Tag Archives: advocacy

TRIAL OF LABOR, A New Film About Four Mothers and Their Determination To Give Birth Naturally After A Prior Cesarean

22 Jul

Two fathers, Robert Humphreys, an independent, award winning film maker and Dr. Elliot Berlin, a Chiropractor specializing in alternative prenatal care, set out to make a documentary film about the VBAC Ban in U.S. hospitals and its impact on the physical and psychological health of women who want to birth naturally after a prior cesarean. TRIAL OF LABOR, a documentary initially conceived as an educational film about the medicalization of birth in the U.S. and the pros and cons of VBAC and repeat cesarean, evolved into a powerful and inspiring personal journey of four mothers who had a prior cesarean and who were determined to find caregivers who would support their choice for a VBAC. The children of both Humphreys and Berlin were born at home. As men and fathers, they witnessed how powerful and validating birth can be.

With a healthy pregnancy, and a low horizontal scar on the uterus, women who go into labor on their own at term have about a 70% to 75% chance that they will have a safe VBAC. Avoiding a routine repeat cesarean protects women from complications of major abdominal surgery as well as potential complications in a subsequent pregnancy.

However, current controversial ACOG guidelines (Practice Bulletin #115) requiring that trial of labor (TOLAC) should take place in hospitals where resources for emergency cesarean are “immediately available” make it very difficult for expectant mothers to find VBAC supportive careproviders.

The National Institutes of Health (NIH) found that this “immediately available” recommendation was based on consensus and expert opinion rather than strong support from high-quality evidence.  The NIH also found that this recommendation had influenced about one-third of hospitals and one-half of physicians to no longer provide care for women who want a VBAC.

Told from the mothers’ own point of view, TRIAL OF LABOR is a sensitive and insightful look at four strong and courageous mothers who challenge an irrational and un-affirming medical care system to escape from a routine repeat operation-initially, the only option they thought they had.

Their journey to VBAC forces them to look back at their unexpected and unwanted cesarean birth. Face conflicting emotions about their ability to give birth and examine carefully the benefits and downside of both a natural birth and another operation.

“It was the most surreal Kafkaesk experience,” said one mother about her cesarean. “When I reflect about it,” says another, “I get visibly angry. That I didn’t inform myself enough.”

The mothers’ decision to give birth vaginally, where and with whom , did not come easy. “It’s very difficult to step away from the medical establishment,” expressed one expectant mother and yet,  chose to have a VBAC at home, her last resort, despite the lack of published evidence about its safety. Each mother decided for herself how she can best give birth this time.

The U.S. saw an increase in VBACs from the 1980s through the mid 1990s, but the VBAC rates have consistently declined since. One in four women had a VBAC in 1996 compared to 1 in 100 today.

Filmmaker, Robert Humphreys said, “Women have the power and wisdom to give birth. They have been doing it for thousands of years. We men need to step back and respect their strength and ability to give birth on their own.“

The producers of TRIAL OF LABOR have received an encouraging response to their request for  funding to complete the film and meet their post-production costs. They also plan to produce DVDs of the film. Humphreys and Berlin have launched a Kickstarter campaign to raise the funds and are asking the birthing community and the public at large to view the trailer and spread the news about this important and much needed film.

To view the trailer and find out more about the film visit, TRIAL OF LABOR.

California Reseachers Call For Fewer Cesareans and More VBACs

30 Jan

In a recently published White Paper by the California Maternal Quality Care Collaborative researchers in California confirmed that the high number of cesarean sections performed in the United States and in California put mothers and babies at increased risks and add significantly to healthcare costs with little evidence of health benefits.

The report also confirmed that there are psychological costs that are often overlooked. Postpartum anxiety, depression,  and post-traumatic stress disorder (PTSD). Cesareans affect maternal-infant attachment and breastfeeding as well.  The cesarean rate in California and the United States increased by 50 percent between 1998 and 2008. It rose from 22 percent to 33 percent in ten years. Researchers found no data to document any population-level benefit to mothers or newborns associated with the  increased rate of cesareans.

The authors state, “Today providers seem to see no ‘downside’ to a high cesarean rate; and women seem increasingly accepting of the prospect of a cesarean.”

California healthcare payers pay hospital charges of $24,700 for a cesarean compared to $14,500 for a vaginal birth. The authors state physicians, healthcare payers, employers who pay for childbirth costs, and public health officials are not aware of the “disconnect” between the amount of dollars spent and the health outcomes in U.S. maternity care.

