REDONDO BEACH, CA, March 11, 2010.  The National Institutes of Health (NIH) finished the Conference on Vaginal Birth After Cesarean (VBAC) March 8th-10th, 2010, evaluating issues surrounding VBAC and seeking to quantify why VBAC rates have plummeted in the U.S. over the last decade.  The final report will provide consumers, health care providers and the general public with data currently available on VBAC.  Audience members included members of birth, health, and women’s rights organizations, including ICAN President Desirre Andrews and numerous other ICAN representatives.

“The final statement from the NIH concludes that a VBAC is a reasonable option for most women.  Over 75% of women who attempt VBAC will be successful.” says Desirre Andrews, ICAN President. “Currently less than 10% of women who have had previous cesareans deliver vaginally in subsequent pregnancies, leading to significant and preventable illness and death.”

The NIH made clear that the major driving factors behind this are non-medical reasons including but not limited to perceived convenience, insurance and liability concerns.  Proper execution of the informed consent and refusal process is not routine, and would be one factor in addressing non-medical concerns.

“NIH took the American Congress of Obstetricians and Gynecologists (ACOG) and anesthesiologists to task, calling on them to change the language in their official recommendations on VBAC.  ICAN has understood for years that this language plays a large role in the lack of access to VBAC in the U.S.” continues Ms. Andrews. “We hope ACOG rises to the challenge and also hope they will finally be willing to work with ICAN and other advocacy organizations to improve maternal and fetal safety.”

A survey conducted by ICAN in 2009 showed approximately 45% of hospitals in the United States formally ban VBACs either explicitly or through unsupportive policies and procedures.   Many women are never counseled that they are good candidates for VBAC and thus undergo more risky and expensive repeat cesareans.  The NIH report acknowledges that this represents a serious breach of medical ethics.  ICAN supports every woman’s right to select the care provider, birth setting and birth plan of her choice.

Lacking in the NIH statement is support for a woman’s right to refuse a cesarean section as this was felt to be beyond the scope of the current mandate.  It was acknowledged, however, by many expert presenters that forcing a pregnant woman to undergo an unwanted surgery is medically indefensible, unethical and immoral.  ACOG’s own statement on ethics states that a woman should neither be coerced nor punished for not following a recommendation.  Further exploration of the issue of patient autonomy in the pregnant woman will require vigilance by all concerned parties to make sure the discussion is an informed one.

ICAN encourages health organizations, care providers and consumers to continue to work towards improving the model of maternity care in our country to better reflect evidence-based practices and respect towards consumer rights of informed consent and refusal.  The NIH VBAC statement is available at http://consensus.nih.gov/2010/vbacstatement.htm

The International Cesarean Awareness Network (ICAN) is a non-profit organization that works to improve outcomes for mothers and babies by preventing unnecessary cesareans through education, supporting those recovering from birth and promoting access to vaginal birth after cesarean (VBAC).

As Washington debates health care, this small hospital in a dusty desert town on an Indian reservation, showing its age and struggling to make ends meet, somehow manages to outperform richer, more prestigious institutions when it comes to keeping Caesarean rates down, which saves money and is better for many mothers and infants.

This week, the National Institutes of Health will hold a conference in Bethesda, Md., about the country’s dismal rates of vaginal birth after Caesarean, or VBAC (pronounced VEE-back), which have plummeted since 1996. “I think it’s the purpose of this conference to see if we can turn the clock back,” said Dr. Kimberly D. Gregory, vice chairwoman of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in Los Angeles.

Tuba City will not be on the agenda, but its hospital, with about 500 births a year, could probably teach the rest of the country a few things about obstetrical care.

Tuba City Regional Health Care Corporation boasts the following statistics:

In Tuba City last year, 32 percent of women with prior Caesareans had vaginal births. Its overall Caesarean rate has been low — 13.5 percent, less than half the national rate of 31.8 percent in 2007 (the latest year with figures available). This is despite the fact that more women here have diabetes and high blood pressure, which usually result in higher Caesarean rates.

The article cites three factors that contribute to Tuba City’s success: 1) midwives, 2) salaried care providers, and 3) federal malpractice insurance.

With regard to midwives…

Nurse-midwives at these hospitals deliver most of the babies born vaginally, with obstetricians available in case problems occur. Midwives staff the labor ward around the clock, a model of care thought to minimize Caesareans because midwives specialize in coaching women through labor and will often wait longer than obstetricians before recommending a Caesarean. They are also less likely to try to induce labor before a woman’s due date, something that increases the odds of a Caesarean.

