barbara Stratton: A friend of mine who had a lower transverse incision with her first baby, she was in my Bradley childbirth class. When she went to decide for her second birth, and they were estimating big baby. And she did grow healthy sized babies, as do many of us, as do many successfully birthed them. In my ICAN chapter, we had a woman whose first VBAC was 11 pounds four ounces. And her second VBAC was 11 pounds and came in four hours but this particular

Jen Kamel: Wow.

Barbara Stratton: She chose to have a repeat cesarean and she said to me, Barb, I feel like if something goes wrong during the cesarean, that it's their fault. And if something goes wrong during the VBAC that I've chosen, it's my fault. And in the end they did the repeat cesarean because of scar tissue. She had to have a classical incision for her second one. So she now has scars in both directions on her uterus. Um, there was something about a hernia with mesh being put in as well. It was, you know, kind of an all a big mess. She didn't have any future children after that. I don't know if that was originally her plan or not.

And I know that, when you've interviewed OBGYNs, they've said that same thing. Well, if something goes wrong in the surgery, then that's the fault of the surgery versus, the VBAC, somehow that's my fault or the patient's fault for choosing it. You know, that's a hard thing to hear people say. And my goal is never to dictate how someone gives birth. My goal is to want them to get all that information and then to make their informed decision and to have that decision honored by their team. And sometimes that decision is a repeat cesarean, and sometimes that repeat cesarean is their empowering birth.

I had an ICANer who was treated so poorly during her first birth in her cesarean, when her second one, which was a trial of labor, ended up with a repeat cesarean, and the doctor came in remorseful after to talk to her about it. She said, stop. It's okay. You treated me nicely.

Jen Kamel: Yeah.

Barbara Stratton: made all the difference to her. She just wanted to be treated well and her birth, and that became her empowering birth she was treated respectfully.

Jen Kamel: Well, and I want to circle back to that concept you brought up about how when a complication arises out of a C-section, it's seen as something that is uncontrollable and no one's fault. And yet, when a complication arises out of a VBAC, there's this notion of, well, someone needs to be responsible. Someone, someone made a mistake, there's someone that needs to answer for this.

VBAC Planning Tips

Jen Kamel: I want people to pause and think, if those are the thoughts going through your head, think about why you believe that. If we can understand the thinking behind that idea for both birth professionals and parents, I think we might get closer to why there is this bias, this inherent fear about VBAC, because cesareans feels controlled and VBACs feel a little bit less controllable.

But the reality is, is that we can have a bad outcome in either scenario and in both scenarios, the overwhelming majority of the time, mother and baby are healthy. So we need to somehow, and for me, I feel like that's the power of the research is being able to align.

Okay, so here are my fears, but let me look at the research. How likely is it that we are going to have a bad outcome? What are the types of bad outcomes that we have? Repeat cesarean versus VBAC. How do those choices impact our birth options for the remainder of our reproductive years? And as you shared earlier, when you have someone who goes in and understands the facts, providers look at you entirely differently because they see you as someone who is engaged, informed, committed, really cares about this outcome, and I think good, bad, or indifferent, that is, that is the truth. And so that is why I think it is so important for parents to take the time and invest in learning about VBAC, so that way when they go in and interface with providers, they sound like they understand the information.

Barbara Stratton: important for people that have situations like now they're VBACing after three cesareans. I know you speak quite a bit about how provider options drop off after that second cesarean, and when I teach VBAC 101 classes, most of the couples that have come to me are having VBAC after one cesarean.

And I warn them in those classes, I say, look, here's how important it is to get this next baby vaginally. If you want more children after this, or if you might even have an oops baby, as often happens is after that second cesarean, and I'll do the shrinking motion, your provider options go down to here, and if you have a third cesarean, your provider options are. Almost non-existent. You're looking at traveling to another state. You're looking at paying to bring a traveling midwife to your home. You're looking into having an unassisted home birth.

So it is extremely important if you plan on future children, make the choices you need with this VBAC to have the highest chance of success. Get your cesarean rates and your VBAC numbers from your ICAN chapter, or if there isn't one from your state government, look around. Ah, the hospital I've picked says they allow VBAC, but they only did 13 of them last year. Otherwise they have a 39% cesarean rate. There's a red flag for you there. Pick the model of care that is going to give you the highest likelihood, and then do as little to that birth as possible, because the best way that birth works is to do as little of it as possible. My midwife has a 97% overall vaginal birth rate, 97%, and I always give that example as well. Clearly, women's pelvises are working pretty well, the vast majority of the time, if you let labor proceed in a normal way, and the very first intervention to avoid is the induction.

