News Link Roundup: Articles You Should Read!

The CNN Home Birth After Cesarean story everyone is talking about this week: Mom defies doctor, has baby her way

A mom has a VBAC at home. Shocking to those not in the birth world. Excellent that this story has started the conversation that it has! Yes, women should be able to attempt VBACs "in facilities with staff immediately available to provide emergency care," as the ACOG suggests, but unfortunately doctors will not agree to even allow women to attempt it. And so they turn to other options.


(Bonus: the doula in this article is the woman I shadowed when I first became a doula!) 
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Another highly talked-about article worth reading, all about how people are discovering that Kangaroo Care is the BEST: The Human Incubator

"Sometimes, the best way to progress isn’t to advance — to step up with more money, more technology, more modernity. It’s to retreat."


"Kangaroo care, however, is modern medical care, by which I mean that its effectiveness is proven in randomized controlled trials — the strongest kind of evidence. And because it is powered by the human body alone, it is theoretically available to hundreds of millions of mothers who would otherwise have no hope of saving their babies."
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Should Black Women Feel Guilty for Not Breastfeeding? on Blacktating

"Until we can change the circumstances for working class moms, how can we expect to convince them to breastfeed? Isn't energy better spent securing real paid maternity leave for women and laws to protect a woman's right to express milk at work, even at blue collar jobs?...When it comes to the working poor there is not even the guise of an even playing field. How do we expect breastfeeding rates to change when the life circumstances for these moms is still the same?"
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Birth Around the World at Stand and Deliver:

A Tale of Two Births in Canada and European Court of Human Rights Rules Home Birth Legal in Hungary

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U.S. Cesarean Rate Reaches Record High, Rises for 13th Consecutive Year at The Unnecesarean 

The national cesarean rate, according to The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) report Births: Preliminary Data for 2009, is now 32.9% (which is up from 32.3 in 2008) and is especially on the rise for Black Moms (via Time)

Possible factors, according to the Time article, are obesity and other health problems, maternal choice, patient education, and physician practice patterns. 

“The rate is going up but we are not really improving the health of babies or moms.”

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VBAC and the Law

Women who desire a Vaginal Birth After Cesarean (VBAC) run into a lot of opposition, and with the climbing cesarean rate in the U.S. (now at 32%), VBAC has become a very hot topic.

There is a great deal of controversy surrounding VBACs, and many hospitals do not give women who have had a previous c-section an option of a VBAC - they say its cesareans only, forever.  More than 9 out of 10 births following a C-section are now surgical deliveries.

There have been some recent developments on this topic, including ACOG issuing less restrictive VBAC Guidelines, and the creation of A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations.


Many women worry that even though they want to try for a VBAC, they will be told that they legally have to have a repeat cesarean section. Just so everyone knows...

THERE IS NO LAW ANYWHERE AGAINST VBAC. 

If your OB tells you there is, DUMP 'EM!

Here are the facts on VBAC and the Law:

Legal Rights and Protections for VBAC

By Rebecca Spence and Farah Diaz-Tello
This article is part of A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a collection of resources that address the most common and pressing questions women may have about their birth choices.

What Is this Body of Ethics and Law, and What Does it Mean for a Woman Making Decisions About Birth after Cesarean?

Ethics
The American Congress of Obstetricians and Gynecologists (ACOG) consistently confirms a pregnant patient’s right to refuse medical intervention as a part of her basic right to privacy and bodily integrity. ACOG’s Committee on Ethics’ Opinions respect the pregnant patient as the person in the best position to make decisions about herself and her baby.[3] The American Medical Association (AMA) also recognizes that performing medical procedures against the pregnant woman’s will violates her right to informed consent and her constitutional right to bodily integrity.[4] Yet, some providers may subscribe to the view, described by the NIH panelist, that separates a woman from the fetus she carries. This view may lead them to try to override the woman’s decision-making authority based on the idea that the doctor, rather than the woman, is best situated to make decisions for the separate “fetal patient” where there is any amount of perceived risk to the fetus. Nevertheless, this idea is not supported by ACOG or AMA guidelines.

