I received many requests to share it online, not only from conference attendees but by the women themselves who contributed their stories for this piece.  You can download a PDF copy of this document here.

I’m especially excited that I had the opportunity to share the comments provided by Wendy S. from California, Kristen K. of Nebraska, and Rachel R. of Oregon during the public discussion time which you can view via the Day 2 Webcast.  (You can also view the Day 1 Webcast, download a PDF of the Program and Abstracts, as well as pre-order the consensus statement.  The more people who order the consensus statement, the more powerful the message that people are interested in the option of VBAC.)

While the contributors gave permission for their full names to be used on the  handout I distributed at the NIH, not everyone is comfortable with their name on the internet.

American Women Speak About VBAC

In an effort to bring the consumer perspective to the 2010 NIH VBAC Conference,  Jennifer Kamel, Founder of VBAC Facts, asked women across America, “Why is the option of VBAC important to you?”  This is what they said.

Alabama – To avoid not being able to carry your baby because he’s dead from the placental abruption (or uterine rupture) as a result of those damn previous cesareans. – Amanda M.

Arizona – VBAC is important to me because I don’t want to continue to have increased risks with each major surgery. – Amanda McM.

Arkansas – Personally, VBAC is stellar important to me because I wanted to give birth to my babies, not have them cut out and handed to me.  On a soul-deep level, I believe it was necessary to validate my purpose in existing.  – Jer W.

California – It is important to me because I have the right to experience the complex passage of vaginal birth and the positive cascade of effects for mom and baby.  I want the right to experience VBAC without driving 90 minutes or more with traffic. Successful or not, VBAC empowers women for choice and a chance to fill an emotional void that is unmatched.  The whole “readily available” lawyer talk certainly is not protecting our other high risk patients.  – Wendy S., L&D RN

Because when a woman experiences a VBAC, she reclaims her body and gets to see that she is in fact perfectly capable of giving birth without surgery.  She is no longer broken.  Her body and spirit heal. – Layla M.

To me it is like saying someone should be required to have open heart surgery, even though a laparoscope would be safer, just because doctors/ hospitals/ insurance companies, prefer it that way.  It is so much bigger than our desires to experience a vaginal birth or even to be some kind of hippie earth mother. It is about our right to safe and respectful medical care. Courtney Stange-Tregear

I wanted a VBAC to heal my raw emotions and psychological trauma caused by not having a vaginal birth the first time and because I believe it’s safer. Unfortunately, I had to travel 3 hours to get to the closest facility that allowed VBACs. But having the chance to VBAC was great! – Andrea O.

Because I love women and love babies and have spent 20 years investigating what affords the best possible beginning for them both and that is a vaginal birth. – Joni Nichols BS MS CCE CD(DONA) (CBI)

It is wrong that I have to travel to another county and fight for a normal, safe, healthy birth for my baby.  Hospitals and doctors need to get their priorities straight and practice true informed consent. – Kathleen S.

My VBAC proved to me that I was not as broken as I felt after receiving so many labels [FTP, etc] regarding my cesarean. – Alexandra R.

Colorado - VBAC allowed me to trust in my body and let it do what it needed to do.  My midwife and her assistant viewed my “long labor” as simply a variation of normal.  I was finally able to deliver my 10 lb baby, with a nuchal hand, in an amazing waterbirth.  My body is amazing and strong and did not let me down. Jill K., Ph.D. (Clinical Psychologist and Professor)

Connecticut – Without VBAC, women have no choice and are forced into dangerous births. – Danielle M.

Florida – VBAC matters because it is lifelong; it is forever; it is not short term.  The effects of a VBAC never wear off. – Shannon M.

My VBAC offered me a better recovery without worrying about an incision site. – Meredith S., HBA2C mom

Hawaii – The fact that the possibility of a malpractice suit dictates what most obstetricians offer and results in them pushing the birth option that is more likely to end in a mother’s death is totally incomprehensible to me. Evidence-based care is what our standard should be.  Every single obstetrician should be pushing the safest option for mother and baby, not the safest option for avoiding a lawsuit. – Naomi S.

Idaho – My VBAC was validation of my womanhood. It has made me a better mother and spouse. – Bonnie M.

Indiana - I wanted to have a large family and I think VBAC is the best option instead of repeat c-sections!!  I have had 6 VBACs so far and hope to be able to have as many more! – Stacy G.

Kentucky – Because having my baby cut out of my abdomen was very traumatic for me.  The bonding was more difficult [than my three previous vaginal births] and PPD followed. – Denise H.

Massachusetts – When my son was born by (unnecessary) cesarean, I felt like someone had deflated my belly and handed me a baby. He was mine, but a part of me felt like they could have handed me any baby. But when I look at my daughter’s head and stroke it while I am nursing her, I can say I gave birth to that head. I gave birth to that head! This is my baby. And no one can take that away from me. – Catie Ladd

Michigan – There are all sorts of “soft” reasons why VBAC is great but when it really comes down to the bottom line, what keeps me working for ICAN, what brings tears to my eyes, is the fact that women and babies are dying who shouldn’t, because VBAC is no longer a real option for most women in the U.S. – Gretchen Humphries, MS DVM

Mississippi. After my first baby’s labor ended with a cesarean, I felt that I really hadn’t been given a chance.  I felt bullied and pushed into a cesarean I didn’t want because it was more convenient for the doctor than letting me continue at a ’slower than normal’ dilation rate. – Nancy W.

Nebraska – If VBAC was not an option, my daughter would have been an only child.  I could never willingly conceive knowing my child would be cut out of me via a completely unnecessary surgery. – Kristen K.

New Jersey - VBAC is certainly safe for both mom and baby as long as the original incision in the uterus was a low segment transverse incision. Evidence based medicine reports approximately 75% of women can successfully VBAC. As long as the mom is aware of the risks (minimal) and the benefits (MANY) they should have the right to VBAC. – JoAnn McQueen Yates, CNM

New York - Because I didn’t want to go through surgery if it wasn’t necessary.   Doctors take little stock in the emotional and psychological factors of giving birth – it’s not just about pushing out a baby!! – Carrie Moyer Howe

Ohio - Delivering vaginally for me was a “rite of passage.” I was finally able to cast off the numerous doubts and my sense of failure I experienced. I really was “adequate.” – Ellen B., Nurse Manager & VBAC mom X2

Oregon – After my c-section with my daughter, laughing was extremely painful for weeks.  I would think, how awful that during a time that should be filled with joy, I’m unable to laugh.  - Rachel R., HBAC mom

I think it’s important for the operating room space and staff to be available for a true emergency cesarean, rather than have me taking up their space and time for convenience. – Rebecca C.

Pennsylvania – If I had to plan a pregnancy to end in surgery, I would not have another child, period.  – Judy P., DVM, PhD (molecular biology)

VBAC is important to me because it has the capacity of healing my broken Self. – Monica R., PhD.

South Carolina – VBAC is a natural conclusion to a natural process.  Not to mention, how many babies with true emergencies, would be saved by not having operating rooms tied up with elective cesareans? – Raechel Fredrickson

West Virginia - Aside from the fact that offering VBACs is practicing Evidence Based Medicine and should be offered without question, I would like for other women to experience the joy and self-assurance that comes from working with her body as well as the indescribable feeling of pulling her fresh, warm baby up to her chest as I experienced with my HBA3C. – Teresa S.

You give statistics but don’t list any of the sources. If you want to lend any kind of credibility to this article you really should consider actually posting where you got your information from. Not to mention some people consider it plagiarism

All I see in this article is “I say home birth is awesome. These women agree with me because they had bad experiences in the hospital. Home birth is the best.” You say this is for the number crunchers but I find that rather laughable. I see only a few numbers that actually matter and, like I said before, you don’t say where these numbers came from. For all I know they are made up. If I was a true number cruncher interested in only facts and unbiased information then I most definitely would find this article completely useless. Numbers are supposed to be unbiased information, though they can be twisted, and this article is anything but. I would be far more impressed by an article that can show numbers AND an unbiased point of view. If home birth is as safe as you say then you needn’t go on a raging rant in your article about how it’s so amazing because the numbers and statistics would say it for you.

Nice try though, E for effort.

Angie,

Thank you so much for your comment and for bringing unreferenced statistics to my attention.

This is an article that I’ve been meaning to update and your comment has once again brought to my attention how I can make it better.

You said, “You say this is for the number crunchers but I find that rather laughable. I see only a few numbers that actually matter and, like I said before, you don’t say where these numbers came from. For all I know they are made up.”

Please read the very first sentence in the article where I state, “there are major limitations if you are going to rely solely on case controlled studies to decide between home and hospital birth.  There are so many variables and nuances that haven’t been ‘number crunched’ to that extent but make a HUGE difference in the how your birth progresses and the ultimate outcome.”

I state upfront that this is not a review of the literature, but rather a review of some factors that can have a significant impact on how a labor progresses and the ultimate success such as (please note the resources as I don’t think you saw them the first time):

• the importance of privacy, or lack thereof (which linked to an article from the Journal of Perinatal Education) illustrated by…
• how labor can change upon transfer to the hospital, which leads us to…
• the risks of augmentation (which linked to a very well referenced chapter entitled “Slow Labor” from Henci Goer’s book “The Thinking Woman’s Guide to a Better Birth”)

Additionally, there are factors that women are often unaware of that might impact their perception of hospital vs. home birth:

• some complications can be safely handled at home (such as my post-partum hemorrhage)
• hospital birth carries risks and does not guarantee a good outcome (as demonstrated by the links provided)
• American’s high maternal mortality rate relative to other industrialized nations (per figures cited by the CDC).