…and salaried care providers…

Doctors and midwives here earn salaries and are not paid by the procedure, so they have no financial incentive to perform surgery. (Doctors earn $190,000 to $285,000 a year, and midwives $80,000 to $120,000.)

“My colleagues here truly want to practice medicine and help people,” said Dr. Jennifer Whitehair, an obstetrician. “That’s not true everywhere. Here they’re not thinking, how much can I make off this procedure?”

…and, finally, federal malpractice insurance…

The hospital and doctors are federally insured against malpractice, in contrast to other hospitals, where private insurers have threatened to raise premiums or withdraw coverage if vaginal birth after Caesarean is allowed.

As a result, Dr. Leib said, doctors in Tuba City are free to “think about what’s best for the patient and not what covers our butts.”

But can other hospitals do what Tuba City does? One NIH panelist acknowledges the challenges are steep:

Dr. Gregory said it would not be easy to lower the Caesarean rate because of entrenched practices that raise it, like labor induction, repeat Caesareans and in vitro fertilization procedures that produce multiple births. Obesity also drives up Caesarean rates.

“I believe that a 15 percent rate is possible and not unreasonable — as a researcher,” Dr. Gregory said. “As a clinician, if you factor in patient autonomy and the number of interventions we do, it’s not likely to be possible if we keep doing what we’re doing.”

Allison’s story on The Unnecessarian is all too familiar to many women – pressured into a cesarean for a “big baby”, assured that VBAC will be supported, only to have the rug pulled out from under you at the last minute and instead “agreeing” to a repeat cesarean (but was there really a choice?). What of the evidence supporting VBAC’s safety? What of the rights of women to refuse unwanted surgery? These are the questions Allison’s story raises and other bloggers have sought to address.

VBAC: What about rights and choice?

Sheridan at Enjoy Birth illustrates the quandry faced by VBACing women with an analogy to choosing whether to travel by boat or by plane. Henci Goer at Science and Sensibility discusses the perils of viewing VBAC from a “preference” perspective as opposed to a right.  Janelle at Birth Sense shares the provider’s perspective, including concerns about malpractice insurance, threat of lawsuits, and time constraints, but also argues that providers must stand up for evidence-based guidelines. Courtroom Mama dissects excuses made by hospitals for not allowing VBACs that demonstrate the paternalism behind VBAC  bans. Simone at the International Childbirth Education Association (ICEA) blog shares two VBAC stories, illustrating that, while VBAC “success” is not a guarantee, it is nevertheless a woman’s choice to try and no one should stand in her way. However, as Rachel at Frum doula and Kayce at Hearts and Hands Services argue, many women do not even know they have the choice to VBAC or are misinformed about the risks of VBAC vs. repeat cesarean. Finally, Gina at the Feminist Breeder sums it all up: access to VBAC is fundamentally a human right.

VBAC: Good for Moms and Babies

So much of the focus around VBAC is about the increased risk of uterine rupture due to the cesarean scar. While this risk is real, several of our bloggers point out that VBAC is also protective, of both mothers and babies. Melissa of Melissa’s Space, a VBAC mother herself, discusses how VBAC actually protects mothers and babies from the risks and consequences of surgery. Similarly, Willow at Willow’s Rest, an OB nurse and VBAC mama, shares her own experience of the hidden costs of cesarean for mothers.

Still further, some of our carnival  bloggers assert that increasing VBAC’s availability can help solve major issues facing maternity care in the U.S. Robin at Birth Activist discusses how increasing VBAC could lower the maternal mortality rate.  Heather and Jessie at ICAN of the Twin Cities blog posit that VBACs are vital to reversing the rising cesarean rate. Kim at Tea and Devons states that supporting VBACs will help ensure that cesareans occur only when truly necessary. Finally, Kristen at Birthing Beautiful Ideas suggests that if the wealth of evidence surrounding the safety of VBAC is not persuasive enough, perhaps providers and hospitals that refuse to support VBAC should face regulatory pressure or incentives to severely limit the number of primary cesareans they perform.