Law
There is no law anywhere against VBAC. While there is no guaranteed right to healthcare under U.S. law, federal law prohibits a hospital from refusing to accept a woman in active labor as a patient, and there is no law permitting facilities to deny treatment to women with uterine scars. Any person, pregnant or not, has the right to refuse medical treatment—even in an emergency. The Constitution and court decisions recognize a person’s right to informed consent and bodily integrity. Patients also have the right to change their minds about treatment and can revoke consent at any time. While the law does contemplate circumstances where these rights are not absolute, there is no legal basis for suggesting that women have fewer rights than other people upon becoming pregnant.

You may find these and other rights outlined in a “Patient’s Bill of Rights” or similar document from the hospital.  You may also write your wishes for a VBAC in a birth plan that you review with your provider. However, it is important to remember that birth plans and patient’s bills of rights are not legally binding documents, even if they are in your chart or your doctor signs them.




And let me just repeat this, so you can really have this idea put into your mind:

There is no legal basis for suggesting that women have fewer rights than other people upon becoming pregnant! 

Is this really a concern? Yes. Pregnant women are often treated like second-class citizens, and are court-ordered to comply with cesarean sections (among other things) against their will because they may be hurting the fetus. 

Do we really want to make a pregnant woman’s behavior and choices, any health condition she suffers, or even that she lacks health insurance, a crime because it could hurt the fetus? If we do, then virtually everything a pregnant woman does or does not do could land her in jail, because virtually everything a pregnant woman does or does not do — from what she eats, where she works, and what condition her health was in before she became pregnant — is going to have an affect on her fetus. Allowing the government to exercise such unlimited control over women's bodies, and every aspect of their lives, would essentially reduce pregnant women to second-class citizens, denying them the basic constitutional rights enjoyed by the rest of us.  (from Blog of Rights)

What About Cases of Court-ordered Medical Interventions?
There have been a few rare cases of court-ordered cesarean surgery reported. These cases are outliers and do not represent the law in the area. The only state appellate courts to have ruled on this issue on a non-emergency basis with all the evidence before them all conclude that pregnant women have the same right to informed refusal as any other adult. The few cases in which surgery was ordered were decided on an emergency basis, and the judge did not have the benefit of a full presentation of evidence or participation by experts that would have brought attention to the woman’s rights.  Often, the woman did not even have a lawyer, and was in labor during a quick “hearing” over the telephone. Most of these cases are not binding precedent, for various reasons. The only places where a court might be required to follow the rulings are in the jurisdictions where the cases were decided (a legal concept called “mandatory authority”). In other jurisdictions, they do not have to be followed, but they can be cited to try to persuade a court (“persuasive authority”). The fact that a few women were deprived of their rights is a terrible thing, but it does not mean that these cases are now the law.

ACOG Issues Less Restrictive VBAC Guidelines!!

This is huge news! The birth world is going crazy! The American College of Obstetricians and Gynecologists has issued less restrictive VBAC (Vaginal Birth After Cesarean) guidelines! And while they're not 100% perfect, they are an excellent step in the right direction.

Here is yesterday's press release, which explains the risks of repeat cesareans and provides a great overview of the changed thinking ( emphasis mine):
Washington, DC -- Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans, according to guidelines released today by The American College of Obstetricians and Gynecologists.

The cesarean delivery rate in the US increased dramatically over the past four decades, from 5% in 1970 to over 31% in 2007. Before 1970, the standard practice was to perform a repeat cesarean after a prior cesarean birth. During the 1970s, as women achieved successful VBACs, it became viewed as a reasonable option for some women. Over time, the VBAC rate increased from just over 5% in 1985 to 28% by 1996, but then began a steady decline. By 2006, the VBAC rate fell to 8.5%, a decrease that reflects the restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits. 

"The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns," said Richard N. Waldman, MD, president of The College. "These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate." 

