Category — Research

Not in the opinion of the Commonwealth of Virginia.
As a follow up to last year’s passage of legislation that would require evidence-based informed consent for all women seeking home birth Evidence Based-It’s Now the Law, the Virginia Regulatory Townhall posted the first of two public comment opportunities.
Please read the following open letter to Midwifery Advocates and take a moment to post a comment to the Commonwealth of Virginia regarding your thoughts on informed choice in maternity care.

Dear Midwifery Advocates, Researchers, and Educators -

I am writing on behalf of the Certified Professional Midwives licensed in Virginia to ask for your support involving establishment of regulatory precedent for evidenced-based informed consent for women seeking maternity care.  As some of you may already know, last year the VA General Assembly passed a bill that required CPMs to provided evidenced-based informed disclosure to all women seeking home birth. You can read the history of how this happened here:  http://midwifemonologues.com/making-lemonade-a-recipe-to-support-hb-2163/

Risk factors that were listed in the law included vbac, twins, and breech presentation but also allowed for “other high risk pregnancies”.  The law does not state that these conditions would prohibit CPMs from attending a woman at home, just that the CPM will be required to provide clear, evidence-based informed consent before doing so.

The process that follows a statutory mandate for regulatory change in Virginia is open to the public and participation is simple.  The notice of intended regulatory action (NOIRA) has recently been posted to the Virginia Townhall Website.  The summary and details of the guidelines for this regulatory change are listed in a pdf (here) and there is now a 30 day public comment period.  Comments can be submitted by any member of the public, both in Virginia and outside of the state.

[Read more →]

On March 30 Governer Kaine signed HB 2163, giving final approval to a bill that will set an historic precedent for setting standards for informed choice in maternity care.  Effective July 1, 2009, regulations for Certified Professional Midwives will require that midwives disclose to their clients “evidenced based information” about the risks associated with vbac, breech, and twin deliveries occuring at home or birth centers. Get your reading glasses on everyone, you’re gonna be getting even more stuff to read from your midwife!

Midwives and home birth consumers originally opposed the bill introduced by Delegate Matt Lohr (R), Harrisonburg, because it showed a lack of understanding that the hallmark of midwifery care is already education and informed choice.  Another injustice was that it’s wording implies that only the risks associated with home birth (and not hospital birth) need to be addressed by the Commonwealth as priority issues. Many advocates wondered why women in medical practices aren’t being told of the risks associated, now and for future pregnancies,  with elective repeat cesearean section.  In fact, they aren’t even being given the opportunity to choose between relative risks. (see article on VBAC Bans)

When the midwives asked Delegate Lohr to add the qualifier “evidence based” to the language of the bill, we found ourselves more able to accept the redundant legislation in the hopes that it will not only provide some measure of education and reassurance about the Midwives Model of Care to the medical community but it will also create a legislative model for a standard for informed choice for all other health professionals.

Another great result of this unexpected drama at the General Assembly…a renewal of energy for the midwifery grassroots network in Virginia.  It was pretty amazing to see how quickly we can muster our forces to fight back against any efforts to restrict access to midwifery care in Virginia.  We renewed our connections through the VA Birth PAC listserv and also saw the new technologies of blogs, facebook, and even twitter giving us the much needed connections to all of the people who care about birth.  Perhaps most important, we showed the legislators and the medical community that our community remains a powerful force and that respectful communication and open dialogue will bring the most success in the ongoing struggle to understand how to integrate midwifery care into the existing healthcare system.

Way to go everyone!

Mother's protesting VBAC bans in Santa Barbara, CA

It was enough of a pleasant surprise when Consumer Reports analyzed maternity care in the US and gave the midwives model top ranking,”Maternity Care: High-tech vs high-touch“.  But when the stodgy and mainsteam biased Time Magazine comes out with a story this week in the Health and Science section titled “The Trouble with Repeat Cesareans“, you know the truth can no longer be suppressed by obstetric communities that refuse to practice evidence-based care.
There are many communities in Virginia where hospital or provider “VBAC Bans” are greatly impacting women’s choices for natural birth.  How can we have come to a place where we are mandating major abdominal surgery for mothers when the evidence shows that it is harmful? And more importantly, how do we get out of it?