If you are interested in numbers, let’s review a few.  In the US, 1% of babies are born at home and only 8% of births are attended by midwives. The US has the second highest newborn mortality rate in the developed world. We rank 29th in the world in maternal mortality rates (meaning 28 countries have fewer moms dying) and 42nd in infant mortality rates (meaning 41 countries have fewer babies dying.) In the Netherlands, 30% of babies are born at home and they have one of the lowest infant and maternal mortality rates in the world.  Their infant mortality rate is 60% lower than America’s (4.1 deaths per 1,000 live births vs. 6.9 per 1,000.) (WebMD 2008, CDC 2008)  In fact, the countries that use midwives for low-risk pregnancies and OBs for high-risk pregnancies, have the best outcomes. (CDC 2008) Clearly there is some misconnect in how the US manages birth if we have all these births taking place “safely” in the hospital, yet we have these high rates of death. It was our country’s mortality rates that made me initially question the whole system. How can we spend so much money on obstetrics, and have all this technology available to us, yet we have these atrocious outcomes? Maybe all of those interventions, maybe how we handle birth in general, introduces more risks than rewards? A great book to read on this is Dr. Marsden Wagner’s Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First.

You can get more hard numbers by referring to the VBAC Class bibliography or reading articles like Scare tactics vs. informed consent aka why I started this website or Rebutting Dr. Amy’s Information.  While you might not be interested because it’s not research based, Interview with Dr. Fischbein – An Inside Look at Hospitals & VBAC Bans discusses factors such as hospital politics and the influence of hospital administers which are important pieces of the home vs. hospital decision making process.

I quoted two statistics (3% chance of emergency transfer vs. 10-15% chance of unnecessary repeat cesarean) in the original article without citing the references.

The 3% transfer rate is from the Johnson 2005 study entitled, “Outcomes of planned home births with certified professional midwives: large prospective study in North America.”

The “unnecessary cesarean surgery” rate comes from two pieces of information.  First, the USA’s cesarean rate was 31.8% in 2007 according to the CDC’s 2009 publication “Births: Preliminary Data for 2007.”  Secondly, the World Health Organization (WHO) has repeatedly stated that a 10-15% cesarean rate is optimal.   Below 10% and you have mothers and babies dying because they don’t have access to medically necessary cesarean section.  Over 15% and you see higher maternal and infant mortality and morbidity rates from cesarean related complications.  As the 2009 edition of WHO’s “Monitoring Emergency Obstetric Care: A Handbook” states, “It should be noted that the proposed upper limit of 15% is not a target to be achieved, but rather a threshold not to be exceeded.”

When you subtract the total cesarean rate from the top end of WHO’s recommendation (30% – 15%), you get a risk of 15% of unnecessary cesarean.  Do the same with the low end of WHO’s recommendation (30% – 10%) and you get 20%.  This give us an unnecessary cesarean risk of 15% – 20%, higher than the conservative 10%-15% I stated. But, that is the total rate of unnecessary cesarean sections for all woman.  For women with a prior cesarean, the risk is even higher.

Again, let’s look at “Births: Preliminary Data for 2007.”  There, the CDC quotes a 90.8% repeat cesarean rate in the USA.  The average VBA1C success rate is 74% (Landon 2006) yet only 9.2% of women had a VBAC in 2007 (CDC 2009), so we can extrapolate that to mean that 12.4% of women attempted a VBAC.  Yet the national 2006 Listening to Mothers II survey found that 45% of women were interested in the option of a VBAC.  So while 45% of women want a VBAC, only 12.4% are permitted a trial of labor.  Listening to Mothers II explains the discrepancy: 57% of women interested in VBAC were denied the option primarily due to the “unwillingness” of their hospital or caregiver.  That figure is similar to ICAN’s 2009 Hospital Survey which found that 50% of American hospitals have either a formal or de facto VBAC ban in place.  (ICAN 2009)  So women seeking a VBAC have at least a 57% of having an unnecessary repeat cesarean solely because they can’t find someone to attend their birth.  Add to that women who have bait & switch care providers, and the risk rises.

But this is looking at the rate for the entire United States.  Depending on your local hospital’s rate, your odds might be higher or lower. Some areas, especially rural areas where there might be only one or two hospitals serving a large area, there might be no hospitals within a hundred miles that attend VBAC.  Obviously, a woman’s chances of a successful hospital VBAC there are slim to none.

Other areas, especially major metropolitan areas, have more hospitals and generally more options.  However, if we look at a large area like Southern California (including Los Angeles, Orange, Riverside, and San Bernardino counties), you might be surprised that the VBAC rate is only 5% (California Office of Statewide Health Planning and Development 2008).  This is why it’s so important to truly vet your local hospital and OB/midwife.

But the two statistics I originally quoted (3% chance of emergency transfer vs. 10-15% chance of unnecessary repeat cesarean) don’t give an accurate picture of the risks of homebirth vs. hospital birth and I have expanded the article to include that information.

When considering the risks of home vs. hospital, I think the following are three important questions to consider.

1. Do hospital mandated procedures, policies, and timelines interfere with the progression of labor resulting in an otherwise avoidable “failure to progress” repeat cesarean?

The answer to this question could be a whole book.  I think the Lothian 2004 article Do Not Disturb: The Importance of Privacy in Labor nods possibly yes by examining the impact of the lack of privacy available in the hospital setting.  Books like “Gentle Birth, Gentle Mothering,” “Born in the USA” and movies like “The Business of Being Born” touch on this question as well.

2. Are women more likely to need the advanced emergency equipment available at the hospital because in addition to naturally occurring unavoidable complications, they are at an increased risk for otherwise preventable compilations resulting from cascading interventions?

In other words, are OBs and hospital based nurses more likely to perform frequent vaginal exams, because they have the medications and facilities to perform an “emergency” cesarean if an infection does develop?  Are OBs more likely to perform episiotomies, even though women who have had episiotomies are more likely to tear into their rectum (4th degree tear) (Jandér 2001, Klein 1994, Signorello 2000), because they have the skill set to suture that severe of a tear?

And are women aware that frequent vaginal exams, especially once their water has broken, are linked to higher infection rates or that they are more likely to tear into their rectum if they have an episiotomy?  Or are they just thankful that they were in the hospital so when the infection developed or the tear occurred, they had access to advanced medical techniques?

3. How does fighting your way through labor with an OB who is not supportive of vaginal birth impact the progression of labor, if at all?

There are OBs who will patiently wait for labor to unfold provided that mother and baby are OK.  Most recently, a doctor at Good Samaritan in Downtown LA, attended a woman in labor who was at 8cm for over 8 hours.  Many OBs (the majority?) would have diagnosed a “failure to progress” and recommended/required a cesarean.  Counter that with the birth stories featured in VBACing Against the Odds and Hospital VBAC turned CS due to constant scare tactics.  How your labor plays out depends greatly on your care provider’s personal birth philosophy and your hospital’s standards and policy.  It’s not so much where you are as what is done to you.

Let’s now look at the primary risk of home birth which, in my opinion, is experiencing a 3% chance of a complication (Johnson 2005) that is outside your midwife’s scope of practice or training and requires emergency transfer to the hospital.  The primary question here is:

Does your midwife have the knowledge and skill set that will enable her to quickly diagnose complications, such as uterine rupture, placental abruption, umbilical cord prolapse, placenta previa, severe post partum hemorrhage (1), and coordinate rapid hospital transfer?

I talk about this more in the article, I’m pregnant and want a VBAC, what do I do?:

The most important thing when interviewing midwives is experience.  You need to know how many births she has attended and of those, how many was she the primary midwife (the responsible person at the birth as opposed to assisting a senior midwife.)  I am a full supporter of non-nurse midwives, but please do your homework.  If you have an inexperienced midwife with limited informal or formal education, you are taking on additional risk that is really unnecessary.

…

Additionally, you want a midwife who has enough experience to know when to go to the hospital as well as the professionalism to interface, and even take crap from, hospital employees.  You and your baby’s well being should come well before her possible discomfort.  In states where it is illegal for a midwife to attend a OOH (out-of-hospital) VBAC, your midwife is not likely to present herself as your midwife if you transfer and this is understandable.

You said, “All I see in this article is ‘I say home birth is awesome. These women agree with me because they had bad experiences in the hospital. Home birth is the best.’”  I did not select the birth stories of the women who had “bad experiences in the hospital” because they love home birth.  I highlighted their stories because I wanted to counter the conventional wisdom which states, if you are at home and a problem happens, you are out of luck but that if you are in the hospital, everything will be ok as well as demonstrate that you don’t even need an actual medical complication in order for your birth to become difficult in the hospital.