In keeping with past recommendations, most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered a TOLAC. In addition, "The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC," said Jeffrey L. Ecker, MD, from Massachusetts General Hospital in Boston and immediate past vice chair of the Committee on Practice Bulletins-Obstetrics who co-wrote the document with William A. Grobman, MD, from Northwestern University in Chicago. 

VBAC Counseling on Benefits and Risks
"In making plans for delivery, physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans," said Dr. Ecker. Approximately 60-80% of appropriate candidates who attempt VBAC will be successful. A VBAC avoids major abdominal surgery, lowers a woman's risk of hemorrhage and infection, and shortens postpartum recovery. It may also help women avoid the possible future risks of having multiple cesareans such as hysterectomy, bowel and bladder injury, transfusion, infection, and abnormal placenta conditions (placenta previa and placenta accreta).
 
Both repeat cesarean and a TOLAC carry risks including maternal hemorrhage, infection, operative injury, blood clots, hysterectomy, and death. Most maternal injury that occurs during a TOLAC happens when a repeat cesarean becomes necessary after the TOLAC fails. A successful VBAC has fewer complications than an elective repeat cesarean while a failed TOLAC has more complications than an elective repeat cesarean.

Uterine Rupture
The risk of uterine rupture during a TOLAC is low—between 0.5% and 0.9%—but if it occurs, it is an emergency situation. A uterine rupture can cause serious injury to a mother and her baby. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.

"Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether," said Dr. Waldman. "Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC." 

Women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. "It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance," said Dr. Grobman. And those hospitals that lack "immediately available" staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine ruptures, however rarely they may occur, Dr. Grobman added. 

The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center. 

Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is published in the August 2010 issue of Obstetrics & Gynecology.

TOL = trial of labor

TOLAC = trial of labor after cesarean

The guidelines are 9 pages long, so here is a bit of summary of the highlights:

 

"TOLAC should ideally consider the possibility of future pregnancies."

"The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC."

"...if, for example, a patient who may not otherwise be a candidate for TOLAC presents in advanced labor, the patient and her health care providers may judge it best to proceed with TOLAC."

"More than one previous cesarean delivery... given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC..." (this is a reversal of the 2004 VBA2C ban unless the woman had at least one prior vaginal delivery)

"Macrosomia (big baby)...suspected macrosomia alone should not preclude the possibility of TOLAC."

"Gestation beyond 40 weeks.....gestational age of greater than 40 weeks alone should not preclude TOLAC."

"Previous low vertical incision...patients may choose to proceed with TOLAC in the presence of a documented prior low vertical incision."

"Twin gestation....may be considered candidates for TOLAC."

"Induction and augmentation of labor...remains an option for women undergoing TOLAC."  (mixed blessing, they did say no Cytotec)

"External cephalic version (to rotate a breech baby)...is not contraindicated if a woman is at low risk of adverse maternal or neonatal outcomes..."

"Analgesia (painkiller)....for labor may be used as part of TOLAC, and adequate pain relief may encourage more women to choose TOLAC."

"Other elements of intrapartum management..."Most authorities recommend continuous electronic fetal monitoring.  No data suggest that intrauterine pressure catheters or fetal scalp electrodes are superior to external forms of monitoring..."

"Delivery...There is nothing unique about the delivery of a fetus or placenta during VBAC."

"What resources are recommended for health care providers and facilities offering a TOLAC?"

 

And here is where they loose points: They recommend facilities be capable of emergency delivery.  "ACOG...has recommended 'immediately available' some have argued that this...limits women's access to TOLAC...particularly in rural areas.  Restricting access was not the intention of the past recommendations...Although there is reason to think that more rapid availability of cesarean delivery may provide an incremental benefit in safety, comparative data...are not available.  ...the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care.  When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital's resources and availability of obstetric, pediatric, anesthetic, and operating room staffs."

