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Sunday, February 22, 2009

Access to VBAC is Shrinking

Feb 19 2009

New Survey Shows Shrinking Options for Women with Prior Cesarean

Bans on Vaginal Birth Force Women into Unnecessary Surgery

For Immediate Release

Redondo Beach, CA, February 20, 2009 – The International Cesarean Awareness Network (ICAN) has released the results of a new survey showing an alarming increase in the number of hospitals banning vaginal birth after cesarean (VBAC). The survey shows a near triple increase (174%) from November 2004, when ICAN conducted the first count of hospitals forbidding women from having a VBAC. In 2004, banning hospitals numbered 300. The latest survey, conducted in January 2009, counted 821 hospitals formally banning VBAC and 612 with "de facto" ban. (1) Full results of the research can be seen in the VBAC Ban Database.

The bans essentially coerce women into surgery they do not need. In response to bans, women are either submitting to unnecessary surgery or are traveling long distances to hospitals that do support VBAC. Some women are feeling forced out of hospital care altogether and are having their babies at home in order to avoid coerced surgery.

“There is an alarming disconnect between what medical research says about the safety of VBAC, and the way that hospitals and their doctors are practicing medicine” said Pam Udy, president of ICAN, an all-volunteer patient advocacy organization. “These bans are about business, not about the health and well-being of mothers and babies.”

Research has consistently shown that VBAC is a reasonably safe choice for women with a prior cesarean. According to an analysis of medical research conducted by Childbirth Connection, a well-respected, independent maternity focused non-profit, in the absence of a clear medical need, VBAC is safer for mothers in the current pregnancy, and far safer for mothers and babies in future pregnancies. (2) While VBAC does carry risks associated with the possibility of uterine rupture, cesarean surgery carries life-threatening risks as well. “The choice between VBAC and elective repeat cesareans isn’t between risk versus no risk. It’s a choice between which set of risks you want to take on,” said Udy.

Studies from the National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network, one most recently published in the February 2008 issue of the Journal of Obstetrics and Gynecology, demonstrate that repeated cesareans can actually put mothers and babies at greater clinical risk than repeated VBACs. (3)

Hospitals cite strict guidelines set by the American College of Obstetrics and Gynecology as the driver behind the bans. The ACOG guidelines stipulate that a full surgical team be “immediately available” during a VBAC labor, though the stipulation is a “Level C” recommendation, which means it is based on the organization’s opinion rather than medical evidence.

“If a hospital can’t handle a VBAC emergency, they can’t handle any emergency. VBAC-banning hospitals are claiming to be a safe place of birth for non-cesarean moms, but those mothers are just as likely to have an emergency as a mother with a prior cesarean” says Udy. Placental abruption, cord prolapse, fetal distress are all common emergencies that any mother can experience and require immediate attention.

For physicians, repeat cesareans are often considered more convenient, more lucrative and better insulation from lawsuits. VBACs are inconvenient and costly because they require the physician to be on-site and be available to care for the mother. “ACOG created clinical guidelines that are, in effect, good for business,” said Gretchen Humphries, ICAN’s Advocacy Director, who spearheaded the research. “If physicians think VBAC patients need more attention, then they can simply provide that attention by being in the hospital. But it’s easier to just push women into unnecessary surgery.”

“These bans mean that any mother with a prior cesarean is going to have to be aggressive about seeking out balanced information about the pros and cons of a VBAC versus an elective repeat cesarean, and unfortunately, be prepared for an uphill climb if she chooses to have a VBAC,” said Humphries. For more information, please visit our page about the rights of mothers facing VBAC bans.

For more information about the clinical risks of VBAC and elective repeat cesarean, please visit Childbirth Connection.

About the survey: This survey was powered by an all-volunteer team of callers who called, state by state, hospitals across the country. Survey volunteers used publicly available listings of hospitals and made every effort to call every hospital in each state. Surveyors contacted each hospital’s Labor and Delivery (L&D) ward and questioned L&D nurses about the hospital’s practices. Survey questions were designed to elicit information about formal bans, de facto bans, the reasoning behind the bans, and the level of coercion mothers might face if couldn’t find an alternate hospital option. Information from calls was recorded into a central database. A total of 2,850 hospitals were called. Individual records are available for viewing here.

About Cesareans: ICAN recognizes that when a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. Potential risks to babies include: low birth weight, prematurity, respiratory problems, and lacerations. Potential risks to women include: hemorrhage, infection, hysterectomy, surgical mistakes, re-hospitalization, dangerous placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased percentage of maternal death.

Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are 94 ICAN Chapters across North America, which hold educational and support meetings for people interested in cesarean prevention and recovery.

For Interviews: Contact ICAN President Pam Udy at (801) 458-2190 or ICAN Advocacy Director Gretchen Humphries at (517) 745-7297.


(1)A “de facto” ban means that surveyors were unable to identify any doctors practicing at the hospital who would provide VBAC support.

