Deadly Delivery

Someone recommended that I read the Deadly Delivery report on maternal mortality by Amnesty International. It really was eye opening. Their key recommendations include:

• Health care providers should ensure that sufficient, accessible information is available to all women so that they can make informed decisions about their health care.
  

• The US Congress should direct and fund the Department of Health and Human Services to establish an Office of Maternal Health with a mandate to improve maternal health care and outcomes, and eliminate disparities.

• State and federal authorities should devise and implement programs to improve data collection and analysis in order to better identify and develop responses to issues contributing to maternal deaths and complications. This may include requiring all states to report maternal deaths and morbidity to federal agencies, including the CDC, on an annual basis and standardizing data collection tools.

The stories are so touching and the “care” so appalling.

Don’t forget the blog carnival!

With all this talk of VBAC and NIH, I didn’t want you to forget about the Women’s History blog carnival. Perhaps you found someone to write about who has inspired you, maybe even someone you met at NIH? Your childbirth class? Your birth? Submissions are due by 3/20.

Thoughts on Informed Consent, Refusal and VBAC

If you’ve been listening to the news lately, you’ve probably heard a lot about vaginal birth after cesarean (VBAC). The NIH held a consensus meeting to decide what was appropriate in VBAC care. The general thought was that the overall VBAC rate should increase and that the rate of primary cesareans should decrease due to the risks of surgery to the baby and mother. The panel had several recommendations that can be boiled down into:

• ACOG and ASA should revise their guidelines on the “immediately available” guidelines.
• The decision to do a VBAC or a repeat c-section should be made between a woman and her practitioner, after an informed discussion.

The problem with the last statement is that true informed consent and discussion is very rare in obstetrical care. The closest that we tend to come is the woman who is choosing a VBAC. She is likely to spend the last several months of her prenatal care being told of the risks of VBAC and the parameters in which it will happen. In contrast, had that same woman chosen to have an elective repeat cesarean, she would simply be handed an appointment card for her scheduled surgery and then sign a sheet of paper that would have to suffice as informed consent, all done a few minutes before her surgery. Neither of these is truly informed consent.

So how can women get informed consent, particularly when it comes to a hot topic like VBAC? My advice is:

• Do independent research.
• Seek out information from neutral sources.
• Talk to other mothers who have had a VBAC.
• Talk to other mothers who have had a repeat c-section (planned and not).
• Prepare for your birth by childbirth class, doula support and emotional support.
• Consider alternatives including midwifery led care.
• Make a decision only after a lengthy discussion with many people, including your practitioner.

Providers have to consider multiple issues when recommending one mode of birth over another: health of mother and baby, liability for complications, availability of self and staff during uncomplicated and complicated births, personal beliefs, medical malpractice insurance (if they choose to carry it), what other practitioners will think of their choices, etc.

Women have their own issues to consider when deciding her mode of birth: health of baby and mother, likelihood of the success of VBAC, physical and emotional pain after the birth, personal beliefs, etc.

The final point is that of informed refusal. ACOG has a policy of informed consent and refusal. This states that they believe that a woman who has all the information, is allowed to make a decision to choose not to receive the recommended procedure or therapy that is being suggested by her doctor.

At the panel yesterday, when asked specifically about the policy of informed refusal as it included forced repeat c-section, either by practice policy or individual recommendation, they basically said that this was unclear. Some advocates took this to mean that the consensus panel was suggesting that women did not have the right to choose a VBAC if that wasn’t the recommendation of her doctor or that if she did, it was acceptable to coerce her with threatened legal action. In other words, a woman is free to make any decision she would like, unless it conflicts with what her practitioner decides.

That leaves us in a sticky spot. What’s a birth activist to do?

Related:

• Maternal Decision Making, Ethics and the Law
• Refusal of Care Based on Religious Beliefs
• Women Need a Chance to Avoid Repeat Surgery

VBAC Consensus Statement (Draft)

The draft version of the NIH VBAC Consensus statement is up at: http://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf

PR: wait… I: wait… L: wait… LD: wait… I: wait… wait… Rank: wait… Traffic: wait… Price: wait… C: wait…

VBAC from a Care Provider’s Perspective

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What is it really like to be a hospital care provider attending VBACs? Janelle from Birth Sense describes it in this post submitted to the ICAN VBAC Blog Carnival.

The whole post provides a very rational, no nonsense description of the actual problems that care providers face without an emotional “WE’RE ALL GOING TO BE SUED AND EVERYONE IS GOING TO DIE AND YOU JUST DON’T UNDERSTAND RISK!” She calls upon providers of modern obstetrics to “speak up on behalf of women who want VBAC and insist that realistic, evidence-based guidelines are instituted.”

Furthermore, Janelle points out something that would probably shock the public about hospitals. The “special” mandate that an OB remain in the hospital during the entire VBAC labor with an operating team standing by is hypocritical. If hospitals are so serious about having a team ready to handle VBAC-related emergencies, why would they not want to have the same safety net available to deal with comparable emergency scenarios in “low-risk” women? When I gave birth in a hospital for the first time, I mistakenly assumed that there was an OB and an operating team on hand for those rare emergencies. Why else would I have been in a hospital?

