What do I do now?

(written to a woman who transported from a homebirth and had a cesarean)

Control. Seems to be a strong theme in my life right now. Or rather, my ultimate lack of it. I may get a bit spiritual here, so reader beware.

One thing that I can guarantee is that your next pregnancy and labor will be different from your last one. Every pregnancy, every baby, every labor is unique to itself.

As I wrote in my last letter, in the end, the only responsibility we have is to plan the safest birth we can. There are lots of things we can do, techniques we can learn, knowledge we can gain, expertise we can hire, wisdom we can cultivate, trust we can give, surrender we can make....and all of these things are really important. All of these things can be something that the outcome of a birth hinges on. And every single one of them can be trumped by the universe. And the universe resolutely refuses to give us the guarantee we demand. If you believe in a deity, then you may believe that you are guaranteed an ultimate outcome to your life....but my experience has been that specific outcomes are often, quite deliberately, not revealed to me -- all I'm given is the assurance that there's a plan I'm part of and it is bigger than I can understand....if I believe my God is good, then that needs to be enough in the end (not saying this is easy or that I'm any good at it. I'm not.)

Most of the time, left alone, women have vaginal births. You have the extra burden of not having made the usual mistakes you could then blame your cesarean on. You get to face the universe not caring the same way you do a lot sooner than many. You "should" have had a vaginal birth; after all, you really did do so much "right". That's a scary place to be...what if there's something fundamentally wrong with you? Hang around ICAN long enough and you'll have the opportunity to meet some women who've had to deal with that -- planned a homebirth with a good midwife...ended up cut. Now what? What more can they do? A former president of ICAN had 3 cesarean, the third a failed homebirth...while president of ICAN. And then she had a homebirth with her fourth. Why? I don't know.

I don’t know.

I hate that phrase. Everything in me rebels against not knowing. Why was I in the 10% of clomid users to have twins? I don't know. Why was I then in the 10% with double breech twins? I don't know. Why did this happen to me, who cared SO much about not having a cesarean. I don't know. To make me stronger, bring me to ICAN, this excuse, that rationalization and so on? If any of those are true, that's not good enough. I didn't want a cesarean. Period. I don't know why I had one, not really, and I have a feeling there's no reason out there that I can understand that would make me say "oh, ok, that's why." What I do believe, because, well, that's my world view, is that there was a reason and that no matter what the reason, good or bad, for my betterment or because this world just sucks sometimes, the experience can be (and has been to a great degree) redeemed....over a lot of years with a lot of mileage between then and now.

So what? Well....chances are good that you'll never find a "reason" for your cesarean that you can "fix" and then not have to worry about another cesarean. I can tell you that you'll always have to worry about another cesarean because all pregnant women have to worry about it. Even if you do find a thing to
fix....there are other reasons to have a cesarean and we just can't control most of them (any of them? I guess we can control elective repeats by not signing up for them and we can control for failed inductions by not consenting to induction but are there any others?)

I don't like fake it till you make it. I believe it’s fundamentally dishonest to one's own self. But, sometimes we do have to keep moving even while we look back and try to figure stuff out. If you don't find something to pin your cesarean on, what will you do the next time you are pregnant? Will you plan a repeat cesarean? Or will you go ahead and plan another vaginal birth, maybe at home....and do it, even though you are scared to death you'll have another cesarean? You do have control over what you plan. So keep asking the questions, keep picking through the wreckage and know that ultimately, we all reach that moment when we have to surrender to something that's just a lot bigger than we are, whether you call it birth, universe, fate, karma, evolution, luck, random chance or god.

I've really come to believe that those women who have the sorts of births (or VBACs) where they pat themselves on the back and say "see, I did this, that and the other thing and that's why I got my VBAC" are mistaken about how much credit they can take. They may have made good choices and that may have made a difference (then again, saying "no, I won't sign up for a repeat" might be all it takes for some women to have a VBAC – heck all it takes for a lucky few is to go into precipitous labor before the scheduled cesarean – talk about the importance of plans and choices! ) but in the end, they were blessed that the universe had an outcome in mind that fit what they wanted. Don't get me wrong, bad choices can certainly change an outcome...but think about all the bad choices that end in a vaginal birth.

This is like trying to resolve free will and predestination if you believe such things...they are both true and they are both at work. I guess birth really is life. I don't know why you had a cesarean. I really wish you hadn't. And I really hope you have a VBAC next time. And I know that chances are, you will. And until you do, you won’t know whether it will really happen or not.

What If?

I do not think you are kidding yourself about planning a VBAC and this is why. Your responsibility as a mother is *not* to not have a cesarean or to have a VBAC. Your responsibility is to plan the safest birth for you, your baby and your family. That's it. Now, obviously and for lots of really legitimate and important reasons, we all hope that the safest birth for everyone involved is a vaginal birth, because no matter what the circumstances, necessary or not, surgical delivery can really suck. So the question I would ask you is this -- are you planning the safest birth you can? If your physical condition does change for the worse, will you continue to plan the safest birth you can even though doing that might be incredibly painful and disappointing? Are you doing everything you can to keep as healthy as you can? Do you understand your risk factors and how they could impact the choices you have? Are your circumstances now different from what they were the previous two times? If you answer yes to these questions, then I can't see that you are fooling yourself or kidding yourself or in any way delusional.