(2) Best Evidence: VBAC or Repeat C-Section, Childbirth Connection

(3)Mercer et al, Labor Outcome With Repeated Trials of Labor Am J Obstet Gynecol 2008;VOL. 111, NO. 2, PART 1

Silver et al, Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries, Am J Obstet Gynecol 2006; VOL. 107, NO. 6

Thursday, February 19, 2009

TIME: The Trouble with Repeat Cesareans

ICAN's national VBAC ban survey is featured in this week's issue of TIME Magazine:

The Trouble With Repeat Cesareans

For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. Jessica Barton knows this all too well. At 33, the curriculum developer in Santa Barbara, Calif., is expecting her second child in June. But since her first child ended up being delivered by cesarean section, she can't find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he's not on call the day she goes into labor? That's why, in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles. "One of my biggest worries is the 100-mile drive to the hospital," she says. "It can take from 2 to 3 1/2 hours. I know it will be uncomfortable, and I worry about waiting too long and giving birth in the car."

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries, proving that "once a cesarean, always a cesarean"--an axiom thought to be outmoded in the 1990s--is alive and kicking. Indeed, the International Cesarean Awareness Network (ICAN), a grass-roots group, recently called 2,850 hospitals that have labor and delivery wards and found that 28% of them don't allow VBACs, up from 10% in its previous survey, in 2004. ICAN's latest findings note that another 21% of hospitals have what it calls "de facto bans," i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them. (Read "The Year in Medicine 2008: From A to Z.")

Why the VBAC-lash? Not so long ago, doctors were actually encouraging women to have VBACs, which cost less than cesareans and allow mothers to heal more quickly. The risk of uterine rupture during VBAC is real--and can be fatal to both mom and baby--but rupture occurs in just 0.7% of cases. That's not an insignificant statistic, but the number of catastrophic cases is low; only 1 in 2,000 babies die or suffer brain damage as a result of oxygen deprivation.

After 1980, when the National Institutes of Health (NIH) held a conference on skyrocketing cesarean rates, more women began having VBACs. By 1996, they accounted for 28% of births among C-section veterans, and in 2000, the Federal Government issued its Healthy People 2010 report proposing a target VBAC rate of 37%. Yet as of 2006, only about 8% of births were VBACs, and the numbers continue to fall--even though 73% of women who go this route successfully deliver without needing an emergency cesarean.

So what happened? In 1999, after several high-profile cases in which women undergoing VBAC ruptured their uterus, the American College of Obstetricians and Gynecologists (ACOG) changed its guidelines from stipulating that surgeons and anesthesiologists should be "readily available" during a VBAC to "immediately available." "Our goal wasn't to narrow the scope of patients who would be eligible, but to make it safe," says Dr. Carolyn Zelop, co-author of ACOG's most recent VBAC guidelines.

But many interpreted the revision to mean that surgical staff must be present the entire time a VBAC patient is in labor. While major medical centers and hospitals with residents are staffed to provide this level of round-the-clock care, smaller hospitals typically rely on anesthesiologists on call. Among obstetricians, many solo practitioners are unable to stay for what could end up being a 24-hour delivery; others calculate the loss of unseen patients during that time and instead opt to do hour-long cesareans, which are now the most commonly performed surgeries on women in the U.S.

Some doctors, however, argue that any facility ill equipped for VBACs shouldn't do labor and delivery at all. "How can a hospital say it can handle an emergency C-section due to fetal distress yet not be able to do a VBAC?" asks Dr. Mark Landon, a maternal-fetal-medicine specialist at the Ohio State University Medical Center and lead investigator of the NIH's largest prospective VBAC study.

Part of the answer has to do with malpractice insurance. Following a few major lawsuits stemming from VBAC cases, many insurers started jacking up the price of malpractice coverage for ob-gyns who perform such births. In a 2006 ACOG survey of 10,659 ob-gyns nationwide, 26% said they had given up on VBACs because insurance was unaffordable or unavailable; 33% said they had dropped VBACs out of fear of litigation. "It's a numbers thing," says Dr. Shelley Binkley, an ob-gyn in private practice in Colorado Springs who stopped offering VBACs in 2003. "You don't get sued for doing a C-section. You get sued for not doing a C-section."

Of course, the alternative to a VBAC isn't risk-free either. With each repeat cesarean, a mother's risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman's chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta--in which the placenta attaches abnormally to the uterine wall--has increased thirtyfold in the past 30 years. "The problem is only beginning to mushroom," says ACOG's Zelop.

"The decline in VBACs is driven both by patient preference and by provider preference," says Dr. Hyagriv Simhan, medical director of the maternal-fetal-medicine department of Magee-Womens Hospital of the University of Pittsburgh Medical Center. But while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them. Dr. Stuart Fischbein, an ob-gyn whose Camarillo, Calif., hospital won't allow the procedure, is concerned that women are getting "skewed" information about the risks of a VBAC "that leads them down the path that the doctor or hospital wants them to follow, as opposed to medical information that helps them make the best decision." According to a nationwide survey by Childbirth Connection, a 91-year-old maternal-care advocacy group based in New York City, 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

Zelop is among those who worry that "the pendulum has swung too far the other way," but, she says, "I don't know whether we can get back to a higher number of VBACs, because doctors are afraid and hospitals are afraid." So how to reverse the trend? For one thing, patients and doctors need to be as aware of the risks of multiple cesareans as they are of those of VBACs. That is certain to be on the agenda when the NIH holds its first conference on VBACs next year. But Zelop fears that the obstetrical C-change may come too late: "When the problems with multiple C-sections start to mount, we're going to look back and say, 'Oh, does anyone still know how to do VBAC?'"