Learn your facts before you get to 40 weeks pregnant. Know your facts on post states. Read the studies, and make your own decision. Does risk of stillbirth go up after 40 weeks? Yes, by a very small amount. The number is already small, and then it just becomes a little bit worse. I looked at that and I thought, well, I'm comparing those risks 'cause I did go 42 and a half weeks with my VBAC.

I informed myself of those numbers and I compared those numbers of the increased risk of stillbirth to all the risks that come with cesarean section hemorrhage, infection, anesthesia mistakes, injury to other organs, the risk to the baby of increased chance of asthma, the increased chance of breastfeeding difficulties, the increased risk of maternal death. And I decided for my values, where I wanted to put the risk was allowing my labor to start on its own, even though I was post dates. So you need to know those things.

Hospital Based Childbirth Classes

Barbara Stratton: And when I was a doula, if I found someone who had only taken their hospital childbirth class. I took a deep breath and I knew we were going to have two prenatal appointments in their home, and I was basically going to do a mini childbirth class. Why? Your hospital-based class, those are employees of the hospital. They are teaching with one hand tied behind their back. They cannot give you honest and good information, so you need to take a non-hospital childbirth class, even if this is your second pregnancy, you need good information.

You need to hire a doula. You need to be ready before labor to make these decisions. You need to already know what you feel about Pitocin. You need to already know what you feel about artificial rupture membranes. You need to already know what you feel about continuous fetal monitoring of restricting food and liquids during labor. You need to know that. And when I was a doula, I would make sure that before labor started, everyone had the same information.

So all I had to do when the providers came in and wanted to rupture the bag of water just to speed things along, wanted to introduce Pitocin, I would just say to my client, do you and your partner want some time alone to talk about this? And that was my key to them. We had discussed this, that they had this information and that they need to make their own decision instead of just going automatically with what was recommended.

To me that was how we empowered our clients to get through their births. And I'm very proud of that work that I did. And, you know, the benefit to being an activist for anyone who's considering dabbling in this and fighting their VBAC ban is it's extremely rewarding. Every time we had an empowered birth was a check mark for our side.

And I know in your case that you said after your VBAC, you took the power from that experience and turned it into your VBAC Facts®. I started my activism before I had my VBAC. Mine came from a place of anger. Probably not the healthiest way to go through life, this was me processing what had happened to me. This was me helping other people have it not happened to them. And you know, it sounds braggy, but I have helped hundreds, if not thousands of people have more empowering births. I get those occasional emails. I've gotten those occasional Facebook memory reminders where people say that the information they got in the VBAC 101 class was life changing. It let them know exactly the kinds of decisions they needed to make to increase their chance of that VBAC.

It is very rewarding to be involved in all of this. I've been very thankful for the role that this work that I've done has played in my life.

Jen Kamel: Well, and we are thankful for you because I mean, I, do you have any idea if the VBAC ban you reversed was the first reversal in the country?

Barbara Stratton: I don't know for certain, but occasionally we have a reversal that is not even driven by consumer activists. I used to keep a file of VBAC bans that had been reversed, but it's not up to date anymore.

Searching for the Perfect VBAC Plaintiff

Barbara Stratton: When I was working on one project, we had a lawyer along the way named Sarah Ainsworth, who was willing to file a lawsuit against a VBAC banning hospital. Sarah worked for a nonprofit where she was licensed to practice in three states, Alaska, Washington State, and a third one, I can't remember. And she was willing to create a lawsuit against a hospital in one of those three states.

So my role with Sarah was to find her what she called the perfect plaintiff. And her list included, they needed to have just one previous cesarean. They needed to not have a super complicated medical history, no child protective services involved. And so I went about trying to find this plaintiff for Sarah, and I did it by joining any kind of women's motherhood birth groups in any of those three states. And then posting, this is what we're working on. We're looking for a plaintiff. Then I interviewed people.

Denied VBAC a Week Before She Was Due

Barbara Stratton: One of the sad cases from those phone calls was a woman in Washington State who wanted to VBAC and a VBAC ban went into effect her hospital the week she was due. She was denied, right? She was denied a VBAC, had the repeat cesarean. I spoke to her at some point after that, she was in recovery, she suffered an operative complication where her temperature dropped, her body temperature dropped to a level compatible with death because there was a VBAC ban at her hospital. The other

Jen Kamel: mm.