You said, “If home birth is as safe as you say then you needn’t go on a raging rant in your article about how it’s so amazing because the numbers and statistics would say it for you.”  Please find where I use the phrase “homebirth is safe/amazing/good/better.”  It’s not there.  The only reference I made in the original article about homebirth safety is to quote the 3% transfer rate per the Johnson 2005 study.  I don’t say whether home birth is safe or dangerous.  I leave that up to individual women to decide for themselves by weighting the risks and benefits of home vs. hospital birth.  There are risks to home birth and there are risks to hospital birth.  Each woman selects which set of risks she is willing to accept.  Is a 3% risk of emergency transfer a fair trade when your local hospital has a 96% repeat cesarean rate?  That is a quandary that woman seeking VBAC face daily.

I have to wonder if you even read the entire article including the part where I discuss my post-partum hemorrhage (PPH):

I’m glad I was home, but my story might have ended very different if my midwife didn’t have Pitocin and Methergin and was able to act quickly. This is a testament to hiring a good, experienced midwife and ensuring that they have drugs to manage PPH.

…

I trusted the skills of my midwife to diagnosis my PPH and I trusted those drugs to make my bleeding stop quickly when birth veered off course.  Complications do happen at home and when interviewing a homebirth midwife, I suggest asking her how she handles complications as well as hospital transfers.

…

The truth is, there are no guarantees regardless of where you give birth.

For the record, I thought my home birth was an awesome, incredible experience and I can’t imagine ever giving birth in a hospital again unless medically indicated.  But that doesn’t mean I think you should have a home birth.  Birth at home if that’s what you want to do.  Birth at the hospital if that is where you want to be.  As I say at the closing of the article, “I wish you the best wherever you chose to birth your children” and that is the genuine truth.  I have friends who have birthed in the home as well as hospital.  I have friends who have opted for multiple repeat cesareans.

I am not someone who thinks home birth is always good and hospital birth is always bad.  My objective is not to convince anyone to make any specific decision.  I give information, including references to medical research, to supplement women’s research.  I provide my personal, lay perspective on birth.  As I wrote over two years ago in the article Why Homebirth/HBAC?, “I think the most important thing is for every woman to birth where she, after much research and thought, feels safe and comfortable. Where she feels her wishes will be respected and not just viewed as requests. Where she feels she, and her baby, will receive the best care and experience the best outcome. And I know for many women, this is the hospital. And for a very small minority of us, it’s at home.”  I still believe that.

Warmly,

Jen from vbacfacts.com

I see things daily that I want to write about, but never actually have the time between laundry, dishes, meal prep and daydreaming of going to the National Institutes of Health’s upcoming free conference entitled Consensus Development Conference on Vaginal Birth After Cesarean: New Insights.  I’m hoping to use my Southwest credit from the cancelled Controversies in Childbirth conference to make a little trip out to Bethesda.  We shall see.

I’ve been on Facebook a lot, where you can become my friend or a fan of the site, because committing to a small little 420 character blurb fits in quite well as I unload the dishwasher and retrieve my toddler off yet another piece of furniture. 

However, the best way to stay in touch with me and receive updates and coupons for upcoming classes, is to join my mailing list.  I am investigating my options for doing an on-line webinar as well, so stay tuned!

So I’m using this quiet moment, at 3am when my children are asleep and I can write this uninterrupted (oh, the luxury!!), to share something that is really special.

In the last few days, a woman had a VBAC with triplets with the legendary Dr. Tate of Atlanta, Georgia.

According to Doula Momma:

The details are just coming out about this VBAC but apparently the woman had her triplets in a hospital attended by Dr. Tate. I am assuming she went natural, as in unmedicated, as that’s generally the way with a VBAC with Dr. Tate.  From what I am reading so far, the first two babies were head down and the third was footling breech. Here are the babies stats according to the ICAN of Atlanta chapter posting.
3 girls, all vaginal, all Apgar 8/9.

A= 4# 6oz, 18.25in @ 10:24pm, vertex.
B= 6# 4oz, 18.25in @ 10:37pm, vertex.
c= 3# 11oz, 16.5in @ 10:39pm, double footling breech extraction.

All three babies are successfully breastfeeding as well.

In a time where VBAC is banned in 50% of US hospitals, either through formal or defacto bans, (ICAN 2009 Hospital Survey) and women of multiples believe that they have no other option but a surgical delivery for their children, this is a huge victory.  There are practitioners that support VBAC.  Maybe even one that lives close to you.  Learn more on finding a provider and your options for planning a VBAC here: I’m pregnant and want a VBAC, what do I do?

I want to plan for a VBAC I am not pregnant as of yet but will be ttc in 2 months. I am from La Crosse WI area and they have two hospitals Gunderson Lutheran and Franciscan Skemp..when I called them to get there statistics about VBACs they told me they didn’t have any. So how should I choose which hospital to go to for the better chance of succeeding with my VBAC. I also do not have any doulas in the area is it necessary to have a doula for a successful VBAC? Any thoughts or suggestions would be great. Thank you.

Hi Jeri!

It’s ironic that the person you spoke with at the hospital said that they didn’t have any VBAC statistics, because when I googled “Gundersen Lutheran VBAC,” I found a page entitled "Births by Cesarean and Vaginal Births After Cesarean” on Gundersen Lutheran’s very own website where they state:

A vaginal delivery is the preferred, naturally-designed way to have a baby but when needed, delivery by Cesarean section is a second option. At Gundersen Lutheran, efforts are made to choose a vaginal birth, even after a previous C-section unless there are reasons that would put mother or baby at risk.

“Generally, successful VBAC is associated with shorter maternal hospitalizations, less blood loss and fewer transfusions, fewer infections, and fewer thromboembolic events than cesarean delivery.” [ACOG Practice Bulletin #54 2004)

AIMS
1. To have a cesarean section rate below the national rate
2. To have a VBAC rate higher than the national rate

They have succeeded in their goals as Gundersen Lutheran boasted a 27.3% VBAC rate in 2006.  That is exceptional considering that the national average is 9.2% (CDC 2006) and the Wisconsin state average is 12% (Wisconsin: Infant Births and Deaths 2006).

Ted Peck, M.D. is named “activity leader” on that page so I would contact him and ask for the top three VBAC doctors at Gunderson Lutheran.  I would also check out the resources here for additional referrals and to see if any of the names overlap.  Keep in mind that just because the hospital has a great VBAC rate doesn’t mean that all the OBs are supportive of VBAC.  You will still want to ask the same questions and interview a couple different doctors, just like you would get more than one quote if you wanted work done on your house.  You are the consumer, you have the power to chose who you will hire!  It’s important for you to understand the risks and benefits of VBAC vs. repeat cesarean to you, your baby, as well as your future children and health, but be on the look out for scare tactics masquerading as informed consent.

I also googled “Franciscan Skemp VBAC” and was directed to ICAN’s VBAC Hospital Policy Information where Franciscan Skemp is listed as a de facto VBAC ban hospital.  This means that while there is no formal ban in place, the hospital does not attend VBACs.  They could give you a whole list of reasons like, “Our OBs don’t want to do them” or “Our anesthesiologists don’t want to sit in the hospital during a VBAC labor,” but Dr. Stuart Fischbein gives us another perspective:

[Hospitals] ban VBACs under the guise of patient safety. But patient safety is a euphemism for “we don’t have a good evidence-based reason to do it, other than we don’t want to get sued, it’s more expedient, and we make more money from c-sections—the hospital does, not necessarily the physician, but the hospital does—so we’re going to ban it because it’s easier for us, and we’re going to say it’s for patient safety because of the risk of rupturing the uterus.” But you know what? That risk should be something that the patient decides. Patients have a right to be given informed consent, free from misinformation or coercion, free from skewing information that benefits the practitioner or the hospital. And they have the right to consent or refuse to accept the treatment that’s offered. That right is frequently being denied.

(To read more of this interview with Dr. Fischbein, please go to: An Inside Look at Hospitals & VBAC Bans.)

If I was unable to easily find this information by googling, I would have gone to Wisconsin’s Department of Health Services and just start searching for VBAC, birth, cesarean, and hospital statistics to see what I could find.  Sometimes this data is so deep within a website, it can be tricky to locate.  You could also call the Department of Health Services and ask them if they maintain hospital birth statistics.  The state of California maintains this data, but I don’t know if all states do and if they make that information available to the public.

In terms of a doula, yes, I think it’s very important for any woman laboring in a hospital, especially women seeking a VBAC, to have a doula.  (Here is more information on what a doula is and the many benefits of having one: DONA’s Birth Doula FAQs.)  Some practices are not supportive of doulas, even going so far as to post a sign in the waiting room detailing their anti-doula policy.  Switch providers immediately if you read a similar sign or if you discover that your provider is not doula friendly.  A great way to find out is to ask your OB or midwife if they have any doulas they can recommend.  Their response will quickly tell you if this care provider and you have the same vision for your birth.

I went to findadoula.com, and found there was one doula listed for La Cross, WI:

Renee Plunkett

Telephone: 608-786-4466

Location: West Salem Wisconsin United States

I also cover the following geographic areas:
La Crosse, WI

Hopefully you two will be a good fit and if not, the list of resources I provide for finding a supportive OB or midwife can also be used for finding a doula.  I would add DONA and toLabor (formally ALACE) which are Doula credentialing organizations as additional resources.  DONA lists 64 birth doulas and toLabor lists 10 birth doulas in Wisconsin.

You can find more VBAC statistics by going to the The Birth Survey’s State Resources page which provides links to each state’s birth statistics.