Friday, February 13, 2009

ACOG under question by an insider

I just read this awesome editorial by the editor of Journal of Obstetric, Gynecologic, & Neonatal Nursing, Nancy K. Lowe, here. She really calls it like it is--"audacious." She points out that most doctors and nurses have never witnessed a natural birth, and our "system" has not improved outcomes. She calls into question ACOG's and the AMA's motives for issuing their resolution against homebirth. She sings the rallying cry: "Perhaps it is time for a new woman's movement, one that embraces the normalcy of childbirth and puts mothers and babies back on the center stage rather than the system's need to defend the interventionist subculture it has developed and that it must financially support." AMEN --that is what were are doing! And our numbers are growing!

See you March 9th at St Joes or Regions!



The "Authorities" Resolve Against Home Birth
Nancy K. Lowe Editor
Copyright © 2009 AWHONN

No Abstract
DIGITAL OBJECT IDENTIFIER (DOI)10.1111/j.1552-6909.2008.00300.x About DOI

This editorial has been gathering momentum in my mind since I heard about a resolution introduced by the American College of Obstetricians and Gynecologists (ACOG) to the House of Delegates of the American Medical Association's (AMA) annual meeting in June 2008. American College of Obstetricians and Gynecologists's resolution #205 was adopted by the AMA and is titled "Home Deliveries." So that I cannot be accused of misquoting the AMA or ACOG, you will find the text of the adopted resolution at the end of this editorial. In his "College News" column of ACOG Today (September 2008), ACOG Executive Vice President Ralph W. Hale reported on his attendance at the AMA Annual Meeting and wrote, "Also, there was model legislation related to home deliveries supporting the ACOG position against home births." The point of this resolution is to lobby against home birth as an option for women and against providers of home birth services. This type of resolution by "authoritative" bodies such as ACOG and AMA will certainly influence decisions made by third-party payers when women request home birth services and by liability insurance carriers when providers seek coverage for home birth services.

Rumor has it, as stated in the Los Angeles Times on July 9, 2008, that in the original ACOG resolution, there was another "whereas" that was deleted before adoption. It read, "Whereas, there has been much attention in the media by celebrities having home deliveries, with recent 'Today Show' headings such as 'Ricki Lake takes on baby birthing industry.'" You may not be aware that in 2007 producer Ricki Lake and director Abby Epstein released a documentary film The Business of Being Born. The film asked the question "Should most births be viewed as a natural life process, or should every delivery be treated as a potentially catastrophic medical emergency?" If you have not seen this film, I encourage you to do so and to view it with an open mind, an open intellect, and an open heart. The DVD can be purchased for a modest price at

Evidently, ACOG felt it necessary to highlight Ms. Lake's coverage of this issue as a potential threat to the safety of mothers and babies. It is beyond the scope of an editorial to review the international and national data about maternal and infant outcomes and the relationship of these outcomes to location of birth. However, one instructive example is a prospective cohort study of maternal and infant outcomes in British Columbia during the first 2 years after women were given the choice to plan a home birth with regulated midwives (Janssen et al., 2002). After controlling for appropriate confounding variables, the data showed no increased maternal or neonatal risk for the 862 planned home births compared with 1,314 planned hospital births. The overall transfer rate to hospital care was 21.7% in the home birth group with 16.5% transferred during labor. The multivariate analysis showed that the women who planned to have home births were significantly less likely to undergo induced or augmented labor, epidural analgesia, episiotomy, or cesarean delivery.

I was born in the United States and I am very proud to be an American, but I am embarrassed that our country founded on the ideals of individual liberty and freedom, can also support "authoritative" initiatives such as these by the ACOG and AMA, initiatives that are founded on neither science nor an understanding of the physiologic and psychosocial needs of mothers and babies. What is most risky about home birth in the United States is that for most women who desire it there is a scarcity of qualified providers of home birth services. There is no system of care that provides the needed safety net if transfer to a different type of care is required during labor. Rather, women who desire to birth at home sometimes chose providers unwisely, and those who require transfer are often treated with disdain and disregard as though their decision to give birth outside the hospital system is irresponsible, reckless, and perhaps immoral. There is nothing more inhumane or uninformed than this attitude toward women who desire to birth at home and the qualified providers who are willing to attend them.

When will we remember that pregnancy, childbirth, and lactation are normal healthy physiological processes that are a continuum and do not require medical intervention unless there is a medical problem? A woman's body and the physiology of pregnancy, labor, birth, and lactation are designed to promote the well-being of the fetus and newborn. When will we establish optimal outcomes as the goal of health care during the childbearing cycle, rather than attempting to reduce by small increments the incidence of morbidity and mortality that is compounded by the very interventions we use to attempt to avoid such problems? We all know that in our current health care milieu for childbearing women, the protection of normal is not valued or supported, except in a very few locales. Those who support normalcy are usually swimming upstream against a system that treats every laboring woman as a surgical case. The idea that a normal spontaneous birth is by design the best outcome for a healthy woman and her infant is neither believed nor entertained as a basic concept. Most U.S.-trained physicians and sadly most U.S.-trained nurses have minimal experience with normal labor and birth. Without fetal monitors, intravenous lines, infusion pumps, epidurals, pitocin, endless charting, and rules theses individuals are helpless and unskilled to provide the kind of informed human support and wise guidance that a laboring woman needs while the normal process of labor and birth unfolds.