The part of all this that is so hard to come to terms with is that there are very real factors that can make or break plans for a vaginal birth that are completely out of our control...boy, does that grind...but in the end, it is possible that your body will not stay healthy enough for a planned VBAC in spite of you doing everything you possibly can. It is also possible that the events of your last 2 pregnancies will NOT repeat, because this is a different pregnancy. Previous pregnancies can seem predictive but often they are not. Each pregnancy, each labor, each baby is different. That you CAN be sure of. You can't do anything at this point about having had 2 previous cesareans. Oh, we wish we could! But we can't. You can make plans with those 2 cesareans in mind, and you should. You do have control over all sorts of things. But what you (and anyone else -- ICAN, midwives, physicians) don't have control over is the final outcome.

Remember -- it is NOT about having a VBAC. It is about planning the safest birth you can. Period.

What did I do wrong?

I have 2 good friends who’s VBACs turned to repeat cesareans for "no good reason" that anyone can figure out....yes, the babies were likely (subtly) malpositioned, even after prenatal chiropractic care and great attention to optimal fetal positioning and they hired midwives who knew many tricks to straighten out babies...and the tricks didn't work. They labored for many many hours...they did "everything right"....and still ended up back in the OR...it is heart breaking. And both have asked, many times “What did I do wrong?”

What did I do wrong?

And I have to say that the "answer" I have is two-fold....first, the baby is an independent player in the whole labor and we can't always predict or dictate what the baby will do. Second, there is a very real element of "luck". Just plain bad luck. It is SO much easier if we find something that looks like a cause. A reason gives some closure, some sense of "if I'd just" to help it NOT mean that you really don't have control over the outcome....but the truth is, for those women who make all the plans, "do everything right" and end up with a VBAC? They were lucky too. We almost automatically take credit for "doing it right" being the reason we have our VBACs but we are fooling ourselves if we think we have that kind of control. The flip side of believing you have that control is to then believe an unwanted outcome means you didn't do something you could have or should have. I'm convinced, after a decade of hearing stories, that this just isn't true. Sometimes you do everything you can and it doesn't work. I don't know why.

When the labor is done and you are in that soul searching place, the compulsion to second guess decisions made during labor is overwhelming...because we forget the intensity and immediacy of labor. My friends had good and patient midwives. There was a reason they trusted them -- with the labor and when the decision was made to transfer to the hospital. Whatever that something was that led them to decide on transfer and ultimately to agree to the repeat c/s, it was real. And since no one can recreate that inarguable something now, its compelling to say "if I'd only"....but there *was* a real reason they didn't just keep laboring, even if no one could put it into conscious thought or words then or now. It is SO tempting to think "if I'd just labored for another x hours, I would have had my VBAC" but we have no idea if that is true or not...maybe yes, they would have. Or maybe they would have transferred later. Or maybe the baby would have been in a lot of trouble by then. Or maybe the baby would have been fine but nothing else would have changed. Or maybe something else would have happened...we just have no idea.

I don’t tell women to stop asking questions or to stop trying to understand what happened. I don't think they can stop, I know I couldn't when I was trying to figure out why I made the decisions I did around my c/s. But the advice I do give is to consider that the answers you may get through your searching may have more to do with your understanding yourself rather than you understanding that birth. There are answers there but they may be to a question that you don't yet realize you are asking. They likely will come later than you hope and slower than you think you can handle, but you will.

Won't Play Nice Anymore, Part 3

This question was raised on an email list I participate in: “if OBs are constantly feeling threatened by the angry mob that is the rest of us then how will we ever be heard, and how will we ever come to a consensus?”

(Let me preface all the rest of my comments with this: as women in this culture, we are from a very early age taught in very subtle ways to be nice, act nice, play nice, keep people happy, don’t rock the boat, whatever you do don’t be a bitch…..there’s a price to be paid for not being a good girl. We want people to get along and it’s hard to know exactly what to do when there’s no chance of that happening.)

This topic gets discussed by ICAN’s Board of Directors with some frequency — are we "too extreme", "too angry", "too whatever"….how do we get listened to and become more than just a "bunch of angry women"…. A starter Blaming the Activists — the topic is size acceptance, not birth, but it did resonate with me and the notion of being "angry" or "extreme".

I’ve been involved in some form or another with ICAN for about 9 years now. As my kids have gotten older, rather than getting less involved ("moving on") I’ve gotten more involved, on a larger, more "political" level, I suppose you could say. So I’m going to ramble a bit about where I’ve ended up on this topic…. I’m not sure I can put it all in a concise and succinct form.

On a very fundamental level, I believe there will be no change until the powers involved start either losing money, or believing that they will lose money. That’s the way our system works, that’s the nature of a for-profit system. It’s why I believe that the VBACban crisis will only be solved by the courts — because it will be only when VBACbans are ruled illegal (and thus, those who have them are open to prosecution) that they stop. If it were about asking nicely or not-so-nicely, if it were about facts, if it were really even about what women want, there wouldn’t be VBAC bans now. The hospitals that have reversed bans have done so because the publicity threatened their bottom line. That doesn’t mean we stop educating but it is why we have to be realistic. And when you threaten the bottom line for a large corporation….you will be tagged "radical", "extreme", "unreasonable", "shrill", "hysterical" and any other name they can think of to discredit you.

The status quo in this country for all birth issues is not OK. But, it is the status quo. Which means, if you challenge it, you are going to, once again, be labeled "radical", "extreme", etc etc etc. It means that, since most people in the country don’t look beyond the surface when it comes to birth, anything you say that conflicts with the conventional "wisdom “about birth (which has nothing to do with being wise) will make you seem crazy. If you challenge the pervasive techno-worship that characterizes all of medicine, you look radical. You ARE radical!

