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....

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