In fact, knowledgeable women often must fight to defend the normalcy of the process and their desire to labor and birth spontaneously without medical technology or intervention. In many ways it is reminiscent of the 1960s when many of us who were young women at the time fought for our right to natural childbirth without general anesthesia and to have our husbands accompany us into the delivery room. Breastfeeding was not the norm and was not supported by hospital care. During my 5-day postpartum stay after a vaginal delivery in 1969, I had to repeatedly insist that my newborn son be brought to me during the night for breastfeeding because as I was told by the nurses, "Dr. X's patients are to sleep at night." How audacious authority can be. Amazingly, a few years later a headline in the science section of the Chicago Tribune declared, "Science finds Breast is Best." Since that time the accumulation of scientific evidence has overwhelmingly validated that physiologically obvious statement, and the system, including its "authorities," finally caught up to actively support breastfeeding. Will it take a similar declaration: "Science finds spontaneous labor and normal vaginal birth is best" to change the course that we are currently on and to change the rhetoric of the authorities?

Why do 1% to 2% of U.S. women even want to birth at home? For most it is simply because they sincerely believe that the process is normal and healthy and does not require the environment of an "illness" system to support it. For these women, birth has a unique, earthy, and frequently spiritual component that they want to experience fully under their own terms. They want to actively labor and birth, rather than to have labor happen to them, give over control to a system and people with their own rules, and be delivered of their babies. Some desire home birth because of the subculture of their religious communities, while others are overtly afraid of what may happen to them in the hospital. They may be "on the edge" of the allopathic medical system and be very resistant to interventions that the system thinks are in their best interest. Does this make them wrong? No, it simply means that the system is not meeting their needs for holistic care that supports normalcy.

The point is that we have no system of maternity care in the United States that provides a healthy woman the choice of giving birth at home and if she needs to transfer to a different type of care during labor, the transfer is easy. We do not have a system in which this woman is treated with respect and kindness, and her provider either maintains responsibility for her care or professionally and respectfully is able to transfer responsibility to another provider. Interestingly, while ACOG and AMA have declared that hospital grounds are the only safe place to give birth in the United States, the National Perinatal Association (NPA) adopted a position paper in July 2008 titled, "Choice of Birth Setting." The paper supports a woman's right to home birth services and concludes that, "The National Perinatal Association (NPA) believes that planned home birth should be attended by a qualified practitioner within a system that provides a smooth and rapid transition to hospital if necessary. Safety for all births must be evaluated through an objective risk assessment, especially for non-hospital births. NPA supports and respects families' right to an informed choice of their birth setting" (available at Further, in Canada following the model of British Columbia, the province of Alberta has recently expanded its health care system to include women's access to midwifery services "in a variety of locations including hospitals, community birthing centers, or in their homes" (

Some of you who are reading this know me personally, most do not. I am a nurse-midwife committed to the midwifery philosophy of care, however, I have never attended a home birth. I gave birth to my own children in hospital, and my daughter is a board certified obstetrician-gynecologist. I am part of the U.S. system. Yet the very core of my being, my scientifically trained brain, and four decades experience in the business of mothers and babies tell me it is our system that is not serving mothers and babies well. There is not some inherent danger lurking for healthy American women who desire to give birth at home. The primary danger is that the "system" does not support this choice. To pretend that a normal healthy woman cannot give birth safely without the trappings of a U.S. hospital is not only audacious but also uninformed. Perhaps it is time for a new woman's movement, one that embraces the normalcy of childbirth and puts mothers and babies back on the center stage rather than the system's need to defend the interventionist subculture it has developed and that it must financially support. This system has not improved outcomes for mothers or babies while the cost of care has continued to escalate keeping pace with unnecessary intervention. The recent initiatives of our medical colleagues, the "authorities," simply highlight the painful reality that the "Emperor has no clothes!"

Introduced by American College of Obstetricians and Gynecologists
RESOLVED, That our American Medical Association support the recent American College of Obstetricians and Gynecologists (ACOG) statement that "the safest setting for labor delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, The Joint Commission or the American Association of Birth Centers"; and be it further
RESOLVED, That our AMA support state legislation that helps ensure safe deliveries and healthy babies by acknowledging that the safest setting for labor, delivery, and the immediate postpartum period is in the hospital or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.


American Medical Association (AMA). (2008). Resolutions. Retrieved November 1, 2008, from
Block, J. (2008, July 9). Big medicine's blowback on home births. Los Angeles Times. Retrieved October 29, 2008, from,0,3357453.story
Hale, R. A. (2008, September). ACOG's positions advocated at AMA meeting. ACOG Today, p. 2.
Janssen, P. A., Lee, S. K., Ryan, E. M., Etches, D. J., Farqukarson, D. F., Peacock, D., et al. (2002). Outcomes of planned home births versus planned hospital birth after regulation of midwifery in British Columbia. Canadian Medical Association Journal, 166, 315-323.
print_JCIT('TYPE=JCIT&BIBID=BIB4&SNM=Janssen&SNM=Lee&SNM=Ryan&SNM=Etches&SNM=Farqukarson&SNM=Peacock&FNM=P. A.&FNM=S. K.&FNM=E. M.&FNM=D. J.&FNM=D. F.&FNM=D.&ATL=Outcomes of planned home births versus planned hospital birth after regulation of midwifery in British Columbia&JTL=Canadian Medical Association Journal&PYR=2002&VID=166&PPF=315');
National Perinatal Association (NPA). (2008). Position paper: Choice of birth setting. Retrieved October 16, 2008, from