We are a pain phobic society. If you talk about the emotional fall-out from birth gone bad….you will make people very uncomfortable. You will make the people participating our twisted maternity "care" feel bad…often they will think you want them to feel bad. You will trigger very unwanted emotions in women who’ve stuffed their own trauma in order to survive. People will accuse you of wanting to make other women miserable, of wanting to push your own belief system on others, of intolerance, of just about anything they can to not think about what you are actually saying. Because if you are right, then people have to do something about it. If you say things that don’t have these effects on your listeners….then you are no longer be talking about the issues we are so concerned about. Change is tough….and there’s always institutional resistance to it. If the institutions threatened by the change we want successfully describe us by framing the issue as a personal one ("all OBs are awful people who are only out to get rich and don’t give a flip about women and babies") instead of as a criticism of a broken system ("ACOG is a protectionist organization looking out for the financial interests of their members at the cost of safety for mothers and babies") then it is very simple to marginalize us as a bunch of irrational, intolerant, angry women.

We can be polite to the new president of ACOG, we can write carefully crafted letters encouraging him/her to take on the challenges of the future, blah blah blah….but let’s be realistic here. The people who run ACOG are very politically savvy….and they (think they) know darn well exactly what they can get away with, they know darn well exactly who’s pocket they need to be in….and they have the money to do it. It isn’t about facts. It’s about money. Even if you want to blame "the liability crisis", it’s still about money. Why are they suddenly talking about legislating homebirth into illegality? With less than 1% of all births out of hospital, it certainly doesn’t impact the bottom line….but….now the midwives are getting organized (The Big Push). Now the mainstream is learning about how illogical maternity care really is (BoBB). Now ICAN is telling stories about insurance companies denying medical coverage and distributing information about how to fight a VBAC ban…someone has decided that the bottom line might just be threatened after all…. if ICAN makes any difference at all on the macro level, it isn’t going to be because we are nice. It isn’t going to be because we are nasty, either. It’s going to be because we are numbers. We are the only consumer based organization in this mess….and our biggest strength is you and others who support ICAN with their money and their time. Why? Consumers. Money. Votes. Money. It will be because we do threaten the bottom line and thus, force change. I think that ACOG and AMA understand us (and the midwives) just fine. As long as we aren’t a threat, they ignore us (and until very recently, that’s pretty much what they’ve done). When we are a threat, they will fight us. They will never accept us and willingly make the changes we want. Not because they are made up of bad people (I don’t think they are) but because they are a business.

Of course I’m angry. Doesn’t mean I’m wrong. (or irrational. or mean). What activist hasn’t used anger over injustice to motivate them? I defy anyone to name a successful reformer who didn’t have anger/passion/righteous indignation working for them….political/colonial independence. abolition. suffragettes. civil rights. apartheid. And all of those reformers were crazy, angry, radical, fringe activists too….we are in very good company. The people we are in opposition to (the "OB community") should feel threatened. Because that’s exactly what we are doing. Threatening their comfort, their safety zone, their livelihood. Not because we wish ill upon them as human beings but because we can no longer sit silently as ill is visited upon a larger and larger number of women and babies. Because if we don’t speak, no one else will. If that doesn’t make you mad….well….not much more to say. And certainly, no consensus to be had.

Honesty from ACOG

Sometimes you just have to wonder if someone wasn't thinking. I'm not sure who originally found this, but its a document well worth giving some time to: "Lay" Midwives and Homebirth, from ACOG State Legislative Update Year in Review (August 2007)

Its no secret to anyone that ACOG doesn't approve of midwives or homebirth. They barely tolerate CNMs and have only recently given approval to certain credentialed Independent Birth Centers (which typically restrict access to only the most narrowly defined "low risk" client possible) because of the threat they see in increased public attention to homebirth (there's no reason to think that homebirths are actually increasing, all buzz about The Business of Being Born aside). The thing that I just love about this document is that its so honest! So honest in its deliberate misrepresentation of midwifery (while I've been known to do my share of OB bashing, I don't believe they are mostly idiots -- they know exactly why the term "lay midwife" doesn't apply to most midwives these days) and so revealing in the motivations for why ACOG is opposed to midwifery. Let me share a few choice tidbits:

"Even the nurse-midwives no longer can be counted on to speak publicly against home birth or lesser trained midwives...Nurse-midwives – a fickle ally...Whereas nurse-midwives have been ACOG’s front-line defense against these bills, that’s no longer a sure thing. Today, you don’t see nursemidwives speaking with any consistency against home birth or the certified professional midwives (CPMs)." (Gotta wonder what the leadership of ACNM is feeling about this right not...since it tends to look like they continue to believe their future lies with ACOG. So much for sticking up for each other.)

"Legislators respond to the home birth “choice” message...In 2005, a midwife bill (HB 36) was championed by an unusual coalition – Republicans, including the Speaker of the House, home schooling proponents, the religious right, and the state’s Amish and Mennonite communities. The bill language was deceptive in its simplicity. It said, “Nothing in Missouri law shall encroach on a mother’s right to give birth in the setting and with any caregiver of her choice.” (I can't really see how homebirth isn't a choice. And I don't see what is so odd about the above coalition, other than they aren't usually associated with "choice" in reproductive terms. Now, when the "pro-choice" advocates finally realize that birth in all its forms is just as much a "choice" issue as abortion, THAT will be a strange coalition. Oh, and I'm unsure of what's so deceptive about the Missouri bill -- I think its pretty clear.)