What is most perplexing to me is the mandate that the provider remain in the hospital during a VBAC labor “just in case”, yet other serious causes of perinatal morbidity and mortality are not considered adequate reason to have a surgeon and operating team standing by.  Some examples are:

1. Cord prolapse, with an incidence of 0.14-0.62 percent.  This can cause permanent fetal injury or death.¹
2. Placental abruption, with an incidence of 0.6 percent.  Again, this complication of labor can cause permanent fetal injury or death, as well as potentially life-threatening blood loss for the mother.²
3. Placenta accreta, and its variations (placenta increta and placenta percreta).  With a reported incidence of as many as 1 in 533 births, this is a serious maternal complication which can cause death.³

If we are serious about being able to take immediate action in the event of uterine rupture (approximately 0.5% incidence in low-risk labors VBAC labors), we should be equally serious about being prepared to immediately manage other perinatal emergencies.   The truth is, VBAC is not much riskier than a normal first birth, provided a few criteria are met:

• One low transverse uterine scar
• Normal onset of labor, no cervical ripening or induction
• No use of pitocin augmentation during labor
• Prior vaginal delivery increases chances of successful VBAC
• At least 18 months since cesarean birth

The risk associated with VBAC that concerns hospitals, insurance companies and care providers isn’t just the potential risk to women and babies. They are naturally concerned about the risk to their financial bottom line associated with a potentially predictable obstetric emergency.

The next time you hear anyone try to tell you that patients or laypeople just don’t understand risk, the question should be “The risk to whom?” I would argue that, given accurate information and percentages, most patients understand risk just fine. When you read between the lines, it’s clear that patients are expected to believe that the risk that lies behind scare tactics and lies about necessity of many cesareans and inductions is based on a certain risk to them or their baby. Unfortunately, it often has little or nothing to do with risk to the patient and everything risk to the care provider or institution.

And that’s the risk that most patients do not understand about how decisions are made about their bodies until it’s too late.

VBAC Varies by Hospital Type

From The Feminist Breeder

Adverse Outcomes Compared to VBAC

This shows a slide from the NIH VBAC Consensus webcast, taken by Gina at The Feminist Breeder. It talks about how VBAC compares to other adverse outcomes in perinatal period.

NIH VBAC Consensus Conference is live NOW

You can watch it at: http://consensus.nih.gov/2010/vbac.htm

VBAC is Vital

Vaginal birth after cesarean (VBAC) is a crucial option in maternity care today. I see VBAC as one of the key ways for us to attack the growing maternal mortality.

Many people do not think about the cesarean rate as a two-part issue. There is the primary cesarean rate, the number of women having their first cesarean. There is also the secondary or repeat cesarean rate. Currently, both numbers are growing.

The primary cesarean rate is growing for many reasons. Some of these reasons women can help control, like choosing practitioners who have faith in the process and only intervene when truly necessary. A good example of an intervention that can increase the cesarean rate and isn’t truly needed would be non-medical inductions.

But the secondary cesarean rate is where VBAC comes in. This rate is growing as well, largely because women are not being offered the ability to give birth vaginally after a previous cesarean. The growing body of research is showing that VBAC is safe and successful for more women who try it. Many women want to try it but are turned away by their doctors or midwives – leaving them the option of a repeat cesarean or fighting for a VBAC.

More and more women are choosing to fight for the VBAC. The question becomes – why should women have to fight for something that is likely to be safer for her and her baby?

This is part of the ICAN Blog Carnival.

CDC Releases Home Birth Data

Today the Center for Disease Control and Prevention released some much anticipated data regarding home birth from 1990 to 2006.

Inside the released data, it showed an increasing trend in out of hospital births.  Home births rose about 5% from 1990 to 2005 and were steady in 2006.  About two thirds of these births were at homes and about another third were in birth centers. Which I believe has come from more education on the safety of home birth, as well as the increased interest in women who do not wish to be put through the hospital birthing system, or are looking to VBAC in an area with no hospitals currently permitting the hot button procedure.

What this study also showed was an increase in Midwife attended home birth, showing that women are planning these births and not just accidentally birthing at home, or not making it to the hospital in time. The number of midwife attended home births increased from 43% in 1990 to 61%.

What Robin pointed out on Pregnancy.about.com is that people will try and blame or say these trends are due to the popularity of the film The Business of Being Born, or the Big Push for Midwives campaign but these were unavailable during this time. The Business of Being Born was not released until 2007.

I find these statistics encouraging because women are becoming more educated on their options, and truly are being informed consumers.

_{MacDorman M, Menacker F, Declercq E. Trends and characteristics of home and other out-of-hospital births in the United States, 1990-2006. National vital statistics reports; vol 58 no 11. Hyattsville, MD: National Center for Health Statistics. 2010.}