For Wisconsin, we have Wisconsin: Infant Births and Deaths, 2006 where we are given the following statistics on page 30:

Delivery Method	Number	Percentage
Vaginal (no previous C-section)	52,713	72.9%
Primary C-Section	10,342	14.3%
Repeat C-Section	7,418	10.3%
VBAC	1,017	1.4%
Forceps	812	1.1%
Other	0	0.0%
Total Births	72,302	100%

We can determine the VBAC rate by adding the number of Repeat C-Sections (7,418) and VBACs (1,017) together to get a total number of births after cesarean in 2006 (8,435).

By dividing the total number of VBACs (1,017) by the number of births after cesarean (8,435), and multiplying that number by 100, we get the VBAC rate of 12.06%.  This means that 87.9% of women in Wisconsin have repeat cesareans.

Here’s hoping you are in that 12%!

Warmly,

Jen from vbacfacts.com

This is the same weekend as the Trust Birth Conference, so if you are in town, you will have ample time after the conference is over at noon on Sunday to scoot on over to Century City (10309 Santa Monica Blvd, Suite 300, Los Angeles, CA 90024) and then back again if you want to attend the Stragglers Dinner at 6:30pm.

Additional classes have been scheduled in Claremont in July and Vista in October.

To register for the LA March class, please go here.  Space is limited.

What will the class discuss?

“The Truth About VBAC” delivers a comprehensive review of the medical research to parents, doulas, midwives, nurses and other birth advocates and medical professionals.  Topics include:

• Repeat Cesarean vs. VBAC Realities
• Risks of Hospital vs. Out-of-Hospital Birth
• Finding a VBAC Supportive OB or Midwife
• The Marketing of “Risk”
• Hospital VBAC Strategies
• Factors of Uterine Rupture
• Maternal & Infant Outcomes
• Elements of VBAC Success
• Benefits of Spontaneous Vaginal Birth
• Hospital VBAC Bans

What do past attendees say about the class?

A mom with two prior cesareans:

This class is all about the facts. It is low pressure. It gives you information from scientific journals that will help you make the best decision for you and your baby.   At the end, you get to decide which set of risks you are willing to accept.  It opened my husband’s eyes. Even though I’ve been telling him, he needed to hear the research and the numbers.  Thank you!!!

A Labor & Delivery nurse:

Thanks for an outstanding class! It was very nice meeting you. Your hard work and dedicated research is incredibly impressive. Knowledge is Power, wish it would rub off on the whole OB community. I think the trend to eventually turn that direction for women’s choice of birth options will happen as more people put that kind of pressure on the issue. Bravo to you!

A mom with one prior cesarean:

My husband and I certainly felt even more confident after the class.  I would definitely recommend it to anyone considering a VBAC.

Do I need to be pregnant to attend?

The best time to educate yourself is before you get pregnant when you have time to research, decide what kind of birth you want, and then assemble your birth team without a due date looming.  That said, highly motivated women have decided mid-pregnancy to change gears, reconsider their scheduled cesarean, and plan VBACs.

Why is this class important?

It’s likely either you or someone you know has had a cesarean.  Unfortunately, there is a lot of fear and misinformation about birth after cesarean.  Is VBAC dangerous?  What are the risks of repeat cesareans? What is the safest thing for babies and mothers?  What should you do if you want a large family?  What hospitals are most supportive of VBAC?  Is out-of-hospital (home or birth center) birth an option?

With half of American hospitals actively enforcing VBAC bans and increasing numbers of obstetricians preferring repeat cesareans, many women wonder if their only choice is another surgical delivery.  A 2005 survey revealed that while 57% of American women desire a VBAC, less than 10% succeed.

Banner ads and flyers are available.

I am very disheartened by the tone of this website. I am a board certified Ob/gyn and a very strong advocate for VBACs, IF a patient chooses one within the hospital guidelines. I DO believe and say to my patients my goal is “a healthy mom and a healthy baby” because I truly believe this statement. You would not believe the number of patients who believe that I want to do XYZ to go home to my family, go shopping or improve my golf game. A vaginal delivery is easier for me in the long run because I have less paper work, less rounding and have avoided performing a major surgery on a patient. I have no desire to perform a patient’s 6th c-section!

But each patient who chooses a VBAC has to realize there ARE risks associated with the procedure. I would be committing malpractice if I did not inform each patient of the risks and benefits of both options. The risk of uterine rupture is [less] than 1 percent, but if it happens to my patient she will be upset that I did not inform her of the risks. The “seeds of doubt” you discuss are all things that I have told patients considering a VBAC. I prefer to stretch the informed consent process over the entire course of the prenatal visits versus just one 5 or 10 minute conversation. If I have discussed all the options ahead of a patient’s actual labor, if I come in and say that I need to perform a repeat c-section for XYZ reason, I am not having that discussion for the first time in the LDR, but rather we have discussed the possibility months ago. I use my prenatal visits to build a repoir [sic] with my patients and to educate her/her family about the scenarios we may face in the delivery room.

In an ideal world, every patient would be presented with the option to have a VBAC if she desires. Unfortunately due to the malpractice climate some doctors and hospitals no longer feel comfortable giving patients this choice. The rhetoric in this article does nothing healthy to advance the cause  of ensuring this happens. It only serves to create mistrust between patients and doctors who are true advocates for patients.

Dear VBAC Supportive OB/GYN,

I’m very happy that you left this comment and hope that you stick around and read some more.  We need more OBs who are supportive of VBAC and vaginal birth.  (I’m curious about your hospital’s guidelines.  Would you share?)

The unfortunate reality is that there is a huge segment of OBs who perform surgery under the guise of maternal/fetal health when in reality it is for their personal convenience.  I have had the opportunity to hear that directly from OBs.  Often the “healthy mom/healthy baby” reason is used in the midst of a repeat cesarean recommendation and I believe that is true in the birth story featured in Hospital VBAC turned CS due to constant scare tactics.

If you look over on the category list and click on ‘uterine rupture’ you will see that it is a common topic on this site.  I cite specific rates as well as sources so people can independently verify what I write.  I absolutely agree that women need to understand the risks of VBAC, but they need the accurate numbers, not some inflated risk provided by an unsupportive OB and not some understated risk provided by well-meaning, but misinformed, birth advocates.  (Check out my article Lightning strikes, shark bites & uterine rupture for more on this.)

Here’s how I make the distinction between informed consent and scare tactics.

Informed consent is understanding the risks and benefits of VBAC vs. repeat cesarean.

Scare tactics are just talking about the risks of VBAC without mentioning the risks of a repeat cesarean.

Informed consent includes accurate statistics.  Women write me all the time telling me that their OB quoted a uterine rupture rate of 5% or 10% or even 25%!  A woman just recently contacted me and said that women seeking VBACs are “selfish, unbelievable IDIOTs.”  Naturally she would say this as her OB told her that she and her baby had a 10% chance of dying if she attempted a trial of labor after cesarean.

If the doctor tells you there is a 10% chance of you and your baby dieing [sic] and you do this any way…you are a selfish, unbelievable IDIOT…I have two perfect babies and I wouldn’t have my 1st if it wasn’t for a c-section…why on earth would I risk the life of my 2nd child to say I had a ‘v-back’…do you psychos want a metal [sic]…go away and get off your freakin’ soap boxes…you are all scary and creapy [sic]!

This is why I started the website.  Women are lied to all the time.  They contact me either via angry emails like the one above or really sad depressed emails because they were fed these falsehoods, consented to surgery, and then learned the truth.

So, this is how I responded:

I completely understand why you were happy to have a repeat cesarean given that you were told the risk of mortality was 10%. I’m sorry to tell you that you have been misled. The risk of maternal mortality with repeat cesarean and VBAC is very low, but the risk is higher with a repeat cesarean: 0.04% vs. 0.02% per a National Institute of Health Study of 18,000 women. (Landon 2004: http://content.nejm.org/cgi/content/abstract/351/25/2581) This is 500 times smaller than the risk you were quoted of 10% maternal mortality. That same study found the rate of infant death to be 0.01% and they did a review of 880 uterine ruptures in a 20 year period resulting in 40 infant deaths in 91,039 VBACs which is a rate of 0.04%. They found the combined risk of infant death or brain damage to be 0.05% or 1 in every 2000 VBAC labors which is a 200 times smaller than the risk you quoted of 10%. If you or your OB have a large VBAC study showing a 10% mortality rate, please email me.

Needless to say, she did not respond as there is not one large VBAC study showing maternal or infant mortality rates anywhere near 10%.  This woman was lied to.  Why do you suppose her OB would tell her that?

Informed consent also includes asking how many more children the woman wishes to have.  We know that the risk of uterine rupture, uterine dehiscence and other peripartum complications decrease after the first VBAC, (Mercer 2008) whereas the risk of “placenta accreta, hysterectomy, transfusion of 4 units or more of packed red blood cells, [bladder injury], bowel injury, urethral injury, ileus [absence of muscular contractions of the intestine which normally move the food through the system], ICU admission, and longer operative time were seen with an increasing number of cesarean deliveries.  [In addition] after the first cesarean, increased risk of placenta previa, need for postoperative (maternal) ventilator support, and more hospital days were seen with increasing number of cesarean deliveries.” (Silver 2006)

How many VBAC consent forms include the risks of cesarean?  Not just the risks to mom and baby in the current pregnancy but the downstream consequences for future pregnancies?  I’ve never seen it.  Does your VBAC consent form include this information?