"The situation with hospitals declining to do VBAC deliveries has complicated our advocacy efforts on midwives. ACOG Fellows in California, Washington and other Western and Rocky Mountain states report that women are seeking out alternatives, including home birth with midwives, in their desire for a VBAC." (Well, no kidding. After all, it is a free-market and if you don't provide the service....someone else will. When they provide a service that is exceptionally better than anything you ever offered, you are going to have trouble catching up.)

"Physician back-up for midwives and out-of-hospital deliveries is a growing concern in some states." (lack of back-up IS a problem, one which the homebirth community would love to see a solution to. Oh, wait...) "In Wisconsin, the professional medical ethics of physicians who choose to back-up CPM-trained midwives were in dispute over home birth legislation that got approved in 2006 over the objections of the Wisconsin ACOG Section, the state AAP Chapter, and the State Medical Board." (...the problem is that physicians ARE backing-up CPMs! How unethical.)

With regard to Licensure Bills in various states: "ACOG is playing defense on most of these bills. It’s the rare situation where we can defeat these bills on the merits. For example, in Missouri, ‘lay’ midwife bills get introduced year after year. These bills have been stopped – up to now – mainly by deft political maneuvering and hardball tactics employed by the State Medical Society, not by any persuasive testimony about comparative safety or quality of care." (This might be my favorite. There it is -- they can't defeat these bill based on any evidence that homebirth is less safe or poorer quality care. They have to use hardball tactics.)

There's lots more but you'll need to just go read it for yourself -- the usual "European studies of homebirth aren't relevant to the U.S.", "people just can't understand all the different types of midwives", "midwives are uneducated" drivel, laid out in clearly understood language. Send it to those people you know who think that ACOG really is speaking out for the best interests of women and babies, and not for their own best interests.

Here comes the bus...

For a while now, there's been a big push to legalize CPMs (certified professional midwives) in Illinois, a state with a nasty reputation for persecuting midwives to the utmost extent possible. The women of ICAN have always had an uneasy relationship with "legalization" and licensure of CPMs....because unless the people pushing for legalization are very careful (and sometimes even when they are), usually the state requires a sacrifice to the gods of the medical association before agreeing to legalization. The big three sacrificial lambs are VBAC, breech and twins -- and sure enough, VBAC moms once again find themselves laid out on that altar, under the bus of licensure, hung out to dry while preserving homebirth for "low risk women". I think what really stings this time around is that the ICAN chapters in Illinois have been very active in supporting the efforts to get a licensure bill in front of the state legislature, writing letters, raising money and really getting out there for this cause. And now we find that for our efforts we get a pat on the back, a sympathetic "sorry about that" and a trip back to the surgical suite, since not only are homebirths after cesarean forbidden but we can't find a hospital to "let us" VBAC even if we want to go back into the lion's den. I'm sure the midwives are upset about this and I'm sure they feel like they had no choice. And maybe they didn't or maybe they did. After talking to a few people who know more about Illinois politics than I do, I realize that the situation isn't simple or even logical...so the story isn't nearly done, even if it might look like it. But I've got to say, I'm am SO tired of always being the one who gets locked out, when the women I represent need what a CPM can offer more than any other group out there. Still, while the International Cesarean Awareness Network can't support The Midwifery Licensure Act (Senate Bill 385, House Bill 385) as it is currently written, we are going to keep very close track of its progress, should it make any. Keep watching to see what you can do if the opportunity presents itself.

Read This!

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).

More Thoughts on The Business of Being Born

More thoughts on my experience at BoBB.

Most of the showings that I’ve heard about included a panel discussion afterwards and this showing was no different. It was a pretty diverse group of caregivers – a midwife who works out of an independent birth center, a midwife who works out of one of the local hospitals, a midwife who works as a homebirth midwife and an OBGYN who works out of the big teaching hospital in town. There were quite a number of young, as yet childless women in the audience; I hope that they did get something from the movie and discussion. There were a couple of moments that really struck me – first, the homebirth midwife said something that I’d never thought of quite this way – somehow the discussion had moved to how a transport from home to hospital is handled and how providing seamless care with the OB and midwife working together rather than as adversaries is what we need to work toward but don’t in fact have in most circumstances. Those of us who do a lot of work in homebirth often hear from hospital based caregivers that they know homebirth is unsafe because of the “disasters” they see when a woman transfers in. Of course, the obvious response to that is that they never see what the majority of homebirths look like, since those women never go to the hospital and of course the transfers are complicated or difficult – that’s why they are transfers! But this midwife made the point that as homebirth supporters, we only see the messes from the hospital – and it’s true. We don’t see women planning homebirths who loved their hospital experiences. We see the women who were unhappy, traumatized, discounted, injured in the hospital….it behooves both “camps” to realize that we don’t see each other’s successes very often, if at all.

But the really telling conversation surrounded a statement made by the OBGYN. Now mind you, I do believe that this woman is fairly supportive of unmedicated, uninterfered with birth – I can’t imagine she’d agree to participate in this sort of event if she were a “section everyone of them and be done with it” sort of OB. Early in the discussion, she made the statement that “unmedicated labor and birth are the safest choice for all women and babies”. That’s pretty bold. But one of the younger women called her on it – if you took an oath to do no harm and you believe this, how then can you support women demanding an epidural at 1 cm or demanding a cesarean for no medical reason? And the OB gave the standard blame the woman response – “oh, it’s not because I push for the medication/surgery, it’s the women who are driving this. The women are demanding the epidural in the parking lot, the cesarean on demand. Of course I tell them the risks to having that epidural at 1 cm but they don’t want to hear it.” Given the esteem with which most women hold their OBGYNs, I fully believe that if the OBGYN community (or even individual doctors) were truly committed to reducing the intervention rate, it would come down. And I hear too much from doctors and nurses, read too much on their message boards, to really believe that they “love it” when a woman comes in wanting a natural birth and want to do everything they can to help her achieve one. More than anything, I got the feeling that she was like my 4 year old daughter – she wasn’t lying because she wanted to tell an untruth, she was lying because she really wanted what she was saying to be true.