Since your bill would essentially mandate surgery for the underprivileged women in your community, I highly encourage you to become educated about the risks of cesarean section, especially when a woman has more than one.  The maternal death rate is rising in our country.  The CDC has acknowledged that the death rates are actually under reported and that many of these deaths are attributed to the rising c-section rate and the associated complications for future pregnancies.

Dear Delegate Lohr:
 
Thank you for your prompt reply and your attention to this important issue of access to midwifery care. I appreciate your willingness both to hear and act upon some of the items we discussed this week. Thank you for your promise to pull HB 2163 from the docket.

I am looking forward to reviewing your amendments to HB 2167.  Without seeing the actual wording, I remain a bit unclear as to how this bill will affect CPM practice. As I discussed on Wednesday, the issue of VBAC (vaginal birth after cesarean) is an evolving area of medical and cultural understanding. Since the scientific and medical experts still disagree about the best route for a woman to take for all of her birth options, l contend that legislation seems premature.  The next several years would be expected to bring about emerging information that will help to inform the most evidenced based decision making for women and their providers.

When we understand that the rate of uterine rupture (the primary concern among some obstetricians for VBAC deliveries) is 27 out of 10,000, we know that 400 women will need a repeat c-section to prevent 1 uterine rupture during labor. Since uterine rupture itself has varied degrees of severity and since midwives do not induce or augment labor and because they provide constant, hands-on care and one-on-one monitoring to identify the slightest variation in heart tones well before they become a problem and take appropriate measures to stabilize or transport, many researchers, mothers and Virginia DMAS have all made the evidenced-based decision that Home VBAC (or HBAC) is a reasonable choice for families to consider. Every study has shown that when providers follow these guidelines, the risks associated with VBAC are reduced to the very same level as for other extremely rare events, all of which CPMs are trained to identify and assess well before they become emergencies. Link to Research on Uterine Rupture

I make the comparison between VBAC at home and repeat c-section because the option of VBAC in hospital is not available to many women in the Commonwealth.  Many hospitals and providers in Virginia have “No VBAC” policies, which leaves women no other choice but to stay out of the hospital for their normal birth.  Since your bill would essentially mandate surgery for the underprivileged women in your community, I highly encourage you to become educated about the risks of cesarean section, especially when a woman has more than one.  The maternal death rate is rising in our country.  The CDC has acknowledged that the death rates are actually under reported and that many of these deaths are attributed to the rising c-section rate and the associated complications for future pregnancies. When you factor in the reality that many of your constituents plan very large families, the physical and financial burdens of 5-10 future surgeries is staggering.  [Read more →]

An article published this month is the journal of the American College of Obstetrics and Gynecology recommends labor prior to a primary cesarean as a preventive measure against uterine rupture in future pregnancies.

A powerful argument against medical induction, the researchers tracked over 10,000 women from their primary c-section to the end of their second delivery. Of 10,160 women who had a trial of labor, 39 (0.38%) had a uterine rupture. Women whose primary cesarean delivery was planned or followed induction of labor had an increased risk of uterine rupture and this risk remained after adjustment for other factors. Women with a history of either spontaneous labor or vaginal birth had one uterine rupture for every 460 deliveries; women without this history who required induction or augmentation to proceed with a VBAC attempt had one uterine rupture for every 95 deliveries.

Conclusion: Labor before the primary cesarean delivery can decrease the risk of uterine rupture in a subsequent trial of labor. A history of primary cesarean delivery preceded by spontaneous labor is favorable for VBAC.

Other findings: Augmentation is still bad for VBAC. The study also showed that women with a previous c-section who were induced or augmented for their trial of labor had a greater relative risk (4.24 fold) of uterine rupture.

The study authors convey a desire to see their research actually change the standard of care for all women. If implemented, this standard would likely lower the primary c-section rate in the first place. The authors state, “Our results can inform protocols for treating women who intend a first trial of labor,” …which means: let/encourage a women to spontaneously labor (don’t induce) and you can protect her uterus from damage, now and in the future.

I sat down this evening with a cup of tea to read all about the new publication Evidence-Based Maternity Care by Childbirth Connections, The Reforming States Group, and The Milbank Memorial Fund. [Read more →]