]]> http://blog.ican-online.org/2010/03/08/vbac-blog-carnival-why-is-vbac-a-vital-option/feed/ 6 http://blog.ican-online.org/2010/03/05/rachel-rays-dr-ian-vbac-should-be-a-womans-choice/ http://blog.ican-online.org/2010/03/05/rachel-rays-dr-ian-vbac-should-be-a-womans-choice/#comments Fri, 05 Mar 2010 21:00:57 +0000 blog http://blog.ican-online.org/?p=540 In case you missed it, talk show host Rachel Ray featured Joy Szabo’s fight for VBAC on her show yesterday. In a segment called “Going Too Far?” Medical Edition, Dr. Ian and Rachel discussed VBAC bans an the rights of women to choose whether or not they have a cesarean. See the video here:

By Maureen Finneran Hetrick
ICAN Conference Director

Have you been wondering what you can do to help ICAN?  Do you want to make a difference in the lives of women?  Consider joining the ICAN 2011 Conference Committee!  You can help make next year’s conference the best ever!

Top Ten Reasons to Volunteer on the 2011 ICAN Conference Committee:

10.  A chance to meet the women you have been chatting with online for years and develop a relationship forged from working on a project together.
9.   You get to help make the conference what YOU think it should be and to KNOW that you are making a difference.
8.  The opportunity to be adored and thanked by hundreds of women.
7.  You get to wear an awesome ribbon during the conference so everyone knows how awesome you are.
6.  You get a sneak peek at the speaker list, exhibitors, and advertisers.
5.  You get a sneak peak at the silent auction goodies, conference bags and raffle items.
4.  You get an extra raffle ticket to help improve your chances of winning!
3.   Extra snacks to fuel you during the conference.
2. You get to bid first on silent auction items.

and the number one reason to volunteer on the 2011 ICAN conference committee is….

1.  FREE Registration to the conference!!!

We really can’t do this without your help!  No experience is necessary, and we all support each other, so you won’t ever be on your own.  This is a great way to help ICAN and to help women.  Your input can make the conference better than ever.  So please consider helping out!

For a list of open positions and an application, please email me at conference@ican-online.org.

I need your help!

Your weekly one-stop for highlights from the birth blogosphere. Visit weekly for the latest on childbirth, especially related to cesarean prevention, recovery, and VBAC. To nominate a blog post to be featured here, email me at blog@ican-online.org

Hey birth bloggers! Don’t forget to submit an entry in our first-ever blog carnival. Details here. And now for this week’s best:

Midwives of all stripes are under fire across the country. Kathy at Woman to Woman Childbirth Education shares this joyful news of defeated legislation to ban Certified Professional Midwives in Mississippi. In California, Ina May Gaskin weighs in on Dr. Fishbein’s blog on the removal of privileges for CNMs at St. John’s Pleasant Valley hospital.

In a follow-up to her inspiring VBA3C story last week, Danielle at Informed Parenting links to a great Midwifery Today article on where the rule of 10 centimeters dilation before pushing came from. Speaking of inspiring VBA3Cs, Nurturing Hearts Birth Services posted Nicki’s triumphant birth story (ok, it was posted last week, but it needs to be shared!). While we’re on the topic of VBAC, don’t miss The Feminist Breeder’s tips on how to have a better VBAC and Birthing Beautiful Ideas‘ cautionary tale on why knowing the facts about VBAC are essential.

Photo credit: Birgit Amadori

This mother-size activism task takes less than 2 two minutes and can be done from the comfort of your computer chair!

As we’ve blogged previously, the National Institutes of Health (NIH) is planning a conference called Vaginal Birth After Cesarean: New Insights.

ICAN President Desirre Andrews says:

The weeks are counting down to the NIH VBAC meetings March 8-10 in Bethesda, MD.  Attending the meetings along side many other birth activists who are birth professionals and/or consumers is very exciting and I am certain more than I am hoping for. Packing up and leaving my family for several days is bittersweet to be sure. I know this sort of involvement can very well pave way for more judicious use of cesarean, much more openness and offering of VBAC regardless of the NIH stance or viewpoint. The time away from my family is never easy, however, I am reminded every day that every facet of this work that takes time from my family ultimately gives back to them and countless others.

While ICAN encourages all that are able to attend the conference in-person and make our voices heard, we understand that not everyone who is interested will be able to do so.  The good news is, you can still be involved by pre-ordering a free copy of the conference statement or viewing the live conference webcast.

What you can do: Follow this link, check the applicable boxes for the Conference Statement as well as the box to register to view the live webcast.  Fill out the form, then submit.  It’s really that simple!

How can something so short and simple make a difference? Pre-ordering the statement and registering to view the live webcast shows the NIH and its presenters that  VBAC matters to consumers.  It shows that we want to be active in and knowledgeable of decisions and statements regarding our rights to access of health care options.