I was impressed by the honesty of some of the panel members when I asked about the cesarean rate and the difficulties women face when they don’t want to have another cesarean and what they were doing about it. After the short but awkward pause that followed my question, the midwife who works out of the independent birth center pretty much laid it on the line – in this state, if you want a VBAC, you have to stay out of the hospital. The VBAC rate in 2006 in this state was 1%. (I’d bet the majority of those were out-of-hospital, to be honest.) She’s helping by attending VBACs at her birth center. The homebirth midwife is helping by attending VBACs at home. Interestingly enough, the midwife who works out of the hospital and the OBGYN didn’t answer the question. I suppose that is a good indication of what they are doing to help. I can cut the hospital based midwife some slack, she’s probably more than eager to attend VBACs but she may well be constrained by hospital policy – she did talk to me quite a bit afterwards and took my information and was very excited that ICAN had a presence in the community. The OB didn’t stick around to talk to me.

I made some good contacts – a couple of local ones who have pledged some support to the DC BoBB showing and a contact with someone from MANA, who was also very excited about the DC BoBB showing. All asked that I keep them in the loop. Believe me, I will.

Finally saw The Business of Being Born

I finally had a chance to see The Business of Being Born, Ricki Lake’s documentary about birth and midwifery care in the U.S. I’d heard a lot about it and I’ll be the first to confess that initially, I was very cynical about the whole thing – it seemed like more of the same preaching to the choir was going to be about all we could expect. Well, it turns out that I was wrong, much to my delight – it seems that a lot of people have seen it and it seems that some people are a bit rattled by it (If anyone doubts that, just read ACOG’s latest statement on homebirth and their supposition that it is a choice made to be “trendy and fashionable” – they never quite mention Ricki or the movie by name but I can’t think of anything else that would provoke that sort of language.) Anyway, one of the criticisms that I’d heard from various sources was that the movie ended on a bad note, with the director Abby (who was unexpectedly pregnant during the filming and thus became a subject of the film as well) ending up with a cesarean, instead of the homebirth she’d planned. There has been some discussion of how she talked about “maybe this was just the way he needed to come” as if she were totally fine with the outcome and this was in direct contradiction to the message of the film. Maybe it’s just because I see her with the eyes of a woman who has shared the experience of an unwanted cesarean completely derailing plans, maybe it’s because I’ve spent so much of my life listening to and walking alongside other women as they journey through life post-cesarean, but it was incredibly obvious to me that Abby was NOT ok with the cesarean at all, and that at 8 months post-cesarean (not very long at all) she was still wrestling with trying to make sense of the experience. Even though her cesarean probably was the best choice for her baby, even though her cesarean wasn’t a doctor convenience or institutional protocol cesarean, but in fact, her baby was sick and needed to be born quickly, her grief and loss were real and understandable. I was sad with her while also being thankful that her boy was healthy and thriving 8 months later. Her experience actually illustrates how safe homebirth really is, because her midwife knew when they needed to go to the hospital, because the prenatal care she got might have been the reason her baby did survive, because planning a homebirth doesn’t mean refusing to change plans when it becomes in the best interest of mom and baby to do so. It is very common (and very wrong) to assume that those of us who work against the rising tide of cesarean surgery are opposed to any cesareans at all – nothing could be farther from the truth. Obviously there are times when a cesarean is life saving and we are happy that they are available and reasonably safe. More than anything, I think what I oppose is the normalization of cesarean surgery – and the refusal to acknowledge the loss that having a cesarean entails (I’d argue the loss is there even if the woman doesn’t perceive it) even when it does save the life of the mother and baby.

So I hope the next movie is about VBAC and the struggles that we post-cesarean moms face when we try to plan a normal, non-surgical birth the next time. And I hope, if and when Abby does get pregnant again, she is able to plan and have the birth of her dreams. The birth that is both what she wants AND the best birth for her and her baby.

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.

**************

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/

*******************

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!

VBAC ban

The VBAC ban project is finally up and running! What is this you ask? Well, simply put, we are going to call every hospital in the U.S. and find out what their policy is on VBAC. The International Cesarean Awareness Network did this a few years back and found out that over 300 hospitals officially "ban" VBAC (even though this is patently illegal). Needless to say, we are sure the situation is much worse now. But, the cool thing is that ICAN is about to launch a fantastic new website and included on that website is a map of the U.S. upon which every one of the hospitals we call will appear....with information about that hospital and its policies on VBAC. AND, there will be a way for anyone to leave feedback about that hospital, so you can see what other women experienced there. But, in order for this to happen, we need people to call! So if you are interested in helping out, please email me and I'll get you set up and going.

Help ICAN shine the light into the oppression that so many hospitals are inflicting on women.

I wish I'd written this!

This is one of the best bits of birth writing I've come across in a while. So check out Looking glass Alice examines birth and parenting in our culture. Her other stuff is good too -- I like the fact that she's not afraid to "offend" and seems to have a good handle on why we shouldn't be afraid of "offending".

After all, which one of us ever changes if we aren't offended to begin with?

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?

Howling At an Uncaring Moon (ADULT language follows)

Here's the obligatory warning. I'm gonna drop a number of F-bombs and equivalent offensivenesses so if that's a problem, stop reading now.