It’s one thing to understand the risks of VBAC, but they must be countered with the risks of repeat cesarean, otherwise the patient is left with the false notion that repeat cesareans are risk free.  This does not benefit the patient and I believe it’s only because women haven’t started suing over complications resulting from repeat cesareans that this erroneous philosophy on informed consent continues to thrive.

Informed consent is putting the risk of uterine rupture into perspective by comparing the risk to other obstetric complications as Larry Leeman MD MPH and Eve Espey MD MPH do when expressing their concern over the rising cesarean rates in Native American populations due to hospital VBAC bans.  They say:

Should you offer vaginal birth after cesarean delivery at your facility?

Should your referral facility be offering VBAC?

Let’s put some of the above issues into perspective.

What are just a few of the risks that you should currently handle very well:

[Note from me: I used the chart they provided here and combined it with uterine rupture & infant mortality/morbidity stats for use in the VBAC Class I teach.]

Taken on their own individual merit, most of the above common urgencies and emergencies occur more frequently than 0.5 percent. Taken as an aggregate, the risks above far outweigh the risks of VBAC. Now seeing the above risks, if you feel you need to re-evaluate offering obstetric intrapartum care because the above risks, then please contact me as soon as possible.

Scare tactics are simply saying, “VBAC is dangerous” or “Is it worth your baby’s life?”

Informed consent is having a thoughtful thorough conversation where you ascertain if this is the first time the woman has heard about the risks of uterine rupture, or if she is an informed patient who is well aware of her risks, benefits, and options.

I do believe that coming back to the risks of VBAC again and again during a pregnancy conveys to the patient that you really think this is a considerable risk, and not one worth undertaking.

Lisa Allee, CNM, wrote this in response to a hospital that instituted a VBAC ban.  The hospital said that their ban wouldn’t impact many since only 2 patients a year perused VBAC after the VBAC counsel.  She recommended:

Re-evaluate how VBAC counseling is done. To provide true informed consent the numbers need to be presented clearly. The data consistently shows a uterine rupture rate of 0.5-3%–it is important to explain that this means 97-99.5 women out of 100 will not have a uterine rupture and out of the few that do, not all will have problems. It is, of course, important to discuss the risk of uterine rupture to mother and baby, but to put it in this perspective of being rare and review the high-quality, careful care we provide to women who are VBACing to help prevent problems. It is also very important to review the differences in postpartum morbidity and risk between a vaginal birth and cesarean delivery, (be sure to include the oft ignored higher rates of breastfeeding and orgasm difficulties post cesarean delivery.) If, in contrast, providers only make a recommendation of repeat cesarean delivery and an institution has a policy that only allows for repeat cesarean delivery, then they have effectively negated a woman’s right to make an informed decision in a situation where there is a choice.

And she suggests that women be given an accurate picture of what a cesarean is like:

Review the postpartum morbidity and risk differences for women post vaginal birth vs. post cesarean delivery. This will help to dispel the delusion that a woman who has had a cesarean delivery is walking out of the hospital “healthy” and bring a more accurate sense of respect for what is really happening for that woman. She has just had major abdominal surgery and is in recovery from that surgery. She is in pain and is at risk for a number of post-surgical complications. Her future pregnancies have also now taken on a longer list of potential risks. Along with all this she is also a new mother with a newborn to care for and feed every 1-2 hours with an abdominal incision that she is fully aware of each time she moves. This human perspective of the implications of a cesarean delivery might help providers to be concerned with their personal and institutional cesarean delivery rates.

I did not get the feel from the birth story relayed in Hospital VBAC turned CS due to constant scare tactics that the OB was really supportive of VBAC, did you?  Would you classify this OB as a “true advocate for patients?”

• OB only talks about the risks of VBAC.
• OB required a VBAC consent form that only lists the risks of VBAC.
• OB wants to schedule a cesarean at 38 weeks.
• OB “did not seem very please” when the patient expressed her desire to VBAC.
• OB began NST at 37 weeks.  Patient lists no reason for this.
• OB does not put the process and significance of dilation into context.  Patient seems to believe that no dilation at 37 weeks and no change till 40 weeks is a bad sign.  Patient does not understand that dilation is not a hard sign of labor.
• OB tries to scare patient by telling her that her baby was big and it “could be a very hard delivery” for her.  It is this scare tactic, and the subsequent recommendation for cesarean based on suspected macrosomia  that convinces patient to schedule a cesarean.  Baby ends up weighing 7lbs 2oz.  ACOG does not recommend cesarean for suspected macrosomia unless the baby is 11lbs (ACOG’s Practice Bulletin No. 22 on Guidelines for Fetal Macrosomia published in the November 2000 issue of Obstetrics and Gynecology).
• OB makes a “threatening call” to patient upon her spontaneous labor and lies by saying that if patient doesn’t have the “C-sec at the decided time, [OB] was not going to be available for the entire week and that some random doctor from the hospital” would perform her surgery.
• OB gets caught in this lie when the nurse tells patient that OB “has asked to be informed about your progress [and] will continue to be there for you.”
• OB then has a colleague tell patient that “she was sure it was going to be a very tough delivery” because of “baby’s head was big” and would weight “at least 8 lbs.”
• OB who said she wouldn’t be available after 11:45am, suddenly becomes available and is present to perform the surgery.

You stated in your comment that my article “only serves to create mistrust between patients and doctors who are true advocates for patients.”

Here is my sole goal with that article and this website: To implore women to put as much effort into interviewing and hiring an OB as they would for someone to install a pool.  Educate yourself.  Get referrals.  Ask questions.  Don’t just stay with your current GYN because they do a great pap smear and you enjoy the small talk.  Hire someone who has a birth philosophy similar to yours.  Hire someone who is supportive of vaginal birth!  And look for the red flags!  There were so many in this woman’s story.  I know we disagree on that.  Maybe that is because you are a VBAC supportive OB who doesn’t see stories just like this one every day.

While there are OBs who are truly supportive of VBAC, I personally know three, most are not.  Most behave exactly like this OB.  And I don’t believe for a second that this OB ever intended to give this patient a genuine opportunity to VBAC. I really wish the OB would have just said that upfront to the patient so she could have had the opportunity to hire a truly supportive practitioner.  At the very least, this OB can post a sign in their waiting room, like this one above from a Provo, Utah practice, so women know their birth philosophy as soon as they walk in the door.  As unappealing as it is, this practice is providing their patients with informed consent on the type of birth they provide.  What is shocking to me, is that there are enough patients who are so ill-informed that they would continue care with a practice like this.

And this site will be there for the women who had cesareans under the care of OBs, like this Provo practice, to provide them with accurate, easily verifiable information for them to make an informed decision on what kind of birth they want the next time.

Warmly,

Jen

Claremont VBAC Class

The "Truth About VBAC" seminar in Claremont, California is 8 days away on Saturday, October 24th from 1p – 4p.  Don’t miss out on your opportunity to experience an extensive review of the best VBAC and repeat cesarean research as well as learn specific, practical tools to maximize the likelihood of hospital or out-of-hospital VBAC success!  To register or sponsor a ticket, please visit: http://vbacfacts1024.eventbrite.com/

Do I need to be pregnant to attend?

The information is targeted towards women with prior cesareans who wish to have more children and the childbirth professionals who support them.  The best time to educate yourself is before you get pregnant when you have the luxury of time to research, decide what kind of birth you want, and then assemble your birth team without a due date looming.  That said, many women, have decided mid-pregnancy to change gears, reconsider their scheduled cesarean, find a new care provider, and plan successful VBACs.

Fullerton Class Recap

The Fullerton class last month was full of inquiring parents, midwives, doulas, Bradley childbirth educators, and labor & delivery (L&D) nurses some of whom drove over two hours to attend.  Not only did the moms and dads learn about VBAC, but they participated in a lively and candid discussion with the L&D nurses and doulas who were able to share exactly what it is like to VBAC in a hospital environment.  It would be very hard, if not impossible, to have these same exchanges on the L&D floor.  We also had homebirth midwives and doulas who provided the out-of-hospital perspective.

Here’s some feedback from one of the L&D nurses, who works in a hospital with an official VBAC ban and is working towards change:

Hi Jen, Thanks for an outstanding class! It was very nice meeting you. Your hard work and dedicated research is incredibly impressive. Knowledge is Power, wish it would rub off on the whole OB community. I think the trend to eventually turn that direction for women’s choice of birth options will happen as more people put that kind of pressure on the issue. Bravo to you!

"The Truth About VBAC" Book

Included with each ticket is one "Truth About VBAC" book which includes all the slides from the presentation, the bibliography, as well as lined paper throughout for easy note taking.  As the class is research heavy, this will enable you to sit back and absorb the information rather than frantically copying statistics and study citations, as I have often done in seminars.

Additional books will be available purchase that day for $15.  Quantities are limited.  To guarantee your copy, pre-purchase here: http://vbacfacts1024.eventbrite.com/

VBAC Class Advocacy

If you can’t come to the class but want to spread the word, consider putting a banner ad on your website or blog, posting flyers in your local community, or sharing VBAC FAQ cards with your friends or clients.

