Monday, July 26, 2010

ACOG's Bittersweet VBAC Statement Issued July 21, 2010

The American College of Obstetricians and Gynecologists (ACOG) issued a long-overdue statement this week regarding Vaginal Birth After Cesarean (VBAC):  "Attempting a vaginal birth after cesarean is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans, according to guidelines released today...  The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC...  These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy.  Moving forward, we need to work collaboratively with our patents and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate..."

OK.  My reaction after reading their statement should have been joy.  The natural birth community has waited a long time for this.  To be honest, my initial reaction was anger, followed by sadness.  My eyes even welled with tears thinking of all the millions of women who have been lied to for the last decade about how risky VBACs are and as a result had unnecessary surgery.  Babies suffered.  Mothers suffered.  Doctors benefited. 

We have a generation of doctors who now believe that VBACs are risky -- because ACOG said so for so many years-- and now they are being told that they are not dangerous and to go ahead and allow women a TOLAC (Trial of Labor After Cesarean).  I probably don't need to tell you that a trial of labor can easily make an OB look like he tried to allow a VBAC and (s)he may have no intention of allowing moms to VBAC.  If you are in this situation, ask your care provider what a "trial of labor" means to them.  Will you have time limits imposed on your labor?  Likely.  Do you require continuous monitoring?  Can you get up and walk around?  Are they going to treat you  like a "normal" woman in labor or like an accident waiting to happen -- IV fluids, restricting food and water, continuous monitoring, regular vaginal exams, etc. -- because attitude is everything when a woman is VBACing.  She requires a lot of emotional support.

Who is going to be involved in these changes?  It's not just about an OB and his patient.  It's about hospitals and insurance companies.  There are more than 800 hospitals across America that have banned VBACs over the last decade, the majority of those fairly recently.  Can we expect these changes to be immediate?  Unfortunately, probably not.  If you are a VBACing woman, be very familiar with this statement and fight for your right to a VBAC.  That is probably the first step.  Change is not going to occur immediately.  Women may even find themselves quoting this statement to their insurance companies.

I believe that what led to this statement was not evidence or the demand for VBAC by women.  The evidence against repeat cesareans is strong and always has been.  What led to this statement was another agency getting involved in the cesarean epidemic.  The National Institute of Health (NIH) held their conference in March and at the top of the list was addressing America's insanely outrageous c-section rate.  The number one reason for a cesarean is because a woman has already had a c-section.  If we could raise the VBAC rate, we'll automatically lower the cesarean rate, improving lives while saving money all at once.  A win-win. The statement had to come from ACOG.  The pressure was on.

According to the statement issued, 60-80% of women who attempt a VBAC will be successful.  I interviewed a group of CNMs in Albuquerque several years ago who loved doing VBACs, and as a result, their VBAC rate was 92.3%.  The care providers in the DFW area who support VBACs also boast 90%+ VBAC rates.  The Mother-Friendly guidelines state that the VBAC rate should be at least 60%.

I have written about the safety of VBACs in the past, so I wont rehash that here.  You know what I believe.  There are a couple more quotes I think are worth repeating here that appeared in the statement.

"Our primary goat is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC."   However, in another paragraph, it says "The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available."  (Remember, the risk of uterine rupture is between 0.5% and 0.9%.)  A statement very similar to this is what led to the VBAC bans in so many hospitals.  Not crazy about it appearing in the statement.  I think we'll see doctors referring to it in defense of continuing with not allowing VBACs. 

The last paragraph says "The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC."  I could not help but think of Allison's story I wrote about last year.  How things would be different for her if this statement had been issued less than a year ago.  Honestly, it makes me feel sick, angry, and sad.  I called her tonight after rereading the statement.  She had read it this afternoon.  We had the what-might-have-been conversation.  It's a moot point.  But now she has 3 cesareans under her belt (pardon the pun -- really not trying to be funny here), but the statement doesn't address women with more than 2 c-sections.  But because she was literally forced into the third c-section solely because of a hospital policy, if they decide to have another baby, she is still going to have to fight for a VBAC. 

So, yes, I am glad that ACOG issued the statement.  The price was high.  Women, I believe, are still going to have to fight to make this a reality.  A friend of mine, former Bradley student turned Bradley teacher, Sarah Clark, aka Mama Birth, titled her post on this topic "ACOG Still Sucks."  And that about sums it up...

Monday, July 19, 2010

What IS Mother-Friendly Care?

I've been tossing this phrase, Mother-Friendly, around for months now, but I am beginning to realize that people have very different ideas of what constitutes true Mother-Friendly care, as defined by the Coalition for Improving Maternity Services (CIMS).

First, let me say that Mother-Friendly is short for the Mother-Friendly Childbirth Initiative (MFCI).  There are 10 steps, which I will address in this post.  They are very specific and some steps are harder to achieve than others.  Do not just assume that your care provider is Mother-Friendly.  Put them on the spot.  Ask them.  These steps are based on the evidence. 

A Mother-Friendly Care Provider, Hospital, Birth Center, or Home Birth Practice:

1.  Offers all birthing mothers access to a doula, or anyone else they wish to have at their birth.  She also has access to professional midwifery care.

2.  Provides their statistics to the public about all aspects of their birth care, including measures of interventions and outcomes.

3.  Is respectful and sensitive to the beliefs, values, and customs of the mother's ethnicity and religion.

4.  Provides the birthing woman with the freedom to walk, move about, and choose her positions during labor and birth and discourages the supine (flat on back) position.

5.  Has clearly defined policies and procedures for collaborating with the original caregiver during the perinatal period when transfer from one birth site to another is necessary.  They will also link the new mother and baby to appropriate community resources, including during and after the pregnancy and follow-up breastfeeding support.