They then go on to say if the setting is not ideal, the "best alternative may be to refer patients to a facility with available resources...or create regional centers...However, in areas with fewer deliveries and greater distances between delivery sites, organizing transfers or accessing referral centers may be untenable." (duh) 

"Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk ...Referral may also be appropriate if, after discussion, health care providers find themselves uncomfortable with choices patients have made.  Importantly however, none of the principles, options or processes outlined here should be used by centers...or providers or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC as safe as possible for those who choose this option...Respect for patient autonomy also argues that even if a center does not offer TOLAC, such a policy cannot be used to force women in labor who decline to have a repeat cesarean delivery."

The news world is buzzing with responses. A few reactions:

The International Cesarean Awareness Network (ICAN) says:
 
However, more than a revision of the VBAC Practice Bulletin is required to reverse the over a decade long trend of increasing cesarean rates and decreasing VBAC rates. ICAN challenges ACOG to take an active role in educating both women and practitioners about healthy childbirth practices; practices that not only encourage VBAC but discourage the overuse of primary cesareans.

The LA Times says:

"But, no matter what the medical evidence says, whether the attitudes of doctors and women will change to favor a less-invasive and medicalized — as well as slower and less convenient — approach to childbirth remains to be seen.”

The NY Times says:

"Women’s health advocates praised the new guidelines because they expand the pool of women considered eligible for vaginal births, but they expressed doubts about whether the recommendations go far enough to change a decade of entrenched behavior by doctors, hospitals and insurers...

Maureen Corry, executive director of Childbirth Connection, an advocacy group, said, “Overall, it’s dubious that these guidelines will in fact open up access for women.”

Debra Bingham, president-elect of Lamaze International, an advocacy group for natural birth, said the “immediately available” wording might still pose an obstacle"

Gina at the Feminist Breeder writes about how the ACOG didn't come to this decision on their own in BREAKING NEWS: ACOG Admits What We Already Knew

Birth in the state of Florida

Since I will be moving to Florida come August to study Maternal and Child Health and continue my doula-ing, it is necessary that I learn all I can about the state of birth in Florida.

Both articles - thanks to The Unnecesarean.



Florida Cesarean Rates by Hospital, 2008
Recall that the WHO recommended Cesarean rate is about 10% of all births for healthy moms and babies.

Hospital Name                                              Total Cesareans   Total Deliveries   2008 Rate

                                                                           
Statewide Total Cesarean Rate               84,994            222,645          38.2%
 
Kendall Regional Medical Center            1,439             2,020             71.2%

Seventy one percent?? Are you SERIOUS!?

Boca Raton Community Hospital              735              1,721             42.7%

Shands Hospital at the Univ of Florida     1,041            2,766             37.6%

Coral Springs Medical Center                    841              2,311             36.4%

Tampa General Hospital                            1,752            5,554             31.5% 
To view the entire list of hospitals and rates, click here.

State of Florida to Ban VBAC in Birth Centers
On Wednesday March 24th the State of Florida's Agency for Health Care Administration will move to permanently ban VBAC (Vaginal Birth After Cesarean) in Florida birth centers.

Further, if the State feels women should have VBAC's in hospitals...they should mandate that hospitals allow women AHCA adequate trial of labor and welcome VBAC's. If fewer than half of Florida hospitals 'allow' VBAC, and fewer than 1% of obstetricians 'allow' VBAC candidates as patients, and Florida women are limited in their choice of birth place and care provider…well, you do the math. Our primary c-section rates aren't getting any lower (Florida's average is around 37%). 

Basically, this means that Florida women who want a VBAC in a hospital with an obstetrician (for fear of uterine rupture, or any other complications) they are almost definitely not going to be allowed to try for one. Unless they want to try for one at home.

VBAC is not allowed in Birth Centers in FL, but can be done at home with a Licensed Midwife and consult physician sign-off. There is virtually no difference in medical equipment between a birth center and the gear of a homebirth midwife. If the state considers a Licensed Midwife with VBAC at home safe, it is literally contradictory to ban VBAC's in birth centers. Many women would feel more comfortable in a birth center than in their homes, for a variety of reasons, and should be offered this opportunity

So it home birth VBAC's are allowed, why not birth centers? To sign a petition to legalize VBAC's in Florida's birth centers: Click here

a position change or an unnecessaren?