Shape the 2010 Class Schedule

You can influence where the next VBAC Class will be held!  I expect to hold 3-4 classes in Southern California throughout 2010.  I’m looking at the area bordered by Santa Barbara, Lancaster, Palm Desert, and San Diego.  If you want "The Truth About VBAC" to come to your city, please email info at vbacfacts dot com with your name, city, and zip code.  Those cities with the most requests will determine the next VBAC Class!

If you have facilities that can accommodate 20-40 people and want to host a class, please contact me at info at vbacfacts dot com.  I will be emailing those who have contacted me in the past in the coming weeks to discuss scheduling a class.

Win Two VBAC Class Tickets at the LA Holistic Moms Open House!

VBAC Facts has donated 250 VBAC FAQ cards as well as two tickets to a 2010 "Truth About VBAC" class to the Holistic Moms Network LA Open House Raffle.  Please join us Wednesday November 4th, 6:30pm at South Pasadena Library Community Room, 1115 El Centro St, South Pasadena, CA.  Here is a flyer with all the details.

Chino Birth Center Open House before VBAC Class

If you would like to tour a birth center and speak to a out-of-hospital midwife before heading over to the VBAC Class, the Oaks House Family Birth Center at 13770 Oaks Avenue, Chino CA 91709 is having an Open House on Saturday, October 24th from 11am – 2pm.  For more information call (909) 464-0974.

mybestbirth San Diego Party & Screening

I’m going to  this event which is scheduled for Thursday, November 12, 2009 at 5:30 PM and can’t wait!  To register please visit: http://mybestbirthsd.eventbrite.com/  All proceeds benefit the Business of Being Born Educational Outreach Project, ICAN and the San Diego Birth Network. Here are the details:

Join us for an exclusive VIP Reception at Babies in Bloom at 5:30 pm. Meet Ricki and Abby, enjoy delicious appetizers and beverages, and see a sneak peek of Ricki and Abby’s new film! We will also have a silent auction of fabulous items from our sponsors.

After the party, "The Business of Being Born" will be shown at the Krikorian Theaters in Vista Village at 7 pm. Several local birth professionals (including midwives Barbara Herrera and Michelle Freund, and Dr. Robert Biter) will join Ricki and Abby for a discussion panel  following the screening.

Private Screening of "Laboring Under an Illusion"

I’m so bummed this is the same night at the mybestbirth event!  Hopefully CABO will host another screening in the future!

Attend a private showing at Laguna Hills Community Center on Thursday, November 12, 2009 5-8pm of "Laboring Under an Illusion," a documentary that depicts how the media portrays labor and birth.  It is quite comical and contrasts delivery and birth.  Hope you will consider this and join us and distribute widely. Women that are pregnant or planning to have a baby may be interested as well!  All proceeds support the efforts of project CABO (Community Alliance for Birth Options). 

Here is a flyer with all the details.

If you have have discriminated against due to your prior cesarean, our government needs to hear about it!

ICAN needs stories about discriminatory insurance practices based on a previous cesarean.  This can include but is not limited to demands for sterilization, restrictions on how soon you can have another pregnancy and be covered, higher premiums, restrictions on the total amount of benefits they will pay, excessively high deductibles for maternity care.  Even if all you have is your name, state, contact information (email is fine) and a description of the circumstances (with the name of the relevant insurance company(ies) if possible) we can use it.  If you have written documentation, that would be pure gold.  There is interest about this at the highest levels of the Federal Govt. and we will use this to open the discussion on other areas of discrimination (like VBAC bans, lack of transparency, etc)….so please, take a moment and get the information to ICAN.  You can email me at advocacy@ican-online.org or you can snail mail to ICAN of Ann Arbor, PO Box 48, Stockbridge, MI  49285.

Your story could make a difference that would improve the care available for millions of women and their babies.

Below is a press release illustrating ICAN’s latest efforts.

ICAN Mother Provides Testimony on Capitol Hill Discriminatory Insurance Practices Investigated by Senate HELP Committee

REDONDO BEACH, CA, October 15, 2009 – Gretchen Humphries, Advocacy Director for the International Cesarean Awareness Network accompanied Peggy Robertson of Centennial, Colorado to a Senate hearing in the Health, Education, Labor and Pensions (HELP) Committee. Ms. Robertson testified about her experiences with discriminatory insurance practices based on her history of cesarean.

Ms. Robertson was featured in a New York Times article in July 2008 after she was declined insurance due to her previous cesarean. She was informed by the insurance company that her application would be accepted if she agreed to be sterilized.

As of 2007, 31.8% of childbearing women in the United States had a cesarean delivery and the rate continues to increase each year. These increases are due, in part, to the growing number of women who are denied the opportunity to have a vaginal birth after cesarean (VBAC) through similarly discriminatory VBAC bans. “The prospect of rendering a third of women uninsurable is frightening and unconscionable,” said Desirre Andrews, President of ICAN. “Many of these women are being pressured or bullied into first-time and repeat cesareans, and to doubly inflict them by leaving them without health insurance is offensive.” Clearly this type of practice potentially affects a very large number of women now and in the future as the cesarean rate continues to climb and the vaginal birth after cesarean rate continues to decline.

The practice of denying a woman health insurance because of a prior cesarean also indicts the medical community. Many of the cesareans performed today are unnecessary or the by-product of an over-interventive labor management process that is rooted in defensive medicine practices. “It is absolutely wrong to deny coverage to women either because of past cesareans or the risk of future cesareans, but it is also wrong to prop up a system where physicians can overuse surgery that both harms the health of women and babies, and forces insurance companies to take on excessive costs.” said Gretchen Humphries, ICAN’s Advocacy Director.

Cesarean section is associated with double to triple the cost of a normal vaginal birth. Cesarean also imposes the risks of medical complications in the short-term and long-term, which often carry high costs. “Insurance companies, in their actuarial pragmatism, are doing the math and recognizing that moms with a history of cesarean are high-cost beneficiaries and working to weed them out of the pool of people they cover. It’s discriminatory and lawmakers need to address this issue and determine a way to protect mothers, both from the practices of the insurance industry and the non-evidence based care from obstetricians,” said Humphries.

Maternity care is the number one most expensive line-item in the U.S. healthcare bill. From 1996 to 2006, the national cesarean rate rose by 50 percent, setting a new record each year from 2000 onward. The proportion of medically induced labors rose by 135 percent from 1990 to 2005, with strong suggestions that these official induction rates identify only roughly 50 percent of actual inductions. The burden on the health care system is staggering for maternity care as it is today. In 2005, the combined hospital charges for birthing women and newborns totaled $79,277,733,843 and exceeded charges for any other condition. Private insurers paid for 51 percent and Medicaid paid for 42 percent of these stays. “Pregnancy and delivery” was the most expensive condition, followed by “newborn infants” for both payers. Six of the ten most common procedures billed to Medicaid and to private insurers in 2005 were maternity related. Cesarean section was the most common operating room procedure for Medicaid, private payers and all payers combined.

As policymakers focus on healthcare reform and finding ways to improve outcomes while lowering costs, ICAN calls on policymakers to address the needs of pregnant women and make low-cost, optimal-outcome birth easier to access.

Currently: ·

Few women are given the information they need to navigate the pitfalls of the defensive medicine model of care that is rampant ·

Women are routinely coerced or pressured into expensive care that does nothing to improve outcomes, especially through the increasing practice of banning vaginal birth after cesarean (VBAC) ·

Access to low-intervention midwife-attended births are hampered by reimbursement issues, or onerous collaborative agreement requirements for practicing midwives

“The unique beauty of maternity care is that we can simultaneously improve quality and reduce costs,” said Andrews. “But we need to start by treating women fairly and equitably, and intelligently reserve medical technology and interventions for when they are appropriate.”

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 117 ICAN Chapters across North America, Canada , and various international locations which hold educational and support meetings for people interested in cesarean prevention and recovery.

Citation: C. Sakala & M. Corry. Evidence-Based Maternity Care: What It Is and What It Can Achieve. 2008.

Traumatic Birth Healing Spiral

When is it? Saturday, October 17, 2009

Who should attend? Women who have experienced a traumatic birth experience, either cesarean or vaginal.

What is it?  An interactive workshop to assist in emotional healing.  Storytelling, artwork and a blessingway will highlight the event.

Where? Springdale, Arkansas (Directions will be provided to all attendees at time of registration)

Please RSVP by October 15 to Aly Kirkpatrick 479-251-8446 or alynwaican@hotmail.com

$10 suggested donation per person, scholarships available

The International Cesarean Awareness Network 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 (VBAC). Visit our research based website www.ican-online.org or email alyNWAican@hotmail.com

Please feel free to forward this email to anyone you know who may be interested

I had the privilege of hearing Dr. Declercq speak at the 2009 ICAN Conference in Atlanta.  Not only is he an engaging speaker, but he has a great sense of humor which helps when going through statistics which can be dry if presented by the wrong person.

It’s amazing because your typical American really believes that they are receiving the best health care and that American hospitals are the best places to give birth.  But as Dr. Declercq reveals, it is the overuse of our sophisticated technology, namely cesareans, that results in unnecessary infant and maternal deaths.

Please click here to see the video: Birth by the Numbers.