Tuesday, February 10, 2009

Let's read again Dr. Wagner's critique of ACOG's VBAC recommendations

Today, Sarah was shamed on her blog by a physician’s assistant for having an HBAC. Today, I read a nurse defend St. Joe's VBAC ban policy by saying it would be impossible for them to defend themselves against litigation because of ACOG's recommendations. Last night, I watched again Orgasmic Birth and saw what birth can, and should be. Today, I read the most amazing VBAC story from a woman we didn’t even know we were helping. In theory, most people agree that the c-section rate is too high, but as to why it continues to climb, well, I see alot of blame, and alot of reasons, and alot of excuses. But in the end, it is the doctors performing the c-sections and the doctors wanting more c-sections, and they all point to ACOG as to why they must.

As we prepare to march for better birth, and think about VBAC bans, such as the one at St. Joe's, I think it would be good to read this again. From Midwifery Today:

What Every Midwife Should Know About ACOG and VBAC: Critique of ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section”
by Marsden Wagner, MD, MSPH
[Editor's Note: To order copies of this practice bulletin (ISSN 1099-3630), contact:
The American College of Obstetricians and Gynecologists409 12th Street, SWP.O. Box 96920Washington, DC 20090-6920]

Problems With Final RecommendationsProblems With the First Recommendation in Level C: “Because uterine rupture may be catastrophic, VBAC [vaginal birth after cesarean] should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”
The first problem with this recommendation is that of the eight final recommendations, it is this one which has the largest impact on maternity care in the United States. Yet by the American College of Obstetricians and Gynecologists' (ACOG) own admission, there is no evidence to back up this recommendation. This is of course the reason this recommendation has been placed in Level C, thus making it ACOG's confession that since there are no data, ACOG will simply have to go on the basis of “expert opinion.” This is a sad regression to the days of “Trust me, I'm a doctor”—in spite of the new direction of medical care to evidence-based practice.
This is not the first time ACOG has been willing to make recommendations without any evidence base. For example, ACOG's written statement that homebirth is not safe also doesn't try to reference any data and flies in the face of overwhelming scientific evidence that planned homebirth and planned birth in an out-of-hospital freestanding birth center are perfectly safe options for the great majority of pregnant women.
So this recommendation—“VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available”— has no data to support it, no studies showing improvements in maternal mortality or perinatal mortality related to the characteristics of institutions or availability of physicians. What ACOG doesn't say is that one study included in their reference list in their document compared VBAC and repeat cesarean section in three types of hospitals—community, regional and tertiary care—and while community and regional hospitals had more repeat cesarean sections and more failed VBAC, no difference in mortality rates for these two procedures by type of institution is reported1. This study suggests the ACOG recommendation is scientifically unfounded.
The second problem with the recommendation “VBAC should be attempted in institutions…” is that it is based on an unproven assumption: Cesarean section can be accomplished faster if the labor takes place at a tertiary care hospital. ACOG presents no data in support of this assumption.
On the other hand, out-of-hospital birth has been shown scientifically to be safe when attended by midwives who, when necessary, can be in close contact with a hospital capable of emergency cesarean section. This is why homebirth and freestanding birth centers have been proved safe in those places in the United States with good communication and respect between home and hospital. The midwife can telephone the hospital and describe the emergency, and while the woman is in transport, the hospital staff is preparing, scrubbing in, etc.
How long does it take to do a cesarean section if the labor is in a tertiary care hospital in the United States? While ACOG has recommended in the past that the "decision to incision" time be no more than 30 minutes, in one study at a university hospital in the United States2, 52 percent of the emergency cesarean sections for fetal distress had a decision to incision time that exceeded 30 minutes.
One reason for this delay is that in the United States it is not the laboring woman who is in transport, it is the absent doctor who is in transport, the doctor who has been trying to monitor the labor in the hospital by telephone. The ACOG recommendation “to have a physician immediately available” is in reality a criticism of the U.S. system, in which the laboring woman's doctor is usually not available and must be called to come in.
The elegant solution is not to take away valid choices for childbirth from the woman and her family but to change the system. Rather than insisting that the woman having a VBAC be transported at the beginning of labor to a big hospital that is away from her primary caregiver, her family, her friends and familiar community, instead do what is done in the other highly industrialized countries with maternal and perinatal mortality rates lower than ours: Develop a system in the United States in which there is close communication during childbirth between primary care in the community—home, birth center, small hospital—and the big hospital so that when the woman in labor needs to be transported, the decision to incision time is no greater than if the same woman were laboring in the big hospital and needed to be transported from the delivery suite to the surgical suite for a cesarean section.
A third problem with the recommendation “VBAC should be attempted in institutions…” is that it is aimed entirely at the treatment of uterine rupture and not at the prevention of uterine rupture. The increasing rate of uterine rupture in the United States during the past decade has been alarming, which rightly concerns ACOG. But ACOG's solution is analogous to responding to an increasing rate of drowning at a summer camp by placing some life rings out in the lake rather than teaching children how to swim better.
Attempts have been made to identify risk factors for uterine rupture, but the focus has been on maternal factors such as number and type of uterine scars. There has been insufficient attention in the obstetric literature or by ACOG to any relationship between the management of the VBAC and uterine rupture. The key issue here is pharmacological induction of labor with VBAC, which leads us to look at another final recommendation.Problems With the Second Recommendation in Level B: “Use of oxytocin or prostaglandin gel for VBAC requires close patient monitoring.”
After delaying for years while Cytotec induction spread like wildfire in the United States—resulting in thousands of VBAC Cytotec inductions, which led to hundreds of uterine ruptures and dozens of dead newborns—ACOG finally closed the barn door on Cytotec induction of VBAC, but only after research showed a rate of uterine rupture with Cytotec induction of VBAC 28 times higher than the rate of VBAC uterine rupture without Cytotec induction3.
But the ACOG recommendation on VBAC under review here does not shut the barn door on the use of other pharmacological agents to induce VBAC, as this recommendation (under Level B, meaning based on limited or inconsistent scientific evidence) states: “Use of oxytocin or prostaglandin gel for VBAC requires close patient monitoring.” Take note that this means it is OK to use it as long as you closely monitor.
