Twisting in the Wind....

If you happen to think that using a Birth Center for your VBAC is a good option, you might have to reconsider. This was just released. An important note -- the original study (Nov. 2004) concluded that VBAC resulted in a significantly higher rate of adverse outcomes but they drew that conclusion by including poor outcomes that had nothing to do with the VBAC status of the laboring woman (much like the Hannah Breech Trial did, to kill off vaginal breech delivery). This is part of the reason there was a push to "redo" the study, because the conclusions drawn were so fishy.

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The Board of Directors of the American Association of Birth Centers has issued a statement regarding the feasibility of another AABC VBAC Study.

After long and extensive review of the feasibility of the American Association of Birth Centers conducting another study on VBAC in birth centers, the AABC Board of Directors has determined it is not possible for the Association conduct such a study at this time and will instead continue to advocate to policymakers for access to VBAC. The AABC Board has struggled for some time with how this small organization can respond to the very large VBAC issue. "It is hard to say that we are not going to do a VBAC study from an emotional point of view, but practically we need to." says AABC President Cynthia Flynn, CNM, PhD.
For some this may seem like an abrupt change and the Board has anguished over this decision for months now. Here is a brief history of how arrived at this decision. . .

AABC conducted the National Study of Vaginal Birth After Cesarean in Birth Centers over a ten year period and the study was published in Obstetrics & Gynecology (November 2004). The study authors concluded, "Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management. Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery. Hospitals should increase access to in-hospital care provided by midwife/obstetrician teams during VBACs."

In response to this study the Commission for the Accreditation of Birth Centers (CABC) advised that CABC accredited birth centers may not do VBACs in the birth center unless they are participating in a national research study, with strict inclusion criteria, on VBACs.

The idea for another AABC VBAC study was presented and first discussed at the AABC Board Meeting in April 2005 (and most meetings since). At the AABC Annual Meeting in September 2006, we announced that we were going to do a VBAC study.

The following month ACOG published a new statement of policy on "Out-of-Hospital Birth in the United States" which had the potential to have a tremendously adverse effect on birth centers in America. The statement was not based on the evidence, and AABC advocated for ACOG to reconsider their statement based on the evidence. The AABC Board decided wait for the dust to settle before proceeding with a VBAC Study.

In February of 2006 we conducted a survey of birth centers to gauge how many centers would participate and how long it would take to generate a sample size that would yield reliable data. We determined that it could take up to 15 years. This was evidence of how much the climate about VBAC's had changed since the initial VBAC study was conducted.

We proposed the idea of including the VBAC study as a subset of the National Study of Optimal Birth that we were launching. We added the necessary fields for VBAC research to the AABC Uniform Data Set (UDS). At the AABC Birth Institute in October 2007 we solicited birth centers to participate in these studies.

After the conference, we sought consultation from respected researchers on the advisability of AABC conducting another VBAC study. Everyone we consulted told us not to do it. These consultants were all experienced researchers who have consistently demonstrated strong support for and a good understanding of birth centers over many years. It seemed clear that, while they were also sensitive to the growing limits of access of women to VBAC's, they also were clear about what was in thebest interests of AABC. And clear about the importance of AABC remaining a credible resource for normal birth. We could not determine how to design a VBAC study that meets Independent Review Board (IRB) criteria for informed consent, that is statistically sound, and that wouldn't be political suicide for such a small group.

Many Board members practicing in birth centers felt conflicted about their desire to provide access to care for VBAC women in their birth centers and the risks for the Association in undertaking such a study at this time. There is a health care crisis in America and midwives and birth centers have an important role to play in structuring solutions. As an association AABC must focus its strategic capital on our mission: the promotion of the rights of healthy women and their families, in all communities, to birth their children in an environment which is safe, sensitive and economical with minimal intervention.

Whether or not to do VBACs in your birth center is a decision for individual providers. The AABC Standards for Birth Centers state that birth centers are appropriate for low-risk women. The National Study of VBACs in Birth Centers found that VBAC is not low-risk, although it is not defined as high risk either. All of the research on birth centers demonstrating our quality, safety and cost-effectiveness has been on low-risk women.

The ability of your birth center do VBACs depends on several variables:

Your state regulations for birth centers.
The risk criteria you have developed in consultation with your collaborating physician.
Your timely access to acute care that will be prepared for emergency transfer.
Your willingness to take on the potentially increased liability of doing VBACs in light of the current research.
Your willingness to put at risk access to birth center care for all women if there is a bad VBAC outcome.
A birth center's decision to do VBACs does not preclude them from membership in the American Association of Birth Centers.