I'm so FUCKING sick and tired.

I FUCKING tired of people being surprised at my hurt. I'm FUCKING tired of being nice, political, detached, dispassionate, reasonable.

Today I had someone (who I like and respect) express surprise that I would call a midwife (who answered a query in a public forum) on the fact that she thinks women who express their birth trauma in terms of rape are just crazy, basically. Oh, she phrased it in terms of prior experience, bad expectations blah blah blah. Its bullshit. Unadulterated BULLSHIT.

You know what? My cesarean felt just like a rape. Because I've BEEN raped, I can pretty accurately make the comparison. But you know what? I don't think a prior experience of sexual assault is necessary for a woman to KNOW she's been raped. Of course, the fact that something like 1 in 3 women in the U.S. have experienced a non-consensual sexual contact before the age of 18 means that there's a whole bunch of women who DO know what they are comparing to. So pretty much all I have to say to those who aren't happy with my comparison of my "good" cesarean with my rape is FUCK YOU. How dare you. How fucking dare you.

My cesarean was 9 1/2 years ago. It wasn't even a "bad" one compared to the horrors that most women endure. And I CRIED tonight on the way home about it. THAT'S what happens when I let myself think about it. Me -- controlled, professional, even-tempered, fair-minded, appropriately detached, 2 VBACs later, well on the way to being healed ME. Also the me who since the cesarean has had to deal with anxiety disorder, depression and substance abuse...oh, the cesarean certainly isn't the only "reason" for these problems but it sure as hell didn't help, now did it?



And you know what? I'm FUCKING tired of the Business of Being Born (Ricki Lake's movie). Why? Because everyone who cares is all about how wonderful it is and how profound it is and blah blah blah...it isn't going to make one stinking bit of difference. Because the women who NEED to see it wouldn't GET it even if they did see it. They are so fucking brainwashed that the very thought that their precious OB might not have the same dreams they do is impossible for them to fathom. I'm also really really sick and tired of the fucking choir. I'm tired of midwives carrying on about how important they are. Oh I get how they have to protect their living, their licences, etc. I get that, really I do -- the prosecutions (persecutions) against midwives are nothing less than immoral and maliciously hateful to boot....but frankly, most of them are so fucking full of what a great job they are doing that they won't see the slaughter and if they do, they have to blame it on the women who run so willingly to it. And ok, I can't be that mad at them, after all, part of the reason I'm ranting here is because the slaughter is so damn depressing and overwhelming.



And I'm really really tired of women not getting it. Who do I blame for that? What the hell has happened that women are OK with getting their genitals mutilated for no good reason? What the hell has happened that women ARE abused during birth, more often than not, and they don't care? It pisses me off that women don't care. It pisses me off that somehow, they've been so manipulated from the time of their own births that they think it really is ok to be sexually abused (in all sorts of ways, having a baby only being part of it). Because that's exactly what it is, sexual abuse (aka rape -- oh, I can't believe she said that! whatever). Except part of me KNOWS that every single woman does KNOW that what happened to her was wrong. Most of the time, she just shuts up, stuffs it and acts like the good little girl that she's supposed to be, to the degree that she'll rip you a new asshole if you DARE imply that she might have reason to be hurt....whatever. I'm fucking tired of that woman too. Fighting with each other when really, we are the only hope we have. Why is it ok for a virtual stranger(s) to stick his (her?) hands up your vagina for no good reason on any number of occasions and then require you to submit to conditions that are pretty much the same as bondage/torture leading to nasty drugs, deliberate cutting of your vagina (and anus, if you are really lucky), or your stomach, muscles and uterus, putting you at risk of serious and life threatening complications for THE REST OF YOUR LIFE. Oh, and did I mention the fact that IT ISN'T GOOD FOR YOUR BABY EITHER????? Your Obstetrician LIED to you. Gasp.



Oh wait. I'm just an angry woman, probably unstable, certainly hysterical, projecting my own mental illness on poor innocent you. Well, that's ok, I'm well acquainted with the finer points of denial so I get it.

Catch me as I fall
Say you're here and it's all over now
Speaking to the atmosphere
No one's here and I fall into myself
This truth drives me
Into madness
I know I can stop the pain
If I will it all away
Don't turn away
(Don't give in to the pain)
Don't try to hide
(Though they're screaming your name)
Don't close your eyes
(God knows what lies behind them)
Don't turn out the light
(Never sleep never die)
I'm frightened by what I see
But somehow I know
That there's much more to come
Immobilized by my fear
And soon to be
Blinded by tears
I can stop the pain
If I will it all away
Don't turn away
(Don't give in to the pain)
Don't try to hide
(Though they're screaming your name)
Don't close your eyes
(God knows what lies behind them)
Don't turn out the light
(Never sleep never die)
Fallen angels at my feet
Whispered voices at my ear
Death before my eyes
Lying next to me I fear
She beckons me
Shall I give in
Upon my end shall I begin
Forsaking all I've fallen for
I rise to meet the end
"whisper" -- amy lee and ben moody



right now, that song describes what it feels like to me to get cut open and then told it doesn't matter. yeah, even 9 1/2 years later....I wish more women didn't close their eyes.....



Ok, so I'm winding down now. I really don't even know exactly what to do with all this....I'll gather myself together and keep plugging away, at least for the sake of my kids, if not for any real change now.

Ramblings of a bored Veterinarian

Funny the things I can figure out when its actually not the middle of the night (which is usually when I have time to even contemplate writing). I figured out how to make the screens smaller with the embedded youtube videos. Yay! So I now have 2 videos prominently displayed on my sidebar....and links to several others that I hope you will check out.