The authors of  Cesarean Deliveries, Outcomes, and Opportunity for Change in California: Towards a Public Agenda for Maternity Care Safety and Quality found that the increasing cesarean rates can be attributed to two main reasons: cesareans performed on mothers having their first baby and the dramatic decline in VBACs.

The number of cesarean performed during labor vary widely and reflect individual physician discretion rather than clear medical indications.  In fact researchers found that 90 percent of the variation in cesarean rates during labor is due to only two indications: failure to progress and non-reassuring fetal heart tones (fetal distress).  The number of cesareans performed for these two indications vary widely and depend on the physicians’ individual response to these two conditions.  Attitudes of physicians and nurses on the labor and delivery unit also play a part.

The White Paper showed that overall, hospital cesarean rates in California varied from 18 percent to over 50 percent of all births. Hospital cesarean rates for low-risk mothers giving birth for the first time varied from 9 percent to 51 percent. More recent data showed that in 2009 hospital cesarean rates in California varied from 16 percent at Sutter Davis Hospital in Davis to 68 percent at Los Angeles Community Hospital.

The Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States, states, “Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes. There are no data that higher rates improve any outcomes, yet the CS rates continue to rise.” 

The argument has often been made that hospitals with high cesarean rates have a higher proportion of high-risk births and that rising cesarean rates are due to “maternal request.” This report clearly shows that there is no foundation to these arguments.

With regard to the decline of  VBACs, researchers say it will take persistent pressure from childbearing women and advocates for evidence-based practice in childbirth, public reporting of  hospitals who support VBAC and increased awareness by childbearing women about the safety and benefits of VBAC. Citing a national survey  of women’s experience of childbirth, the authors found that reality-based television shows on childbirth and many websites send an incorrect message that cesareans are easy, pain-free, and risk-free. Most women have very little knowledge of  common hospital procedures and their impact on the normal progress of labor.

Based on interviews of California careproviders, the report found that VBAC is also “not popular” with physicians due to the longer time commitment needed for a vaginal birth and their perception of increased liability.

“Whatever the motivation for today’s more ‘defensive’ approach to delivery,” the authors state, ” it is not resulting in better outcomes for babies or their mothers.”

The White Paper is an extensive and insightful study of the rising cesarean rate in California, the health risks of surgical birth, the medical factors driving the trend, and the socio-cultural factors that keep cesarean rates high. It also dispells several myths about cesarean section.

The report includes a valuable, multi-faceted response to reducing cesareans. Strategies include, quality improvement measures, examining hospital practices that lead to cesareans, public reporting of hospital cesarean and VBAC rates, payment reform, and an education campaign to increase awareness about the short- and long-term health risks of cesareans for mothers and babies.

The authors make a  strong recommendation to use several facility-appropriate approaches at the same time since many of  “these interventions interact positively with and reinforce each other, making the whole greater than the sum of its parts.”

The White Paper is a collaborative report by researchers from the California Maternal Quality Care Collaborative, the Pacific Business Group on Health, and the California Perinatal Quality Care Collaborative.

 

Resources

To find out more about reducing the odds for “failure to progress,” during labor, see

Six Lamaze Healthy Birth Practices

To see how Contra Costa Regional Medical Center in California made changes to support women who want to plan a VBAC, see the video

The Birth After Cesarean Improvement Project

To find out more about what some hospitals are doing to reduce cesareans, see

Michigan Health & Hospital Association Keystone Center- Obstetrics

Sutter Health, California,

West Virginia Perinatal Partnership- First Baby Clinical Initiative

For a list of support groups for mothers who experience psychological stress after a cesarean see,

Support Groups 

To find out more about hospital intervention rates and what mothers think of their careproviders, see

The Birth Survey

A Mother Writes, “I Do Not Want a Repeat Cesarean.”

20 Mar

A mother from North Carolina wrote to ask what she can do to get hospitals in her community to provide care for VBAC.

” I just found your site, and I know you must be really busy, but I wanted to drop a line to tell you why your site will be very important to me. I live in a small town, and the local hospital will not allow VBAC’s. I just had my first baby 6 months ago, and after laboring 26 hours (13.5 of which were at the hospital) they then realized that my baby was breech and ushered me into a cesarean. The only options they gave me at that time were to undergo general anesthesia and be put to sleep, or have a spinal block and my husband could be in the OR with me.