AABC will continue to advocate for access to care for VBAC women. We have developed the AABC Uniform Data Set, an online data registry, which will be used in collecting data for the American Association of Birth Centers' new research project "The National Study of Optimal Birth". The instrument for the study, in development over the past ten years, is designed to uniformly collect comprehensive data on both the process and outcomes of the midwifery model of care - including VBACs. It is anticipated that a large set of prospective data collected simultaneously from all providers in all settings - hospital, birth center and home will make an important contribution to our ability to evaluate and improve the delivery of care to childbearing women and families. We invite you to enroll your birth center or practice in this study.

Sincerely,

Kate E. Bauer, Executive Director
American Association of Birth Centers
3123 Gottschall Road - Perkiomenville, PA 18074
Tel (215) 234-8068 - Fax (215) 234-8829
KateBauer@BirthCenters.org http://www.birthcenters.org/

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A few things strike me -- So VBAC isn't low risk but it isn't high risk either. But it certainly isn't "normal" because AABC feels it is necessary to leave the VBAC women out in the cold to preserve Birth Centers for "normal birth". I don't know, both my VBACs felt pretty damn normal to me. I particularly like the way they re-emphasize that in the several variables they list...."Your willingness to put at risk access to birth center care for all women if there is a bad VBAC outcome." really doesn't pull any punches does it?


As a good friend of mine said: "We were marginalized just as the Birth centers have been marginalized and rather than sticking with those of us who have supported them, we're being left out to be picked off. I hope they know they are next..they are on the AMA hitlist, too." If you don't know what she's referring to, see here. If we don't hang together....

Cesarean Rate Rises. Again.

So I'm a bit behind in the blogging (what's new?). But I will add my voice to all the others expressing our outrage and grief (though not surprise) that the National cesarean rate for 2006 was reported by the CDC to be 31.1%, a 3% rise from 2005. Given what I see in the stories from just the women who join the ICAN email list, I'm not surprised at all. What with VBAC bans, early inductions and cesarean surgery becoming the "treatment of choice" for suspected macrosomia....I knew the numbers would be bad.

You want to know what's really bad? These numbers are very likely lower than the reality. Why? Well, because some states (Florida is one) exclude "high risk" cesareans from their data -- so if a woman has a cesarean and she was carrying muliples, or the baby was breech or the baby was premature....that doesn't "count". I'm trying to wrap my brain around why this would be a reasonable thing to do....and honestly, the only reason I can come up with is that it keeps the "official" number lower. The argument that these are "necessary and unavoidable" cesareans doesn't make sense to me (and isn't true anyway since all of those pregnancies can end with a vaginal birth)...and excluding breech alone has to raise the cesarean rate by at least 3%...what I am sure has not had any real effect on the numbers are the "patient choice cesareans"....because they really are very rare. You wouldn't know it from the popular press but anytime anyone has tried to get a handle on how many non-medically indicated cesareans are done by maternal request....a very small number is generated. Add to that the fact that most likely, some proportion of hospitals are just plain lying about their cesarean rates (we have a few cases where we know for sure it happens, I'd assume its not limited to those few hospitals) and you get a number that's higher than 31.1%.

So in my state, Michigan, the cesarean rate was 29.8%. About the only good thing I can say about that is that it isn't 37.4%, which is where New Jersey, the state that cuts more women than any other, falls. You know things are getting bad when you see a rate below 25% and want to celebrate (or move to that state). Look up your state -- and then look at the Press Release from ICAN...and then send it to all the media outlets in your area you can find, and to your state and national legislators. Let them know that you are tired of your healthcare and tax dollars being pocketed by the medical and insurance industries, while the U.S. suffers one of the worst maternal and infant mortality rates in the developed world. Let them know that you are tired of women's legal rights to informed consent and refusal being systematically trampled on.

And then, put your money where your mouth is. Join ICAN. If that doesn't appeal, join Lamaze Intl., or CIMS, or Citizens for Midwifery or birthNETWORK or ANY organization that's trying to make a difference.

If you want to get personally involved, email me -- I've got a big project just about ready to launch and I'll need people who are willing to donate time and phone minutes. The problem is huge....but you know what else? If even a quarter of the women who've been through the medical establishment while having a baby got involved....we could make a big difference. So how about it?