My intention with this article was to address the visceral and fearful response parents often have when they see a cord wrapped around their baby’s neck which is called a nuchal cord.  I wanted to clarify that babies receive oxygen through the umbilical cord, not through their mouth, so they cannot be “strangled” in the conventional sense of pressure to the throat.

Yet despite my good intentions, it quickly became clear that the title was confusing to not only parents and health professionals, but insulting to those who did lose a baby from cord compression.  As a result, the title was changed to something more accurate.

Even though nuchal cords are common and occur 25% – 35%¹² of the time, rarely a baby’s cord will be wrapped so tightly around their body that the cord is compressed and oxygen delivery to the baby is compromised.  When this occurs, a cesarean is prudent and in its absence, a stillbirth could occur.  Fortunately, nuchal cords are rarely the cause of stillbirth.

However, this is no consolation to those who have experienced the horror of their child’s death because when you are the statistic, it doesn’t matter how rarely something occurs.

__________________________________________________________________________________________

How many times have you heard, “I’m so glad I had a cesarean because the baby’s cord was around his neck 3 times!!”  What people do not understand is about one-third of all babies are born with the umbilical cord around their neck/body and it does not mean the baby is in harms way.

Per Wikipedia:

Retrospective data of over 182,000 births, with the statistical power to determine even mild associations, proved conclusively, that a single or multiple nuchal cords at the time of delivery is not associated with adverse perinatal outcomes, is associated with higher birthweights and less cesarean sections in births. (5,6,7) Nuchal cord does not need any additional obstetrical intervention unless there is evidence of fetal compromise. The most common clinical sign of fetal effects are fetal heart rate decelerations during labor or a change in fetal behavior prenatally.

Per Schäffer L, Burkhardt T, Zimmermann R, Kurmanavicius J. Nuchal cords in term and postterm deliveries—do we need to know? Obstet Gynecol. 2005;106(1):23-8.

Nuchal cords do not influence clinical management at delivery, and neonatal primary adaption is not impaired. Our data show that ultrasonographic nuchal cord assessment is not necessary at the time of admission for delivery.

Per Mastrobattista JM et al. Effects of nuchal cord on birthweight and immediate neonatal outcomes. Am J Perinatol. 2005;22(2):83-5.

The cesarean delivery rate was significantly different among the three groups [infants with 0, 1, and 2 or more loops of cord encircling the neck] and was the highest among the group of women whose fetus had no nuchal cord (p < 0.01). A nuchal cord at term is not associated with untoward pregnancy outcomes.

Per Sheiner E, Abramowicz JS, Levy A, Silberstein T, Mazor M, Hershkovitz R. Nuchal cord is not associated with adverse perinatal outcome. Arch Gynecol Obstet. 2006 May;274(2):81-3. Epub 2005 Dec 23.

Nuchal cord is not associated with adverse perinatal outcome. Thus, labor induction in such cases is probably unnecessary.

Per Outcome of infants born with nuchal cords. Journal of Family Practice, April, 1992 by William F. Miser

Several studies in the past have implicated nuchal cords as a cause of fetal death.[1,17-20] Harrar and Buchman[17] reported 14 unanticipated death occurring in the second stage of labor due to nuchal cords. in contrast, several authors agree with the present study that nuchal cords do not increase fetal mortality.[7,10-12] Shui and Eastman[8] found a higher fetal death rate in those deliveries not involving nuchal cords, and concluded that coiling of the umbilical cord around the infant’s neck was a rare cause of perinatal death. Horwitz et al[9] found the neonatal death rate to be 1%, regardless of the presence of nuchal cord.

Per eMedicine:

The cord may become coiled around various parts of the body of the fetus, usually around the neck. Nuchal cord is caused by movement of the fetus through a loop of cord.

One loop around the neck occurs in approximately 20% of cases,²⁷ and multiple loops occur in up to 5% of pregnancies.²⁸

Nuchal cord has been associated with labor induction and augmentation, prolonged second stage of labor, and fetal heart rate abnormalities. One report has described a decrease in umbilical cord pH at delivery with nuchal cord, but the difference found (7.32 vs 7.30) does not appear to be clinically significant.²⁹

Nuchal cord can be detected using color Doppler ultrasound, with a sensitivity of over 90%.³⁰

Nuchal cords rarely cause fetal demise and are not intrinsic reasons for intervention.^28,31 Given the minor decrease in pH, fetal monitoring in labor would appear to be prudent, but no data are available to address this issue.

Per the March of Dimes:

About 25 percent of babies are born with a nuchal cord (the umbilical cord wrapped around the baby’s neck) (1). A nuchal cord, also called nuchal loops, rarely causes any problems. Babies with a nuchal cord are generally healthy.

Sometimes fetal monitoring shows heart rate abnormalities during labor and delivery in babies with a nuchal cord. This may reflect pressure on the cord. However, the pressure is rarely serious enough to cause death or any lasting problems, although occasionally a cesarean delivery may be needed.

Note that they discuss pressure on the cord, not on the baby’s neck, because the concern is the cord being compressed to a point that the blood cannot make it to the baby.

Perinatal Death Low with Home Births

By Nancy Walsh, Contributing Writer, MedPage Today
Published: August 31, 2009
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
Earn CME/CE credit
for reading medical news

Action Points 

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• Explain to interested women that there was a very low risk of perinatal death and other complications associated with home birth with a midwife in a Canadian study.
• Caution them that all midwives in the study were highly trained and experienced, and the study was not randomized.
• Also explain that the American College of Obstetricians and Gynecologists does not recommend home birthing.

Planned home births attended by registered midwives were associated with a very low rate of perinatal death, comparable to those of hospital births, a prospective Canadian cohort study found.

The rate of perinatal death per 1,000 planned home births was 0.35 (95% CI 0 to 1.03) compared with 0.57 (95% CI 0 to 1.43) among hospital births attended by midwives, and 0.64 (95% CI 0 to 1.56) among hospital births attended by physicians, according to Patricia A. Janssen, PhD, of the University of British Columbia in Vancouver, and colleagues.

Planned home births also were associated with fewer obstetric interventions and other adverse outcomes, the researchers reported online, ahead of print, in the Canadian Medical Association Journal.

Debates about the safety of home births continue in the literature and among policymakers, with the American College of Obstetricians and Gynecologists having long opposed the practice.

In contrast, the U.K. Royal College of Obstetricians and Gynaecologists considers it a viable choice for uncomplicated pregnancies, while the Society of Obstetricians and Gynaecologists of Canada has not taken a specific stand.

Previous studies of home birth conducted in North America, Europe, and Australia have been limited by inadequate statistical power, incomplete data, and nonrepresentative sampling.

To address these concerns, Janssen and colleagues acquired outcomes data for all planned home births attended by registered midwives in British Columbia between January 2000 and December 2004.

Eligibility requirements for home birth, according to the College of Midwives of British Columbia, include the absence of preexisting or pregnancy-onset maternal disease, a singleton fetus, and gestational age between 36 and 41 weeks.

A total of 2,899 women who began labor with the intention of giving birth at home were compared with 4,752 who also met the eligibility criteria for home birth but began labor planning to give birth in the hospital attended by a midwife.

The same cohort of midwives, all of whom had extensive academic and clinical training, attended both groups.

A second comparison group included 5,331 matched, physician-attended births, all of which took place in the hospital.

Among the women planning to give birth at home 78.8% did so, while among those planning hospital birth, 96.9% did so.

Compared with women planning a hospital birth with a midwife attending, those who planned home birth were significantly less likely to experience these complications:

• Third- or fourth-degree perineal tear (RR 0.43, 95% CI 0.29 to 0.63)
• Postpartum hemorrhage (RR 0.62, 95% CI 0.49 to 0.77)
• Pyrexia (RR 0.45, 95% CI 0.29 to 0.76)

The following neonatal complications also were less likely in the setting of home birth:

• Birth trauma (RR 0.26, 95% CI 0.11 to 0.58)
• Resuscitation (RR 0.23, 95% CI 0.14 to 0.37)
• Oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24 to 0.59)

The rate of infection did not differ significantly between the two groups (RR 0.39, 95% CI 0.13 to 1.14).

Compared with women giving birth in the hospital attended by a physician, those who planned birth at home had neonates at reduced risk for:

• Birth trauma (RR 0.33, 95% CI 0.15 to 0.74)
• Resuscitation (RR 0.56, 95% CI 0.32 to 0.96)
• Oxygen therapy beyond 24 hours (RR 0.38, 95% CI 0.24 to 0.61)
• Meconium aspiration (RR 0.45, 95% CI 0.21 to 0.93)

However, neonates born at home were more likely to be admitted to the hospital, or readmitted if they were born in the hospital, despite the planned home birth (RR 1.39, 95% CI 1.09 to 1.85).

The reason for this, according to the investigators, may have been a greater incidence of admission for treatment of neonatal hyperbilirubinemia [jaundice]in the home-birth cohort — a condition that can be identified and treated before discharge in up to 40% of neonates born in the hospital.

Among the strengths of the study were the completeness of data and the fact that the same cohort of midwives attended the home and hospital births.

Limitations include the self-selection of women choosing home birth, despite the investigators’ efforts to closely match the comparators.

The study findings cannot be generalized to settings where midwives are less highly trained and experienced, they cautioned.

Nonetheless, they concluded, "Our study adds to the body of large cohort studies of planned home births that have reported on the relative safety of home versus hospital birth."