Physician Preference Drives VBAC Ban Reversal

Barbara Stratton: I recall from making those phone calls was that Juno, Alaska. The only hospital in Juno Alaska had a VBAC ban, and out of all of the cases you hear of people having to go through extreme measures to get to a VBAC accepting hospital. If you're in Juneau, Alaska and you want a VBAC, at that time, you had to take an airplane in labor to get somewhere else. I mean, that was pretty much your worst case scenario. Now the good news is, I called them within the last year and checked on that ban, and it wasn't activist pressure. There was an OB there that wanted to offer VBAC, and they have reversed that ban. So that was great news.

Jen Kamel: Wow. Wow. Yeah, and again, it just shows the impact of one OB at that facility who said, you know what? I want to offer VBAC. I want to make this happen. So it just shows the power of just speaking what you want. People can always say no, and then you can continue the fight, but at least see what you want. Start there.

Barbara Stratton: And you know, when I'm supporting women on the ICAN National Group, I'll often try to plant the seeds of activism and say, well, okay, so you learned better since you had your cesarean. What are you going to do with that information now? Do you have an ICAN chapter in your area you can get involved in? Can you create an ICAN chapter? Can you at least speak to the people in your community and in your family and in your network about the reality of what birth is like today? You know, one of my own family members said to me, well, I'm going to birth in the hospital, but you know, I'll do anything I need to, you know, I'll stand on my head if I have to to get my vaginal birth. And I thought, you just don't know. You don't know. You know

Jen Kamel: Yeah.

Barbara Stratton: that what a typical birth is like in our country. It has nothing to do with whether you're willing to stand on your head. There is a process. You're triaged, you're on the monitor, you're often still deprived of food and water. You're given a lot of vaginal exams. Even if your bag of water's already broken. Now you're introducing infection risk. You're given Pitocin, if your bag hasn't broken, they break it and your baby either comes flying out or you have a cesarean. It's kind of in a nutshell what's happening. I want women to not just learn for themselves.

The cycle will not change until we share that information with everyone. Oh, your niece is going to give birth, have a little talk with her. And we know from our experiences, those of us in birth activism, you can't push hard. You know, once in a while I'd see a husband in the room who's kind of checking out, like, you just cannot believe the stuff I'm saying is the truth.

I'll see that and I'll just stop and I'll say, I have been a doula. I have led the ICAN chapter for X number of years. I am the ICAN National VBAC ban Chair, and I have reversed two hospital VBAC bans. I have worked on the issue of VBAC bans nationwide when I am telling you that this is what's happening in birth and to VBAC, I'm not making this crap up.

I joke that if I ever wrote a book about my birth activism, it would probably be called, I'm not making this crap up. You know? And they would kind of snap too. And then I would get the email after the class where the wife is like, I'm so thankful for this information. You know, the first thing I did was hand them the hospital cesarean rates, and then I handed them the VBAC numbers immediately. They could just look down the list and see what they're up against. You know, and how VBAC just does not happen. You've got to fight for your VBAC. Look at those numbers.

Advice for Birth Professionals

Jen Kamel: Yeah. Yeah. What do you wish all birth professionals knew about reversing VBAC bans?

Barbara Stratton: So birth professionals, like hospital staff or birth professionals like midwives and doulas?

Jen Kamel: All of the above.

Barbara Stratton: so,

Jen Kamel: can give different answers for each too.

Barbara Stratton: I have a friend who used to be a doula and a childbirth educator, and then she trained to be a midwifery home birth apprentice. And then she became a single parent and had to switch to full-time work, so she went to nursing school and is now a labor and delivery nurse. She has brought with her into that role, all of those skills and experience. She is the person on her labor and delivery unit that is the go-to person to get a baby born vaginally. They say if she doesn't know how to do it, it's not going to happen. They will bring her into the tough cases. She'll use the positioning her skills and can change the course of a labor because she brings those skills. My wish is that all birth professionals who care about women and birthing people, educate themselves and bring those skills into their jobs and work from within the system. Sometimes there are staff that get together and decide that they want to lower the cesarean rate. We've seen those news stories. Oh boy, do those make my day? I love, now that I hear that hospitals are bringing in Spinning Babies. Training for their staff.

'Cause let me tell you one, of the doula verse I did back in the day, the labor and delivery nurse we had told me she had never heard of using positioning changes to help a baby get born. When I hear that they're bringing in the Spinning Babies, when I hear that every nurse on that labor and delivery unit has gone to the Spinning Babies training, oh, how happy that that makes me. And how encouraged you know that things are changing. So those things make me happy.