Read carefully the paragraph titled “Induction” in this ACOG document. It is an example of trying to torture the data until they confess to what you want them to say.
Induction or augmentation with oxytocin has been suspected as a factor responsible for uterine rupture. A meta-analysis found no relationship between the use of oxytocin and rupture of the uterine scar. However, other studies indicate that high infusion rates of oxytocin place women at greater risk. Although there are studies that suggest that prostaglandin gel applied to the cervix or vagina appears to be safe, there are occasional reports of uterine rupture with prostaglandin preparations.
The statement “A meta-analysis found no relationship between the use of oxytocin and rupture of the uterine scar” is false. The meta-analysis they are referring to—by Rosen et al.—found a uterine rupture rate of 2.3 percent with oxytocin induction of VBAC, compared with 1.5 percent with no oxytocin induction of VBAC4. So there is a relationship, but it does not reach a level of statistical significance. It would take a larger sample size to reach statistical significance because uterine rupture is an unusual event. But it is what scientists call a "trend," and this trend is consistent with a relationship found in other studies. As ACOG states in this same paragraph: “However, other studies indicate that high infusion rates of oxytocin place women at greater risk [of uterine rupture].”
So the evidence, while not totally conclusive, strongly suggests that using oxytocin with VBAC increases the chance for uterine rupture. Yet ACOG does not recommend against oxytocin VBAC induction. Why? If the evidence is inconclusive, the cautious, conservative approach would be to follow the basic rule of medical practice: “First do no harm.” But induction is extremely obstetrician friendly, as it allows the practitioner some control of a busy practice through scheduling the induction at a convenient time rather than waiting for spontaneous labor, which is 24/7. Proof? Data from the Centers for Disease Control (CDC) show induction of labor in the United States ruing the past 10 years doubled, to 20 percent of all births from 10 percent. The same CDC data also show an increasing trend throughout the last decade for more births Monday through Friday5. This is the same decade in which uterine rupture also increased. The CDC data strongly support the possibility that the increase in uterine rupture the past 10 years is due to increased induction of labor, including induction of VBAC.
ACOG's Process for Making These Recommendations
Who Made These Recommendations?
In the practice bulletin's summary it says Level C recommendations are based “primarily on consensus and expert opinion.” Who was involved in the consensus, and who are the experts? There is an urgent need for transparency here. I contacted ACOG, but they were unwilling to say who was in the group making this practice bulletin. Since the first recommendation in Level C—“Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care”—affects the care of a large group of pregnant women at the time of giving birth, consensus needs to include not only obstetricians but also midwives, nurses, family physicians, perinatal epidemiologists and consumers. Were any of these groups represented, or were only obstetricians? This is particularly important when a recommendation, such as this one, is of the “you need more of us” variety. Since this recommendation is friendly (an advantage) to obstetricians and unfriendly (a disadvantage) to family physicians, midwives and many women, the recommendation easily could be seen as self-aggrandizing for obstetricians.
Here, an editorial from The Lancet, January 8, 2000, is instructive:
Advocacy guidelines developed by a single-specialty group in isolation may be counterproductive, because those disciplines and professions that were not involved in the development of the guidelines but may be required to implement the recommendations mount their attacks and lodge their disclaimers. Some of the guidelines may be of the Good Old Boys Sat at Table (GOBSAT) variety, based on received wisdom rather than current scientific evidence, and may be biased by undeclared conflicts of interests.…Studies have shown that the balance of disciplines within a guideline-development group has considerable influence on the guideline recommendations. Widespread multidisciplinary participation is essential not only to ensure that the guideline is valid, but also that it is valued by all the members of the multidisciplinary team, in order to be incorporated successfully into practice.6
Inappropriate Influence of Non-Medical Factors
Near the beginning of the document, mention is made of ACOG's fear of litigation: “Physicians in the United States, facing increased medical-legal pressures…” Furthermore, in this document, ACOG’s fear of litigation focuses on fear of VBAC litigation: “Increasingly, these adverse events during trial of labor have led to malpractice suits.” ACOG’s fear of VBAC itself is revealed in the Figure 1 algorithm, which includes the need to “counsel patient regarding benefits and risks of VBAC” but does not include a similar need to counsel patient regarding benefits and risks of the woman's other choice: cesarean section. To what extent do ACOG’s fear of VBAC and fear of litigation influence the recommendations in this document? To understand the importance of this question, it is necessary to understand ACOG.
ACOG is not a college in the sense of an institution of higher learning, nor is it a scientific body. It is a “professional organization” that in reality is one kind of trade union. Like every trade union, ACOG has two goals: promote the interests of its members, and promote a better product (in this case, well-being of women). But if there is conflict between these two goals, the interests of obstetricians come first.
Proof that ACOG puts members’ interests first? In September 1998 ACOG published Committee Opinion No. 207, “Liability Implications of Recording Procedures or Treatments,” which includes the statement: “Recording solely for the purpose of patient memorabilia or marketing is not without liability.…The Committee strongly discourages any recording of medical and surgical procedures for patient memorabilia.” In other words, ACOG recommends that doctors and hospitals refuse permission for women and families to make a videotape of their baby’s hospital birth. Fear of litigation against their members has higher priority for ACOG than women’s rights and family values—the need of the family to record one of the most important events in their lives. This is why ACOG recommendations cannot always be considered the gospel and the recommendations in this document are suspect. Should the United Auto Workers have the final say on standards of auto safety?
Impact of Recommendations
The first Level C recommendation, “VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care,” has a huge impact on the system of maternity care in the United States that goes far beyond obstetric practice. If this policy is followed, it drastically reduces or eliminates several options available to women with previous cesarean section, including having their birth at home, in a freestanding birth center or in a small community hospital. Because of all the unnecessary cesarean section in the past, American women with a scarred uterus are a significant minority of pregnant women—in the neighborhood of 15 percent. If the nearest large hospital is at some distance, it makes a family-centered birth difficult or impossible and is likely to eliminate continuity of care throughout pregnancy and birth. Scientific data show such continuity of care significantly improves birth outcomes.
In addition to this impact on women and families and birth outcomes, this recommendation also has a major impact on community-based midwives, family physicians, birth centers and small hospitals.