An accompanying editorial acknowledged the study’s "important contribution to our knowledge about the safety of home birth," but called for more research.

"Few issues in maternity care remain as contested and unresolved as the debate surrounding the safety of home birth versus hospital birth," wrote Helen McLachlan, PhD, and Della Forster, PhD, of La Trobe University in Melbourne, Australia.

A well-designed randomized trial would help clarify the persisting questions about home birth, the editorialists argued, but such a trial would pose challenges such as women’s possible unwillingness to be randomized and the large sample size that would be needed.

They suggested that a feasible option would be a multicenter trial using a composite primary outcome.

The study was funded by the Canadian Institutes of Health Research.

The authors and editorialists declared no competing interests.

Primary source: Canadian Medical Association Journal
Source reference:
Janssen P, et al "Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician" CMAJ 2009; DOI: 10.1503/cmaj.081869.

There is also the Claremont class in East Los Angeles County on October 24th.

These are the only classes for 2009.  Register and save your spot!

First, our definitions of the day from Wikipedia…

Evidence-based medicine (EBM) aims to apply the best available evidence gained from the scientific method to medical decision making.^[1] It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment).^[2]

EBM recognizes that many aspects of medical care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBM, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable.

Informed consent is a legal condition whereby a person can be said to have given consent based upon a clear appreciation and understanding of the facts, implications and future consequences of an action. In order to give informed consent, the individual concerned must have adequate reasoning faculties and be in possession of all relevant facts at the time consent is given.

Scientific consensus is the collective judgment, position, and opinion of the community of scientists in a particular field of study. Consensus implies general agreement, though not necessarily unanimity. Scientific consensus is not by itself a scientific argument, and it is not part of the scientific method.

Scientific evidence is evidence which serves to either support or counter a scientific theory or hypothesis. Such evidence is expected to be empirical and properly documented in accordance with scientific method such as is applicable to the particular field of inquiry.

… and a quick review of ACOG’s Practice Bulletin #54, published in July 2004 and the reason why some American hospitals have banned VBAC, recommends, “a physician [be] immediately available throughout active [VBAC] labor who is capable of monitoring labor and performing an emergency cesarean delivery.”

Back to our interview with Dr. Fischbein:

Don’t hospitals ban VBAC because it is dangerous?

They ban VBACs under the guise of patient safety. But patient safety is a euphemism for “we don’t have a good evidence-based reason to do it, other than we don’t want to get sued, it’s more expedient, and we make more money from c-sections—the hospital does, not necessarily the physician, but the hospital does—so we’re going to ban it because it’s easier for us, and we’re going to say it’s for patient safety because of the risk of rupturing the uterus.” But you know what? That risk should be something that the patient decides. Patients have a right to be given informed consent, free from misinformation or coercion, free from skewing information that benefits the practitioner or the hospital. And they have the right to consent or refuse to accept the treatment that’s offered. That right is frequently being denied.

What role does malpractice insurance play in VBAC availability?

The reason that a lot of hospitals ban VBACs anyway [despite meeting ACOG’s “immediately available” recommendation] —and this isn’t very well known to most people—is because their insurance carrier will tell them that if they allow VBACs, their premium will be much higher. Rather than pay higher premiums, they just ban VBACs and do so under the guise of patient safety. The hospital lawyers, the insurance company lawyers, the insurance company executives, and the hospital administrators are making decisions for patients and then lying about why they’re doing it.

Aren’t uterine ruptures the primary reason for repeat cesareans in women with a prior cesarean?

Most emergency c-sections, the ones that occur suddenly, have nothing to do with a uterine rupture.  They are for placental abruption, prolapsed cord, or prolonged fetal heart rate decelerations.  Far more often, it’s something unrelated to the VBAC that causes an emergency.  And somehow the hospital can manage to take care of those situations. If hospitals can take care of those things, why can they not take care of VBACs?

ACOG’s latest VBAC recommendation was based on consensus opinion, not scientific evidence.  Doesn’t that matter to hospitals when implementing VBAC bans?

Ultimately it won’t matter to the hospital. It’s not about evidence-based medicine. It’s very clear to me in discussing this with the committees that they don’t care. They’re being told by the risk managers, the lawyers, and the insurance companies that they cannot do VBACs. And that’s the final word. The anesthesia departments are also often behind VBAC bans. They talk about patient safety, but really it is that reimbursement is so bad and they don’t want to have to sit around in the hospital all day long and they are fearful of being sued.

Does the hospital impact how an OB counsels a woman on VBAC?

I’m supposed to tell patients that they have to go elsewhere if they want a VBAC, that they can’t stay in their own community, that they have to drive 50 miles. … I’m not supposed to tell them that they have the option of showing up in labor and refusing surgery. The hospital actually put in writing that I should avoid telling them that. They’re telling me to skew my counseling, and they have no shame in doing so.

How to OBs feel about working in hospitals with VBAC/breech bans?

For physicians who are not really committed to doing VBACs or breeches, it’s a lot easier to do a section. You get paid about the same. With a section, you can do the surgery at 7:30 am and you’re in the office by 9 am. If you have a breech or a VBAC, you have to cancel your day or spend the night at the hospital. It’s a lot more work, and you don’t get paid any more for it. So you really have to be either dedicated or crazy or somewhere in between. You have to keep your ethical feet well-grounded.

How do VBAC bans impact hospital revenues?

For hospitals, it’s easy. Does a hospital make more money off a practice that has a 5% c-section rate or a 25% c-section rate? That’s an easy question. Although they will never admit that; [the official reason for VBAC bans] will always be patient safety. Clearly, there’s no incentive for them to offer a VBAC to anybody.

How do VBAC bans impact women seeking VBAC?

A successful VBAC occurs about 73% of the time. If a hospital bans VBAC, they’re basically telling 73% of women that they have to undergo a surgical procedure that carries more morbidity than if they had a vaginal birth.

How could tort reform impact VBAC supportive OBs and birthing women?

[With] tort reform, you might be able to make changes by improving competition. If you get rid of some of the restrictions on businesses, you might see more competition start up. You might see more birth centers open, or birth centers that actually have operating rooms, little maternity hospitals. Just like we’ve seen specialty surgery centers open up recently. For years hospitals tried to squelch these things because they know they can’t compete with them. Some day, maybe the major hospital model will go out of business. And would that be so terrible? We have specialty hospitals that do heart surgeries, gastric bypass, or plastic surgery. Why not specialty hospitals that just do maternity? Run by doctors and midwives.

FOR IMMEDIATE RELEASE

Class Explores Birth After Cesarean Options in Fullerton & Claremont

POMONA, CA (September 2, 2009) – VBACFACTS.com announced “The Truth About VBAC,” a class on vaginal birth after cesarean, will be offered in Fullerton on Sunday, September 20 and in Claremont on Saturday, October 24. Incorporating the latest medical research, the class provides clear and concise information as well as specific, practical tools for women considering or planning a vaginal birth after cesarean (VBAC).

With half of American hospitals actively enforcing VBAC bans and increasing numbers of obstetricians preferring repeat cesareans, many women wonder if their only choice is another surgical delivery. A 2005 survey revealed that while 57% of American women desire a VBAC, less than 10% succeed.

“If you are a candidate for VBAC and have the knowledge, tools, and support, the likelihood that you will successfully VBAC is high, at least 75%,” states Jen Kamel, founder of VBACFACTS.com. “Hire an OB or midwife that is truly supportive, because they will set the tone of your birth. Aim for an unmedicated birth because drugs can impact the mother’s mental clarity and increase the risk of complications resulting in an otherwise avoidable repeat cesarean. Select a birth location that will be encouraging rather than be a source of fear and doubt. Find women who have birthed vaginally after a cesarean or are planning a VBAC and use them as your cheerleaders and sounding board. “

“The Truth About VBAC” provides women with a extensive analysis of their options. Topics include:

• Repeat Cesarean vs. VBAC Realities
• Risks of Hospital vs. Out-of-Hospital Birth
• How to Find a VBAC Supportive OB or Midwife
• Hospital VBAC Strategies
• Factors of Uterine Rupture
• The Marketing of “Risk”
• Maternal & Infant Outcomes
• Elements of VBAC Success
• Benefits of Spontaneous Vaginal Birth
• VBAC Ban Rationale & Rebuttal
• History of VBAC – From Encouraged to “Unsafe”

Cost is $25/person or $40/couple and pre-registration is required. For more information or to register, visit www.vbacfacts.com/vbac-class.

The Fullerton class will be held on Sunday, September 20, 2009 from 1pm – 4pm at Belly Sprout, 426 W. Commonwealth Avenue.

The Claremont class will be held on Saturday, October 24, 2009 from 1pm – 4pm at No Sugar Added, 141 Yale Avenue.

About VBACFACTS.com

An evidence based source on vaginal birth after cesarean, VBACFACTS.com empowers women with information, tools, and resources.

About Jen Kamel

A former commercial real estate research manager, Mrs. Kamel retired upon her daughter’s birth via cesarean section in 2004. After her son’s birth in 2007, a successful VBAC, she created VBACFACTS.com in order to make the information and research she had compiled easily accessible to others.

Contact:
Jen Kamel
E-Mail: press@vbacfacts.com
Website: www.vbacfacts.com
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