I also added a bunch of blogs and websites to my lists...there's a lot of action right now. We'll see if it lasts. Everyone is all excited about Ricki Lake's movie...I haven't seen it yet, though I'd like to. But honestly....how many women are actually going to see it? Who aren't at least halfway in our choir anyway? And how many women are actually going to make the jump OUT of the hospital....no, they'll just persist in believing that a good birth plan and a doula will guarantee the birth they want...and sadly, in many (most?) cases, hospital staff are very good at getting around both those things.

I try really hard not to get too depressed about the state of things. I think I must be in a "down" phase right now....it seems like its the same old thing over and over and over....I want to have a VBAC but...my hospital banned them....my OB won't do them....my husband doesn't want me to....there are no midwives in my area....we can't afford a homebirth....or....I planned a VBAC but....my OB told me it isn't as safe as we thought....the baby looked big and they wouldn't induce me....I went to 42 weeks and the baby had to come out.....the ultrasound showed my placenta was getting old....my fluid getting low....I didn't want another cesarean but.....

Which leads to a fairly controversial topic, I suppose. The "godly submissive wife". I don't know enough about other faiths to know for sure if this bit of doctrine exists elsewhere -- I suspect it does in some form or another in both Islam and Judaism but I'm familiar with it as an expression of Christian belief. It is a wildly debated topic, since the Bible actually doesn't define it very well....and certainly doesn't define it in terms of modern society and culture. First, the disclosure -- I am an evangelical Christian (by a more traditional and non-political definition -- you can't call me fundamentalist or right wing) and I do believe that a wife should be properly "submitted" to her husband (of course, all believers are to be submitted to each other, too. And, it always pays to remember that the same scripture that urges wives to submit to their husbands instructs husbands to *die* for their wives. Personally, I think I got the better end of that deal). Anyway, the rub is "properly". There are some groups that believe this means the wife has to get her husband's permission for any decision of import. There are some groups that mean this gives a husband complete veto power over any choice his wife might make. There are some groups that believe this means a wife has to do anything her husband demands of her. And I suppose, if a husband were also properly laying his life down for his wife, all the potential abuses inherent in this sort of extreme interpretation probably wouldn't be an issue. But, guess what....humans pretty much will screw anything up. And so, we screw this one up. I have heard too many times "I'm a (Godly/Biblically) submissive wife and my husband doesn't want me to have a VBAC. (or home birth. or midwife. or something of that sort) Unless God changes his mind, I have to have another cesarean because I'm submitted to him." My response to that is "if your husband said any of the following, would you do it? 'I want you to watch porn with me.' 'I think car seats aren't that important and I'm not going to pay for one, you can drive without one.' 'I want you to sign this tax form, even though I haven't been honest on it.' 'I want you to tell your mother we are busy this Thanksgiving.' 'I don't want you talking to your sister, I think she's a bad influence on you.' 'I don't want you going to that Bible study, you need to be home.' 'I want you to have a boob job/tummy tuck/other elective surgery so that you are more sexually attractive to me.'" The fact is, the Bible *never* provides justification for immoral behavior. Lying, cheating, sexual sin, withholding oneself from the body of Christ, endangering children, frivolously endangering oneself....there's never a good reason for any of those things. It doesn't matter if the husband "thinks" any of those things are ok. If I know that what my husband is demanding of me is contrary to God's plan and purpose...I'm not obligated to do it. I'd say I'm obligated to NOT do it, rather the issue is my attitude toward my husband as I choose to obey God. What does this have to do with birth? Well....if a woman truly believes that a given choice is the safest one for her baby, then I'd argue is it immoral to then choose to do otherwise. The fact that the overall risk of something bad happening to mom or the baby is small regardless of the actual choice doesn't matter. The fact that most people might disagree with the conclusion a woman comes to doesn't matter (after all, most people would probably disagree with the overbearing interpretation of submission but she chooses to live that way). A husband has no right to demand immoral behavior from his wife, even if it is "his child too". But, you say, its different. Is it? Is how our children enter this world not that important? If that's what you truly believe, then why are you bemoaning the fact that your husband says you have to have a repeat cesarean. If it isn't important then it really shouldn't matter. (For the record, in my marriage, wifely submission means that in a situation where we disagree on the path we should take, as long as both choices are morally acceptable choices, he gets to choose. IF we absolutely can not come to an agreement. We never rush to this conclusion. This has happened exactly 2 times in over 16 years.)

I'll end with another potentially hot opinion. All of the excuses for why a woman can't have a VBAC or home birth or whatever are just that -- excuses. Women hide behind "my husband would never agree to it" or "we just don't have the money" or "neither of the hospitals in my town allow it" or "there aren't any midwives in my city" or "it's my husband's baby too" or "I don't want to ruin my marriage fighting about this" when in fact, the issue is that while they think they *should* plan a VBAC or home birth or whatever, they actually don't want to. Not really. I know this will be unpopular....but too often I've seen that where there is a will, a way is found, too often I've seen it to believe that a woman can't get what she wants for her baby if she really wants it.

I suppose I sound rather cynical right now. In some ways, I suppose I am. It just seems like we are going round and round and round in the very same circle while most women quietly run toward slaughter and then spend the rest of their lives telling themselves its ok.

VBAC bans and other nonsense

Well, look at that, here I am again. I should probably be sewing Hallowe'en costumes...gonna be a busy couple of weeks I think. Anyway, I'm going to ramble this time about VBAC (that's vaginal birth after cesarean if you don't know, and if you are google searching blogs for that particular term ;-) and how much harder it is to have one now.