I think you can work from the inside. I think that need to take a hard look at your career. Decide where your allegiances lie decide whether you're there for the paycheck or there for the good of the people giving birth. And my hope is that you're there for the good of people giving birth. The frustrating thing is, you know, they're all working with the constraints of what their licensing allows in that state, what the hospital policies are.

I was once on a talk back panel after a showing of Ricki Lake's birth film. It was me at the end, and then a whole line of nurse midwives to my right. There was an audience question and a nurse midwife responded that they felt you could have a great birth no matter what birth location you choose, as long as you have a good provider. And I let that filter out into the audience for a moment. And then I said in response to that, I agree, you can have a great birth no matter where you choose as long you have a good provider. I said, as long as you go into labor by 41 weeks. And then I could feel all the nods in the panel. Well, yeah. Well, yeah, working in a system. Do you tell people in their very first prenatal appointment with you that you're going to face this 41 week deadline that they have, you know, no authority because of their backup protocols to push that? Are you going to be honest with, with women? To let them know they have this 41 week deadline, and if they don't start labor as many people don't, by 41 weeks, it all hell is going to break loose? Can you go to sleep at night knowing that you're, that's the constraints of the employment that you have accepted? And if it is, I hope that you're in there working to change it.

Key Differences in Birth Centers

Jen Kamel: Well, and I really want people to hear the difference between a freestanding birth center, so that means a birth center that is not affiliated, or attached, to a hospital versus a birth center that is inside a hospital, because I think a lot of parents get confused. They're like, well, I'm seeing a midwife at a birth center. Can you share, how is that different? Between a freestanding birth center versus a birth center in a hospital?

Barbara Stratton: Marketing.

Jen Kamel: Yes.

Barbara Stratton: It's just marketing to try to bring in the people that, that sounds real good that it's a birth center. The birth center that I chose, it was not part of the labor and delivery wing, it was its own business, but they were attached by a hallway to that backup hospital. One of the things when you toured, they would talk about is they had done timed drills to see how fast they could run a woman on a gurney from their facility over to the hospital if there was an emergency.

You know, I learned as Dr. Maya Angelou says, when you learn better, you do better. After my experience with my first pregnancy, I learned that different types of midwives, nurse midwives, are going to have a more medicalized approach compared to certified professional midwives. Regulations that the nurse midwives are practicing under may be more stringent than the certified professional midwives. What I learned, back to that Our Bodies, Ourselves picture of the woman having the home birth supported by people who were there to help her, is that my value system was really more towards the certified professional midwives.

With my second pregnancy, I used a certified professional midwife, and I considered it to be the relationship. It was the epitome of the perfect situation. I was informed. We discussed things. We, we did share decision making with me having the final decision. You know, no one was happy that I went two and a half weeks post dates, I didn't choose that, but she knew I was informed. She knew that I accepted whatever outcome I had from those choices.

And I even told my partner, leading into the birth. I said, you know, I support what this midwife does and her role in the community and the empowerment she gives to birthing people. And even if I had a negative outcome, I would never want you to pursue legal recourse against her because I'm making these choices. Right. And I support the way she practices as she continues to this day. She's of retirement age and she's still catching babies 'cause she loves it and she's just such an asset to the community for letting people have the perfect kind of situation with a birth provider.

Advice for Parents

Jen Kamel: And so how about for parents who want to reverse VBAC bans? What would be your biggest takeaway that you want them to get from this interview with you?

Barbara Stratton: That it is possible. It is possible. It absolutely is possible. You can create change. You know, there's no magic to what I do other than persistence. Referring back to my bio, you read at the beginning , I legalized domestic partnership health insurance for gay people in the state of Maryland. I didn't know how to do that, right? I just dug in and I did it and I was successful. And from then on, you know, gay people in the state of Maryland could get on each other's health plans, if the company agreed, it didn't mandate the coverage, but it illegally allowed for it.

Myself and a group of parents opened a public charter school in Baltimore City. The city had never had a charter school before the state passed a charter school law that allowed for them. When we applied for ours, the city refused to give us a charter. They really didn't like the idea, so we sued them. And our founder created a song that she played on the guitar in her media interviews. We opened what became the first charter school in Baltimore City. And now there's been a whole slew that have followed it. And that original charter school eventually went on to open a middle school and a high school, now it educates 800 students a year, with an art inspired curriculum.

You can do these things. It's just persistence and finding your voice and being brave. And don't be afraid of your voice is shaking. At NIH I don't think I was any less effective because my voice was shaking right. It

Jen Kamel: Yeah,

Barbara Stratton: a very important moment in birth activism. What happened when I was at that microphone, I could have just been too afraid to do that, I'm glad I wasn't too afraid because look at the change that it made.