Two of the eight recommendations are without scientific justification. One recommendation—VBAC only with surgeons right there—has a tragic, unnecessary, negative impact on maternity care and maternity care providers in the United States. The second—oxytocin and prostaglandin induction is OK during VBAC—is quite likely dangerous for birthing women.
We see a double standard in ACOG recommendations depending on whether or not they are doctor friendly (are of benefit to ACOG members). If a recommendation has no evidence to support it but is of benefit to obstetricians—VBAC only in hospitals with surgeons standing by—ACOG will make the recommendation. Other solutions to the same problem that are not obstetrician friendly—facilitation of communication, collaboration and transport between primary and tertiary birth care—will not be recommended even though they would benefit many women. As a second example of this double standard, if there is inconsistent evidence on an issue—oxytocin or prostaglandin induction for VBAC—ACOG will make the doctor-friendly recommendation, approving its use even though the data show a trend that is likely to put some women at risk. ACOG recommendations consistently put the needs of ACOG members before the needs of women unless there is overwhelming evidence that may finally force an ACOG recommendation which is not doctor friendly—no Cytotec induction for VBAC.
We also see little evidence that ACOG is trying to find out why there is increasing uterine rupture so that it can be prevented in the future. ACOG should be making every effort to promote research on the management of those labors during the past 10 years that ended with uterine ruptures, including the percent of ruptures associated with VBAC and the percent associated with the use of Cytotec, oxytocin or prostaglandin gels. There is also an urgent need for far more research on the relationship between characteristics of places of birth (home, birth centers, community hospitals, regional hospitals, tertiary care hospitals) and uterine rupture. Armed with this kind of data, ACOG could make evidence-based recommendations, be they doctor friendly or not.
ACOG's primary allegiance to the needs of its members over the needs of women and families requires their recommendations to be suspect unless confirmed by overwhelming scientific evidence. As ACOG recommendations come from a single-specialty organization, they always must be carefully evaluated as to bias and should never be the sole basis, nor even the most important justification, for maternity care policy in the United States.Marsden Wagner, MD, is a neonatologist and perinatal epidemiologist. He was responsible for maternal and child health in the European Regional Office of the World Health Organization for 14 years. Now living in Washington, D.C., he travels the world talking about appropriate uses of technology in birth and utilizing midwives for the best outcome.
McMahon, M. (1996). Comparison of a trial of labor with an elective second cesarean section. New Eng J Med 335 (10): 689-695.
Chauhan, S., et al. (1997). J Reprod Med 42 (6): 347-352.
Plaut, M., et al. (1999). Uterine rupture associated with the use of misoprostol (Cytotec) in the gravid patient with a previous cesarean section. Amer J Obstet Gynecol 180 (6): 1535-1542.
Rosen, M., et al. (1991). Vaginal birth after cesarean: a meta-analysis of morbidity and mortality. Obstet Gynecol 77 (3): 465-470.
Editorial. (2000). Development of practice guidelines. The Lancet 355: 82-83.
Learn more about cesarean prevention and VBAC in Midwifery Today Issue 57. In "Choosing Cesarean Section" Marsden Wagner tells us that the risk/benefit factors of c-sections depend on the reason for doing them: "Where the baby is not in trouble, the risks to the baby still exist, meaning that the woman who chooses CS puts her baby in unnecessary danger."