There's a lot of research on VBAC out there. For the most part it can be pretty easily summed up as follows:


The one complication that's relatively unique to VBAC is uterine rupture. Uterine rupture can be catastrophic, so it isn't something to ignore but catastrophic ruptures are also rare unless you do some stupid things. The rate of uterine rupture in labors that are spontaneous (that means no induction) and in the hospital is roughly 0.5% (1 in 200), but not all of those are catastrophic. Other than uterine rupture, there's no difference between a VBAC labor and any other labor. If you use things like pitocin or prostaglandins, you will increase the rupture rate. If you've had more than one cesarean, the rupture rate will be higher but its looking like it isn't really much higher (in one recent and very large study, it wasn't higher at all). If successful, VBAC is much better for the mother (obviously -- surgery really isn't "good" for anyone, it can be necessary but not good) and probably better for the baby too. It certainly isn't worse for the baby. The rupture rate is higher with incisions in the upper part of the uterus but we really don't know what the rates are -- all the numbers are quite old and women with these sorts of incisions are rarely "allowed" to have VBACs, so we don't know what the uterine rupture rates would be in this population. Things that do not increase the uterine rupture rate include being past your due date, having a "big" baby, having twins, being old, being young, being fat, being skinny or being short. Unless of course you are being induced because of any of those things.

Back in the 90's, the medical community "supported" VBAC. I'm too cynical to believe that this support was because of some noble desire to see women avoid the knife -- well, ok, maybe that was part of it....but really, it was about managed health care and cost cutting. And that's not a good reason...the good reason would be because its better care for mothers and babies to encourage VBAC (which it is) not because it makes the profit margin look better to the share holders. The reason I say this is because the OBs just couldn't keep their hands off ... birth of any sort goes better if you just leave it alone...and they couldn't. So they started doing stupid things like inducing women willy nilly and getting very casual about the whole thing...and so, because bad behavior begets bad behavior, there were some spectacular lawsuits. Though, I've been told that this has been somewhat overblown by the obstetrical community....I don't doubt it but I can't confirm it either. Anyway, ACOG (American College of Obstetrics and Gynecology, functionally the trade union for OBGYNs) came out with a practice bulletin that made "suggestions" about how to manage a VBAC and basically VBAC became an endangered species...ACOG claims that the practice bulletins are just "suggestions" but realistically, if an OB does something counter to the bulletin, they have little to stand on if they are sued. Which leads to VBAC bans.

ICAN is in the process of updating our list but as of a few years ago, there were over 300 hospitals in the U.S. that officially banned VBAC - in other words, you can't have one at that hospital, even if you've had one or more already. At least, that's what they'd like you to believe. Many more hospitals have de facto bans in place because there aren't any attending physicians who'll accept a patient who wants one or the restrictions on having one are so outlandish that it just never happens. I don't know about you but I find it really offensive that anyone, much less a hospital administrator or Board of Directors can tell a women how she's allowed to have her baby. Plus, I'm pretty sure its illegal. Why, you ask?

I'm still figuring this out but I think there are two different laws/regulations that actually make it illegal for a hospital to refuse to allow VBACs. The first is EMTALA (Emergency Medical Treatment and Active Labor Act) which says that if a woman shows up at a hospital in active labor, that hospital may not turn her away, no matter what. The hospital is required by law to admit her and stabilize her (defined as both the baby and the placenta out) OR if they are not able to provide care, transfer her to a facility that can (if they can transfer her before the baby and placenta are delivered. A physician friend explained to me that if the baby and placenta are delivered in transport, the hospital that shipped the woman gets in big trouble because obviously, they could have handled it). What EMTALA does is get the woman in the door. THEN there are the Medicare Conditions of Participation (CoP)- these are the rules any hospital that accepts Medicare dollars (most of them) must follow. The CoP has some very specific things to say about a patient's right to refuse treatment in the section on patient's rights:

"The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate."

Now...the one thing that I see a potential problem with is that last sentence -- "medically unnecessary or inappropriate." If someone did request a judgment on whether or not VBAC bans were illegal under this clause, I have to wonder if the argument would be made that VBAC is under some circumstances "medically unnecessary or inappropriate". The notion that VBAC is a "treatment" or "service" makes me crazy -- might as well say pooping is a treatment or service, it would make as much sense but that's not how it is framed much of the time -- I see VBAC referred to as a "procedure" rather frequently, even though the best way to have a VBAC is to not do anything at all (that's an odd sort of procedure). I wonder if the powers that be in the CoP world would look to ACOG for an "expert" opinion -- calling ACOG an expert in VBAC is like calling the oil companies experts in alternative fuel sources so needless to say, I have no faith that they'd give an unbiased opinion when asked. Its an interesting dilemma...should we push for a ruling on this? Or would it possibly backfire badly. To me it seems SO obvious that it is against everything we say is important in this country with regard to individual rights to bodily integrity, etc...but we are talking about pregnant women (who in some states are not allowed to draft advance directives or living wills because they are considered incompetent by virtue of being pregnant), particularly their uteri and we all know uteri aren't all that important (50% of all women will die without theirs -- hysterectomy is the second most common surgical procedure after cesarean. Can't help but wonder if things would be different if babies came out of prostates or something...) So here I sit wondering....should we push this? Where oh where is a lawyer familiar with Heath and Human Services law when you need one?

If you know of a hospital in your area that does outright ban VBAC, keep an eye out for the online survey that will be on the ICAN website soon. I'd love to have your information.

Gretchen