Mutual Appreciation ❤️

Jen Kamel: And the incredible legacy that you have, Barbara.

Barbara Stratton: Well, and I.

Jen Kamel: Really, I mean, amazing. The charter school, the legislation, the VBAC stuff.

Barbara Stratton: Thank you, and I am very proud of it. But right back at you, Jen, because I have followed you over the years. And can I just say what a gift you are to birthing people. The fact that you get up to your elbows in the studies and then can summarize for people. Just yesterday when I was arguing with that person online, I grabbed your article about rupture rates after a classical incision, offered it to the OB I was arguing with. I'm not saying there's not a rupture risk with classical and section incision VBAC but I wanted to make sure this OB, who said she had written articles about VBAC and promoting VBAC, I said, well, I just want to make sure you're aware of the variables and where these numbers come from, from the classical, because if you're providing this information to people, to me, you have a responsibility to have good information. Jen at VBAC Facts® is a great place.

You know, OB GYN is a very broad specialty. We somewhat can't fault them for not being experts on every single thing 'cause there's so many things that come under the umbrella of their care. But if you're going to be counseling people on VBAC, you have a responsibility to know this information, you know, get a little professional membership going with Jen if you want to shortcut the process.

So you have been such a gift for that, and you're just so well-spoken and so intelligent, and so talented at going through the data that the world would be a different place if you had not started your VBAC Facts®. So thank you as well.

Jen Kamel: I am humbled and touched by your words. This has been my life's work the last 18 years and, um, thank you. What I want to do with this podcast, I mean, we were reaching people through the website and through social media, but you know, there was such a need for a more long form discussion of stories like yours.

We've talked about stories that we've held in our hearts. I've had the opportunity to interact with so many incredible people whose stories don't make the media and whose stories are powerful and show people what is possible, whether that's reversing VBAC bans like you, or another story we have coming up of a woman who had two C-sections at 10 centimeters pushing.

So twice she had the scenario and when she was looking for birth stories online, she couldn't find anyone who had a scenario like hers. So holding up stories to show people what is possible and so I appreciate your words.

Thank you for being here with us. We are going to share a link for people to hire you for consulting so that way they can work with you one-on-one because you've shared so much great information here.

But I know people are going to want to be able to sit down with you and say, okay, here is my scenario. What should I do first? What are the specific ways that I should address this? What individual questions that they have. So we'll share a link for that in the show notes. Are there any final words you want to share, Barbara?

VBAC Bait & Switch

Barbara Stratton: I was just thinking of another story of when I was a doula and you would get phone calls for people shopping for doula services, and sometimes they hired you and sometimes they didn't, I always wanted to relay information. I wanted to help these people with their choices. This woman was pursuing a VBAC.

She ended up not hiring me. I ended up feeling a little cranky after, 'cause I invested quite a bit of time with her on the phone. This was before doulas made a good living. I think I had sent her an email with some follow up resources, but one of the things I had talked to her about is backpedaling with OBGYNs. And we share this a lot on the ICAN support group is that you'll get an OB that says, yeah, yeah, I'm VBAC supportive. Yeah. Yeah. You can have a VBAC, yeah, yeah, yeah. Fine. And then all of a sudden, you know, pick your week, 36 weeks in, all the reasons surface why they don't think the VBAC's a good idea after all. And they start doing what we call backpedaling. I warned her about this. She did not hire me. I was cranky.

Months later I got a phone call from her and she says, I don't know if you remember me. You know, I went ahead and pursued my VBAC. They made me finish laboring in the OR. You know, my OB had said they were supportive, but in late pregnancy they started coming up with reasons and she thought, this is just like that doula warned me about, and in fact, they made her finish laboring in the OR as a tactic. And she did get her VBAC, and so she just wanted to call and thank me about it. So I was glad with how it turned out.

Jen Kamel: Your days of creating positive change are not over, Barbara. Not that you need me to tell you that. I mean, you are a wealth of knowledge and experience and I hope people will take advantage of that and hire you to help them create change at their hospitals. 'cause it can feel like a really overwhelming process. But as you've done it twice.

So let's lean into the knowledge that you have and let's work together to create change. So we'll share that link in the show notes. And until next time, I'm Jen Kamel with VBAC Facts® and don't forget what we're about. Since 2007, our focus has been to share accurate and objective information on vaginal birth after cesarean and repeat cesarean with parents, professionals, policymakers, and the court so all decisions can be informed, ethical, and just. I'll see you again in two weeks. Take care.