Fox in the Hen House hunting Witches

I recently learned about something very disturbing...the American Medical Association formed a group called the Scope of Practice Partnership (SOPP), whose mission is to launch investigations of unlicensed “midlevel providers” and to support initiatives to fight legislation expanding the current scope of practice for licensed “midlevel providers”. If you search "Scope of Practice Partnership" you'll find some interesting and really scary stuff -- unlicensed "midlevel providers" would include non-Certified Nurse Midwives ("lay" or "direct entry" midwives) in states where licensure isn't available, even if those midwives were CPMs and thus, license "ready". If you read between the lines (and on top of them too) you can see that "investigations" is a nice way of saying prosecution and of course, they also oppose legislation introducing licensure to these sorts of health care providers. Licensed "midlevel providers" include the following: chiropractors, advanced practice nurses (aka nurse practitioners), nurse anesthetists, optometrists, podiatrists, physical therapists and psychologists. This whole thing is being sold as an attempt to "ensure quality health care" but my answer to that would be deal with your own lousy health care before you started trying to "fix" someone else's. We all know how well most physicians do with individualized care...Log in the eye anyone?


Alternatively, I've seen it described as a "clearinghouse of information about non physician providers' educational preparation, licensure requirements, and state legislation and regulation regarding scope of practice." The big question is, what do they plan on doing with the information? Oh, well, whenever there is a "scope of practice question" (that would be some non-physician profession encroaching on the income source of the physicians in that state or states) this information can be used to "address the issue" or even better "develop model legislation that can help resolve that concern." A specific example would be nurse practitioners -- currently, the education level to be a nurse practicioner is at the Master's level. There is a move in the nurse practitioner community to move to a Doctor of Nursing Practice degree, rather than a Master's degree. Why is this a bad idea? Why, it would allow nurses to call themselves doctors! And heaven knows, we can't have that...gosh, are they going to come after me too? After all, I call myself doctor....I'm sorry, but physicians don't have a lock on the generic term "doctor".

I think it is most baldly put in this direct quote from AMA resolution 902 : “that state medical boards shall have full authority to regulate the practice of medicine by all persons within a state, notwithstanding claims to the contrary by boards of nursing, mid-level practitioners or other entities.” Needless to say, they define "practice of medicine" very very broadly. Resolution 902 also asserts that “patients may be put at risk for injury or death . . . receiving care from persons
who are not physicians (MD [medical doctor] or DO [doctor of osteopathic medicine])” It is important to realize that there is NO evidence to support this statement and the AMA has been unable to substantiate it. But then again, we all know that patients are never "put at risk for injury or death" by the actions of physicians....who practice only the most scrupulously careful, up-to-date, gold standard medicine, of course.


This is a bully stealing the lunch money from the smart kid, who also happens to be a really nice kid too.


If you'd like to read some analyses of this, I've collected links here:


Coalition for Patients' Rights
Dynamic ChiropracticJune 6, 2006, Volume 24, Issue 12
Dynamic ChiropracticDecember 31, 2006, Volume 25, Issue 02
National Alliance of Professional Psychology Providers
Clinical Journal of Oncology Nursing • Volume 11, Number 2
American Dietetic Association
The Integrator Blog
Maryland Optometric Association
American Association of Nurse Anesthetists



Interestingly enough, I had a chance to discuss the quality empathetic and humane care pregnant women get from "doctors" the other night. For those who don't already know, I'm a Veterinarian and I work at a Veterinary ER Center -- I'm the person you see when your dog gets hit by a car or your cat blocks in the middle of the night (or on the weekend or the holiday, of course). I really love my work and the hours allow me to be other things besides a Veterinarian as well. When I'm working a weeknight overnight shift, I usually have 1 LVT (Licensed Veterinary Technician -- basically the Veterinary equivalent of a Registered Nurse -- they have 4 year degrees and have to pass a written and practical exam to be licensed). Anyway, we were discussing the recent birth events of another employee and I was expressing my disgust at how predictable things are most of the time -- this woman ended up with a cesarean she really didn't want at all and the way she got there was distressingly familiar to me. And my LVT, who is single, childless and in her 50's said all the right things...she was absolutely horrified that over 1 in 3 babies is born surgically. She was amazed that anyone could possibly think its a better way to have a baby. She was shocked that more women are dying in childbirth now than they were a year earlier...she was disgusted at the way OBs manipulate women at the end of their pregnancies when they are tired and exceedingly hormonal.



Too bad I'm not surprised any longer.



Gretchen