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Women of Size and Cesarean Sections: Tips for Avoiding Unnecessary Surgery

A fantastic article written by a fantastic woman. Kmom is probably the best resource for information about birth and breastfeeding for women of size, and is also just about the best resource out there for information on "Gestational Diabetes". She has a real gift in synthesizing and summarizing the research in a non-biased way -- after you read the above article (a companion piece for Our Bodies, Ourselves: Pregnancy and Birth) check out her website: Plus-sized Pregnancy (it isn't just for plus-sized women).

New Website for the International Cesarean Awareness Network

Contact: Laureen Hudson
Publications@ican-online.org
(707) 237-5253

Melissa Collins
Melissa@ican-online.org
(951) 973-1028

For Immediate Release

Advocacy Group Unveils New Web site
Site features easy navigation, community resources

REDONDO BEACH, CA, February 7, 2008 – The International Cesarean Awareness Network launches a new, user-friendly Web site today in an effort to further the group’s outreach efforts.

“The new Web site will make an impact in the battle against the growing cesarean statistics by providing information to moms, challenging them to take responsibility for their births and providing a safe community for moms to heal” ICAN President Pam Udy said. “This will give women the tools they need to make educated decisions about their births – because this isn’t about statistics. It’s about every mom and every baby getting the safest birth possible.”

Easy navigation is a key feature of this Web site, which has been in the works since July when ICAN Board Members recognized the need for a more user-friendly Web site. (The Web site can be found at http://www.ican-online.org/) Site viewers will find information separated into five categories: Pregnancy, Recovery, VBAC, Advocacy and Community.

“In our daily advocacy work, we saw a clear mandate for a site that was simple to navigate, simple to understand and full of easy-to-access information for the woman avoiding a cesarean, recovering from a cesarean or on her journey to VBAC (vaginal birth after cesarean),” Laureen Hudson, ICAN Publications Director said. “ICAN interacts with women on very different journeys -- the messages a pregnant woman needs to hear to avoid a cesarean are not the same messages a woman on the journey to VBAC needs to hear. We like to think that this site addresses those two complimentary, yet divergent, needs.”

The Web site lets women research the VBAC policies of hospitals near them; learn how to correct problems (such as malposition or pre-eclampsia) that commonly lead to cesareans; get quick physical recovery tips to help after a cesarean; and stay up-to-date on medical research on pregnancy and birth. New community features include user birth blogs, videos and images; and the capability for users to create their own homepage on the ICAN site to share with friends and family. ICAN leadership also can connect more easily via the Web site with the women ICAN serves. Further, the Web site features a new logo – the logo, and all of the Web work, were completed entirely by volunteers.

“We wanted our site to be easy for the average woman recovering from surgery and caring for a newborn to find the info they needed quickly and easily,” Webmaster Melissa Collins said. “One of my favorite features is the online social community that is safe for moms planning a VBAC or just wanting to avoid. I’m really excited to watch this new community grow.”

This new Web site comes after research in 2007 by the National Center for Health Statistics showed the cesarean rate reaching a record high of 31.1 percent. Further, a CDC report indicated the maternal death rate rose for the first time in decades and Consumer Reports includes a cesarean in its list of “10 overused tests and treatments.” Other research from 2007 cites a VBAC continues to be a reasonably safe birthing choice for mothers. And while studies indicate a VBAC is a viable option, women often have difficulty finding a health care provider who encourages a VBAC – which is where one of the site’s new features comes into play.

“The most useful tool for women is probably the Hospital VBAC Ban information,” Collins said. “Women can look up the hospitals near them and find out their VBAC policy and if any doctors are actually available to attend them. It is getting difficult for so many women to find a VBAC supportive provider and this is one way to make that a little easier for them.”

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 more than 94 ICAN Chapters across North America, which hold educational and support meetings for people interested in cesarean prevention and recovery.

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....

Cesareans and Private Insurance

I'd started to work on this project but then life happened and it got put on the back burner. But then it happened to a good friend. So its not on the back burner anymore.

Turns out, if you are looking to get private insurance (you know, the kind that isn't provided by your employer, or the govt., the kind that some politicos want to give you tax breaks or special savings plans to buy) you might well be denied coverage if you've had a cesarean within the past 5 years. Why? Well, because there are too many complications in that time, after that surgery. Interesting. But its just another way, a better way, to have a baby. Even better, if you do agree to surgical sterilization, they'll go ahead and cover you. (So basically, I think the complications they are worried about are future pregnancies and the repeat cesarean that they know you'll likely have, whether you need one or not). Because its so politically risky, insurance companies are not allowed to mandate a TOL (trial of labor) or VBAC, and understandably, they don't want to pay for a bunch of expensive repeat surgeries that aren't necessary most of the time. So, because this is a market economy at times, they just don't provide their service to women with previous cesareans. I don't blame them.

But I have to wonder if anyone is warning women about this unforseen longterm complication of having a cesarean? Oh, it doesn't really matter if you don't have to have private insurance. But depending on the outcome of the current bickering about health care, that might be just exactly what a lot of people have to get. Except a pretty good number of them won't qualify....unless they are willing to undergo surgical sterilization, of course. Is that offensive to anyone other than me?

The great part is, I'm not just ranting about this. I already have one very motivated woman who is really pissed off about this. I need a few more. Who would be willing to talk to the media. It is distinctly possible that this could become a national story...if we find at least 3 women, with good documentation of the insurance policies and the refusal, who are willing to talk about it. And if its spun well, it'll really highlight what a disaster the 30+% cesarean rate really is, in ways that most people haven't even contemplated. So, if you are one of these women, please contact me. Ask around, see if you know anyone who's had this happen, who'd talk to me. Email me, please!