Happy Holidays!

I've been partially following the story about Joy Szabo and her VBAC woes due to a change hospital policy which no longer allowed them, but I realized that some of you may not have heard anything about it, so I thought I'd post some info on it here.

Here's some background info:

While seven months pregnant with her fourth child, Joy Szabo was told by her local hospital that she would be required to have a repeat cesarean section rather than allow her to have the birth she wanted, a VBAC. It didn’t matter that she had already had one VBAC at this hospital, the policy had changed and VBACs were no longer permitted there.

After their discussion with their doctor, the Szabos made an appointment to speak with Page Hospital’s CEO, Sandy Haryasz. When the couple told her about their desire for a vaginal birth, they say Haryasz would not budge, even telling them she would get a court order if necessary to ensure Joy delivered via C-section.

The Szabos thought that seemed extreme and rather than succumb to the hospital’s new policy, a few weeks before her due date Joy moved into a Phoenix apartment 350 miles away from her husband and three children while she waited to go into labor. At the Phoenix hospital Joy gave birth to her fourth son Marcus Anthony in an “uncomplicated vaginal delivery.”

CNN wrote a quick-read article on it that I'd like to share, called Mom fights, gets the delivery she wants.

The article also includes some questions you should ask your doctor or midwife in the delivery room if the suggestion is made that it's time to give up on a vaginal birth and head to the operating room, which are interesting. Take a look!

I particularly like the caption on one of the photos, which says... "[so and so] was told she'd need a C-section, but a simple change in position allowed [baby] to come out vaginally."

A Simple Change in Position helped the baby come out, while the doctors were vying for a C-section.  Why didn't the doctors just suggest a change in position first, rather than dangerous, expensive, painful surgery? hmmm... Go Doula!

VBAC

A VBAC is a Vaginal Birth After Cesarean.  I first learned about VBACs from an article in Time magazine called The Trouble With Repeat Cesareans.

There is a great deal of controversy surrounding VBACs, and many hospitals do not give women who have had a previous c-section an option of a VBAC - its more cesareans only forever.  More than 9 out of 10 births following a C-section are now surgical deliveries.

The main risk associated with a VBAC is Uterine Rupture (because the mothers uterus has a huge cut scar running down it from her cesaren), which can be fatal to both mom and baby.

Here are the risks of Repeat Cesareans:
Heavy bleeding/hemorrhage
Increased risk of infection and infertility
Increased risk for hysterectomy and  uterine rupture in subsequent pregnancies
Increase a woman's chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth, such as placenta accreta (in which the placenta attaches abnormally to the uterine wall)

From Birth, Babies and Everything In Between:

Without a compelling reason for surgery, VBAC in most cases is safer not only for mom, but also for the baby. While there is a risk of uterine rupture, for women with low, transverse uterine scars, the risk is 0.6% meaning less than 1 full percent. But in many cases, what we fail to take into the account is the risk for uterine rupture during any time of any subsequent pregnancy after having a cesarean. But most providers fail to tell you this, especially if they are an Obstetrician who would rather you schedule your birth. But no one is going to tell you that you are more likely to be hit by a car or struck by lightening than to suffer a uterine rupture which is the biggest fear of VBAC.

Here are some numbers:

1st VBAC
Chance of Successful VBAC : 63.3% (2 in 3)
Risk of Uterine Rupture : 0.87% (1 in 115)
Risk of Hysterectomy : 0.23% (1 in 435)
Risk of Blood Transfusion : 1.89% (1 in 53)

          vs.

2nd Cesarean
Risk of Hysterectomy : 0.42% (1 in 238)
Risk of Blood Transfusion : 1.53% (1 in 65)
Risk of Placenta Accreta : 0.31% (1 in 325)
Risk of Major Complications : 4.3% (1 in 23)
Risk of Dense Adhesion's : 21.6% (1 in 5)

So why do doctors push repeat cesareans instead of risking VBACs?
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."

Here is a link to a video which is really just a photo montage of a woman's journey from a cesarean to a VBAC at home. Its also a water birth!