After you register to receive the statement and view the webcast, be sure to spread the word on Facebook, Twitter, and by word-of-mouth to your friends, family, and local birth communities (include link directly to this blog post)!

And don’t forget to participate in our VBAC Blog Carnival!

The researchers examined the incidence of TTN among babies who experienced labor and those who did not. Babies delivered by elective cesarean (ECS) at 37 weeks gestation had a nearly 5 times the risk on average of developing TTN compared to those who experienced labor. The relative risk of TTN decreased as gestational age (GA) increased, but even at term (40 weeks), infants delivered by cesarean with no experience of labor had two times the risk of having TTN.

According to the authors (emphasis added):

The main finding of the present study is that the mode of birth and the absence of labor are strongly related to the development of TTN in newborns, irrespective of GA, even at term. Our analyses  are  in  good  accordance with previous  data  indicating  ECS, low GA, male gender, and inappropriate birth weight as main risk factors for TTN. Furthermore, the presence of labor before birth was shown to improve respiratory outcomes for infants with TTN. To the best of our knowledge, this is the first study to demonstrate that not only the presence or absence but also the duration of labor before birth positively influences the course of TTN, with a shorter need for supplemental oxygen therapy. No correlations with other outcome variables were found. Our results clearly indicate ECS as the main risk factor for TTN and the crucial role of labor in respiratory outcomes in TTN.

In light of the upcoming NIH VBAC Meetings, the ICAN blog would like you to be heard in our first-ever blog carnival.The NIH Meetings, to be held in Bethesda, MD from March 8-10, will gather “invited experts” to present evidence on the safety and availability of VBAC in the United States. After the meetings, an “an unbiased, independent panel” will prepare an consensus statement on the issue.

There are 20 minutes designated on the conference agenda for “mothers’ stories.” Here at the blog, we’d like to offer a little more air time for you to share your voice on this important issue.

VBAC as a Viable Option

The ICAN Mission, Vision and Statement of Beliefs demonstrate our ongoing commitment to supporting and promoting VBAC as a viable and overall safe option for women birthing after cesarean:

• Birth is a normal physiological process. Research shows that with emotional support, education, and an honest opportunity, the vast majority of women can have a healthy vaginal birth.
• Research shows that VBAC is reasonable and safe for both mother and baby. A repeat cesarean should never be considered routine– it is major abdominal surgery with many risks.
• It is unethical and unenforceable for hospitals to institute VBAC bans. Women have the right to refuse any procedure, including a cesarean.

We invite you to write a blog post on your blog and submit it for inclusion in the carnival.* We will post the carnival on March 8th as the NIH Meetings begin. Here are the instructions for participation:

Topic: Why is VBAC a vital option?
Submissions are due March 6th, 2010
Email your text and link to: blog@ican-online.org

Join us! Share your voice. Be heard.

*If you you not have your own blog, you can submit your entry to the blog for consideration as a guest post.

Your weekly one-stop for highlights from the birth blogosphere. Visit weekly for the latest on childbirth, especially related to cesarean prevention, recovery, and VBAC. To nominate a blog post to be featured here, email me at blog@ican-online.org

Life prevented us from blogging the best last week, but we’ll make it up to you here! Great stuff this week on standing up to hospital protocols and relating with other women when we don’t agree.

Danielle shares her VBA3C story on Informed Parenting: “I wasn’t given the “choice.” I demanded that they allow it. I didn’t have their support or their understanding. I had to rely solely upon myself and my husband, knowing that if we wavered even for a moment, as we came so close to doing several times, we would be engulfed by the medical machine and processed as yet another number.” Similarly, Sheridan of Enjoy Birth discusses her experience pushing back against hospital protocols in her own birth experiences. “When I was pushing for a natural vbac in the only hospital available to me at the time, I put up a good fight and compromises were made in my  favor.”

Courtroom Mama argues that if birth activists really want to reach all birthing women, we might need to think more seriously about our message: “If we want to reach who Dr. Davis-Floyd refers to as “the epidural woman,” we should make sure that our message is clear.  To the extent that any message has even a whiff of judging the woman as opposed to the practice, or paints all of any type of practitioners with a single stroke, it will fall on deaf ears.” Speaking of epidurals, Rixa at Stand and Deliver asks: “So what is it about birth experiences that’s so divisive? Why are we so quick to take offense, or to react defensively, when people make different choices from ours? Perhaps we allow these significant life experiences to partially define ourselves–so that the choice to have, or to not have, an epidural isn’t just about the epidural any more…it’s about how we define ourselves as mothers and as women.”