Wednesday, February 4, 2009

VBAC Policies in Minnesota

According to a survey conducted by ICAN of the Twin Cities in 2008, 39 out of 101 hospitals (38%) with labor and delivery services in the State of Minnesota have formal policies prohibiting vaginal birth after cesarean (VBAC). Particularly in rural areas of the state, this means that women must either "choose" unnecessary, repeat cesarean surgery or travel extensively to receive maternity care. An additional 30 hopstials (30%) have policies leaving access to VBAC up to individual doctors' discretion. In total, this means that two-thirds of all hospitals with labor and delivery services in Minnesota have formal or de facto policies that severely limit birthing women's access to choice in childbirth. For more information, please contact ICAN of the Twin Cities:

Download PDF here. Key for hospital #s here.

Click here for a PDF of Twin Cities metro VBAC Map

Monday, February 2, 2009

What woman are up against

Hi everyone. I don't post much because Sarah does such a wonderful job, but I came across this article and it illustrates so clearly what women wanting a VBAC are up against:

Hart to Heart: Opinions vary on c-sections
Anne Hart Sunday, February 1, 2009 at 12:30 am

Cesarean sections require more time to heal than vaginal births. They're almost twice as expensive. And multiple c-sections bring risk of complications. Despite those disadvantages, c-sections are now more popular than ever. C-sections accounted for 43 percent of the births last year at Candler Hospital and 37.6 percent at Memorial University Medical Center. They're also on the rise nationally, with some hospitals reporting as high as one in two births as cesarean, according to the International Cesarean Awareness Network, which educates women about the risk and dangers of c-sections.

While c-sections are sometimes medically necessary, factors such as the increase in doctors who've stopped performing vaginal births after a c-section (also known as VBAC) are driving up the rate. Candler only had eight VBACs attempted last year out of 3,191 deliveries. Seven were successful. In 2007, the hospital had one attempted and successful VBAC out of 3,040 deliveries.
Instead of VBACs, women undergo elective repeat c-sections, which now represent about 40 percent of the 1.3 million cesareans performed each year nationally. Are c-sections, which are major surgical procedures, being over-performed? Like most medical questions, the answer depends on whom you ask.

VBACs vs. repeat c-sections
A new study in the New England Journal of Medicine found early, elective, repeat c-sections can lead to an increased rate of complications, including infections. According to researchers, more than a third of elective repeat c-sections are performed too early. The American College of Obstetricians and Gynecologists recommends that elective c-sections be performed no sooner than 39 full weeks of gestation, unless there's a medical indication. The study found that 36 percent were earlier. Both Memorial and Candler follow the ACOG recommendation - when and if VBACs are done at all.

VBACs were briefly popular a few years ago, increasing from 3 percent to 28 percent from 1981 and 1996, but now the trend is going the other way. Doctors don't want to take on the medical and legal liabilities linked with VBACs, experts say. A vaginal delivery after c-section carries a one in 200 chance of uterine rupture.

Dr. Glen Scarbrough, chair of the department of obstetrics and gynecology at St. Joseph's/Candler Hospital, doesn't outright ban VBACS among his patients, but he does discourage them. He says the VBAC success rate is low and not worth all the risks involved. He attributes the VBAC decrease to concern for safety. Scarbrough doesn't see the overall c-section trend as necessarily negative. After all, today women undergo emergency c-sections when labors fail to progress. But decades ago, women used to be allowed to labor for hours upon hours, then forceps were used. "I'm not sure we want to go back to that," Scarbrough said. "Now it's a lot less traumatic for moms as well as babies."

However, Dr. William E. Osborne of Provident OB/GYN Associates supports VBACs when appropriate. "It's a safe procedure, but it just has a risk that some people are unwilling to take," Osborne said. Physicians are required to remain in the hospital throughout the entire labor while a mom attempts a VBAC, rather than just be there through the active labor phase. Osborne is concerned about the move toward c-sections overall and the trend of early labor inductions, especially those being done for the sake of convenience.

There are ways for women to decrease their chances of a c-section. Starting with finding a doctor with a low primary c-section rate. But with medical risks, personal concerns and legal liabilities looming over physicians and hospitals, a mom has no guarantee when it comes to avoiding a c-section. In the end, the outcome is what counts. The goal is for a healthy baby and mom.
No matter how the birth happens.

I am so appalled by Dr. Scarbrough's comments (in bold) and attitude towards VBACs and c-sections that I really don't know what to say, except to warn women that this is the kind of rhetoric doctors use to force us into repeat c-sections, or primary c-sections. He sees nothing wrong with it, yet the evidence contradicts this. Just about everything he says is wrong -- VBAC success rate low--at 70%? VBAC not worth the risks involved...for who? Women "allowed" to labor for hours and hours..isnt that normal and necessary for many of us? C-sections less traumatic for women and babies...who says? -- and makes clear, again, what an uphill battle we have to help make VBAC available to all women. This is a reminder to all seeking a VBAC--be sure to ask your doctor or midwife their views on VBACs. Any comments such has Dr. Scarbrough's should be a major red flag!