6.  Does not routinely practice the following procedures that are unsupported by scientific evidence, including by not limited to the following:
* enemas
* IVs
* withholding food or water
* early rupture of membranes
* Electronic Fetal Monitoring (EFM)
* Induction rate of 10% or less
* episiotomy rate of 20% or less, with a goal of 5% or less
* total c-section rate of 10% or less in community hospitals and 15% or less in high-risk hospitals
* VBAC rate of 60% or more with a goal of 75% or more.

7.  Educates staff in non-drug methods of pain relief and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.

8.  Encourages all mothers and families, including those with sick or premature infants, to hold, touch, breastfeed, and care for their babies to the extent compatible with their conditions.

9.  Discourages non-religious circumcision of the newborn.

10. Strives to achieve the WHO-UNICEF "Ten Steps of the Baby-Friendly Hospital Initiative" to promote successful breastfeeding:
     1.  Have a written breastfeeding policy that is routinely communicated to all health care staff.
     2.  Train all health care staff in in skills necessary to implement this policy.
     3.  Inform all pregnant women about the benefits and management of breastfeeding.
     4.  Help mothers initiate breastfeeding within a half-hour of birth.
     5.  Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.
     6.  Give newborn infants no food or drink other than breast milk unless medically indicated.
     7.  Practice rooming in; allow mothers and infants to remain together 24 hours a day.
     8.  Encourage breastfeeding on demand.
     9.  Give no artificial teats or pacifiers to breastfeeding infants.
     10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospitals or clinics.

This is the criteria the members of the Tarrant County Birth Network support, believe in, and ultimately practice.  Next time someone says they are Mother-Friendly, you'll be able to know exactly what that means.  It's not just a catch-phrase - sure, no one is hostile towards mothers - but are they truly supporting these mothers and fathers in becoming a family?  Step number six is pretty intense and where a lot of care providers do not qualify for Mother-Friendly status.

Mother-Friendly status is what all care providers should be striving for.  Ask your care provider if he/she is Mother-Friendly and what they are doing to become Mother-Friendly.  This is the way we are going to change maternity care in the US.  This market is consumer driven, and you are the consumer.  Demand Mother-Friendly care. 

Monday, July 12, 2010


Centering is coming to Fort Worth!  No, it's not a yoga pose.   It is actually a method of maternity care.  I hope this post explains the Centering program and you will be as excited as I am.

Centering is typically done by midwives -- at least I haven't heard of any OBs doing it.  In very simple terms, it's group prenatal care.  Often, "patients" have the option of doing their prenatal appointments in this manner where it is offered.  If a woman chooses to "center" she'll be put in a group with other women who are due about the same time or month, depending on the size of the practice. 

The women arrive at the same time at the clinic, birth center, or office.  They will each weigh themselves, as well chart their own blood pressure and do their own "pee stick."  This puts their health care directly in their own hands.  Then, each will have a couple of minutes with the midwife to measure fundal height and listen to the baby. The midwife will typically ask if she has anything she wants to talk about that is too personal for the group.  If not, she goes to the circle and waits for the other women to join the group.

The group usually sits in a circle.  It is not a classroom by any means!  There will usually be a topic, such as the size of the baby, typical pregnancy symptoms, etc.  Your midwife is sitting eye to eye with the group.  This puts her on a different level with her clients.  She has the opportunity to get to know these women in a very different setting than a  provider-patient setting.

Because less than 1/4 of pregnant women take a childbirth class, this also meets a need -- whether they know it or not! -- to become educated on the process of labor and birth.  This is very empowering to have this knowledge.  Many women find that the fears they previously felt about giving birth are replaced with excitement and anticipation.

The group cheers each other on.  They become a resource and support for one another.  The midwife may not know the best place to buy a nursing bra, but I bet someone in the group does!

The appointments run about an hour in length.  94% of women who have centered say they would do it again.  From a business standpoint, this is such a smart model.  It saves the midwife hours in her day.  Centering groups are usually made up of 8-12 women.  From the consumer standpoint, women are not sitting in a waiting room and then only getting their provider's attention for a few minutes each month. 

The UNT Midwives are beginning Centering in August.  There are midwives practicing Centering all over the country, with great success.  I expect we will start seeing more and more of this trend.  It's a good thing and I am grateful it has found its way to Fort Worth!

Thursday, July 1, 2010

BOLD Fort Worth

I know, I know, everything revolves around "Birth" (aka BOLD - Birth On Labor Day)  and the Tarrant County Birth Network these days.  I have a great post that I'm working on, but I have to get this information out.  Bear with me.

The date is set for our local production of "Birth" -- September 25, 2010 -- with proceeds benefiting TCBN.  It will be held at Martin Hall on the Texas Wesleyan University campus.  There will be a matinee and also an evening performance with a Birth Fair linking the two.  Each performance will by followed by a "Talk Back" -- led by DFW's own Joe Gumm -- with a panel of birth professionals from our community.  We are so fortunate to have such a strong birth community with so many talented birth advocates. 

We need help in several areas including:  marketing, sponsorship, printing, concessions, vendors, silent auction, community calendars, tickets, "goody bags," childcare for event, etc.  Some jobs will be on the day of production, but many will need to be done before the big day.  Some are people-oriented and others can be done from your computer.  There is something for everyone. 

You can also find updates on Facebook.  Join us online to keep up with what's happening:  Volunteer Page and BOLD Fort Worth page.  Our first Volunteer Meeting will take place this Tuesday, July 6 in Keller.  You can find out more about it at "Events" on our Volunteer page on Facebook. 

We are so excited for this BOLD event.  We hope to make it an annual tradition, making people aware of their choices in maternity care.  BE BOLD FORT WORTH!