I was mortified at the lack of information I had received and the fact that it took so long for them to realize that my baby was breech. When I was getting ready to leave the hospital the nurse proceeded to tell me that next time it will be easier since I will be able to schedule my cesarean because the hospital will not support VBAC.

I was shocked! I do not plan to have any more children for a couple years, but I do not want to wait until I am pregnant to try to fight this system. I do not want a repeat cesarean and I want other women to have the option to VBAC at this hospital. Every other hospital is over an hour away from this town and of the 3 hospitals that are within that approximate hour drive, there is only 1 that will allow a VBAC. That would mean that I would likely have to have all my prenatal care with a provider that is that far from me.

While it would be worth it for me to drive that far, it is not fair that a group of providers and the hospital will not give women a fighting chance. Nor do they educate them on the dangers of repeat cesareans. Instead they scare them into thinking that they can only have cesareans. Thank you for creating a web page to help educate women.”

Crystal

It is not unusual for hospital staff to discover in labor that a woman is carrying a breech. Had the breech been diagnosed during the last weeks of pregnancy, Crystal would have had the option of having an external version or finding a careprovider skilled in breech vaginal birth.

When it comes to hospitals refusing care for women who want to plan a VBAC, current ACOG guidelines for VBAC state that facilities must at least inform women of the availability of emergency care in case of complications from a VBAC and refer women to hospitals and providers that do support VBAC. ACOG also recommends that hospitals do change their policies and find ways to safely support healthy women who want to avoid a medically unnecessary cesarean.

Having said that, sometimes the only way a hospital will change its VBAC policy is in response to pressure from birth advocates in the community. Women with a previous cesarean who plan to become pregnant should canvas the hospitals in their community to find out about available care for VBAC and birth centers will often support women who want a VBAC.

Although ACOG supports VBAC, often physicians and hospitals don’t provide care for VBAC because their malpractice insurance coverage is increased by thousands of dollars for liability insurance coverage for VBAC .  Information about lack of VBAC liability coverage is not usually provided to the public. Many physicians who support VBAC loose business because the hospital at which they have privileges has a no-VBAC policy.

In Northwest Arkansas a grassroots birth advocacy group was successful in getting the hospital in their community to change policy and accept to provide care for women who want a VBAC.

Beth Day and Genet Jones of BirthNetwork of Northwest Arkansas describe how birth advocates made it possible for women to avoid an unnecessary repeat cesarean section.  Beth Day writes,

“Last month in Rogers, Arkansas  three local hospitals  overturned their ban on VBAC.  Our work with one hospital in particular has been a beautiful blend of work, relationship building, and timing.  I  have lived in the area and have attended births at this one hospital as a doula for the past 5 years.  As a result of my work there, I developed a good working relationship with one of the physicians who was not only the only doctor who would allow women to labor and birth in water, but was among the few who championed VBAC.

Then, two years ago, Genet and I were working with our local chapter of ICAN, staging protests at each of the area hospitals that banned VBAC.  The protests themselves were not directly successful.  In fact the hospitals really dug in their heels and stood in solidarity defending the bans.  But perhaps we planted the seed for a swift reversal of the bans once the new ACOG guidelines were published.

This summer, I was contacted by one hospital  They asked me to outline the benefits of supporting mothers who wanted to plan a VBAC.  I jumped on the opportunity and wrote a long email which basically outlined the reasons why they not only should allow VBAC, but why they should seize this moment to attract a niche market of natural birthers by becoming the only “mother-friendly” hospital in the area.

This email was circulated and they invited us to come and present our case for “mother-friendly” maternity care to the CEO, the head of obstetrics, the chief nursing officer of the hospital.  Genet and I prepared a power-point presentation which explained why it made good business-sense to become “mother-friendly” and went together to make the presentation.  We received excellent feedback after the presentation.

The hospital did indeed reverse the ban (along with two other hospitals who simply made the move without our input) and I believe that they are in the process of getting approval to retrofit one of the LDR (labor-delivery-recovery) rooms with a permanent labor tub.  We also hope to work with their nursing staff to encourage them to receive “mother-friendly nurse” recognition.

We are so thankful for the help we received from CIMS and BirthNetwork National in giving us the framework for the information we presented to this hospital.  Without the institutional support of both, I’m afraid we would have looked just like a couple of home birth nuts.  But because we had the CIMS and BirthNetwork connections and information, we were able to put forth a convincing argument for changing the way hospitals do business.”

For additional information about changing VBAC bans in your community see ICAN’s Advocacy webpage.


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