If this truly is a battle, then women and babies are the collateral damage. Mothers need to take charge of their own healthcare decisions by designing and managing their own collaborative care and the US government is now giving them to tools to do it.

Many healthcare consumers are creating collaborative care for themselves when they hire multiple providers, like doulas and obstetricians, to support different aspects of the same conditions. They take what they like from each provider and then try to leave the rest behind.  It amounts to a customized “standard of care”.  The US government is now supporting this movement with the adoption of Final Rules from the Dept of Health and Human Resources on Electronic Health Record (EHR) Incentives. Mandates for patient access to their own electronic medical records will put the flow of information directly into the hands of consumers who will then be able to share their health information with multiple providers during the course of their care. No longer will they need the permission of their primary provider (through a request form) to access their records.

The implications of this simple change in “who really owns the information” stand to create ripple effects in the status quo. Despite the clear challenges presented when collaborating providers don’t even know they are collaborating, there are significant benefits to a shift in power from provider to patient. Changes in maternity models will soon be driven by the economics of consumer demand rather than a profession that holds a lock on our current healthcare system through a monopoly on insurance reimbursement and standards of care. When providers stop fighting over the slices of pie, maybe women will stop being unnecessarily cut when they have their babies.

Why Can’t the Maternity Care Providers Work it Out?

Elton says:

Some observers, including Wax, further suggest that American women should draw only limited conclusions about the safety of home birth from studies conducted in other countries. The experience of home birth in the Netherlands, for instance, where 1 out of 4 mothers delivers at home, bears little resemblance to the process most American women endure.

…In the Netherlands, moreover, midwives are fully integrated into the health care system and obstetrics practices, making transfers to hospitals routine. In the U.S., where 1 out of 200 women gives birth at home, midwives can be and have been arrested for bringing their patients to hospitals in states that do not license CPMs.

It is unacceptable for US obstetricians to point to the lack of timely access to hospital care for women choosing to labor at home when those same obstetricians refuse to adopt integrated collaborative systems like those utilized by countries that support out of hospital delivery and have better outcomes in maternity care as a whole.

Melissa Cheyney discusses one of the biggest obstacles to collaboration in her Huffington Post article, Why Home Births are Worth Considering.  She envisions the most important step in improving outcomes in maternity care:

Instead of a maternity system based on fear and misinformation, we need a system based on collaboration and mutual respect.

Cheyney highlights a lack of mutual respect and understanding between midwives and obstetricians as impacting collaboration and transfer of care:

…research has shown deep mistrust between doctors and some midwives. Many doctors have expressed the belief that only hospital births are safe, while midwives say they often feel marginalized and disrespected.

Such studies [e.g. Wax] only deepen this mistrust and have the potential to increase hostility during encounters when midwives and their clients have to seek hospital care for complications. The end result is a system that can be detrimental to women and their babies because of the impaired ability to communicate across a cultural divide.

Peace between providers due to a change in perspective from either side is an unlikely outcome.  As good negotiators know, the best way to mediate any dispute is to find compromises that result in a win for everyone.  Everyone “wins” in the birth battle when women have better outcomes.  It is the result we all want and we have great examples of birth models that work, and what makes for better outcomes is collaboration.

The question remaining is: how will obstetricians and midwives meet the challenge of a newly empowered patient who creates her own collaborative care?

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.

After the comment period ends (11/25/09), a Work Group consisting of members of the Board of Medicine and the midwifery community will convene to come up with a list of conditions that require additional informed choice, and draft specific informed choice documents that will be included in the regulations for CPMs.  These documents will then be presented to the Advisory Board on Midwifery and the full Board of Medicine for review.  There will be a public hearing and then another 30 day public comment period before final approval.

The midwifery community in Virginia believes that even though this requirement is redundant to our existing statutory requirement to practice the Midwives Model of Care, which is based on informed choice, the opportunity to establish once and for all that women are choosing midwifery care and home birth of their own free and informed will, is worthy of our close attention and support.  We believe that if we can engage the Board of Medicine in an unprecedented process of looking at evidence-based criteria for competent practice, we will widen the narrow band of understanding that is forming between medical and midwifery based maternity providers.  In addition, we need to be vigilant during the process to make sure that any guidelines or rules established do not create unforeseen obstacles to care for women who may fall into gray areas regarding relative risk of home or hospital birth based on current standard of practice in many hospital settings.  Mandated c-sections for VBAC, twins, and breech are good examples of the conundrum many midwives and their clients face when providing and making informed decisions for care.

We ask that you review and consider this outlined process and then post a comment to the Townhall Web site.

For those of you with a background or expertise in evidenced-based maternity care, please include your credentials and give citations to your work or other relevant resources that you can provide to the Work Group.  The NOIRA specifically states that the department plans to look to other states with various models of reviewing and determining risk. Item number 3 under “Substance” is especially interesting and invites response:

“If the factors or criteria have been identified that may indicate health risks associated with birth of a child outside a hospital, a requirement for the midwife to provide evidence based information on such risks. Such information would be specified by the Board for certain conditions and would include statements and evidence from both the medical and midwifery models of care.”

It appears that the agency believes that “evidence” is a subjective term and that is why we need evidence from both sides.  While I commend the Agency in its efforts to be fair and balanced, I believe this statement shows how imperative it is that we provide them with clear and objective evidence (research) from which to draft their documents.

For those of you who have used, are utilizing, or intend to use maternity services in Virginia, please tell the Agency what you would like the documents to include.  It is up to you to remind them that you want your informed choice to include the risks and benefits of home birth and that you want your “evidence” to be based on research, not opinion.  It is up to you to ask for information on the risks of hospital or caesarean delivery in certain situations as part of complete informed decision making. It is also up to you to review the current midwifery regulations and comment on any other aspect or restriction involving access to care that you believe should or could be improved.  They are asking for your opinions and this is a great opportunity to give them.

By providing  your comments, you support and engage the process.  You also remind everyone involved that the process is being carefully watched.  Most importantly, your comments may have a ripple effect in creating a future where ALL maternity providers are required to give evidenced-based informed choice to their clients.

Thank you for your time and attention. Please forward this request to anyone in your contact list that you believe would want to have this opportunity to participate in this process. Feel free to contact me with any questions or concerns.

Brynne Potter, CPM

Legislative Policy Coordinator, Commonwealth Midwives Alliance

brynne@mountainviewmidwives.com

www.mountainviewmidwives.com

o: 434-962-0148

m:434-962-5453

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?

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. 

Your constituent has raised some interesting and valid points.  Obstetricians are struggling in your community. However, fear of liability and lack of reimbursement for normal birth are untenable obstacles to optimal outcomes for mothers and babies.  Something must change and I believe we can all agree on that.  However, I must emphatically tell you that restricting reimbursement for midwives will not affect the problem at all.  As I indicated in our discussion, CPMs do not seek VBAC patients.  Rather, women who desire a VBAC seek out providers who will work with them in order to have a normal vaginal delivery.

Very few midwives are actually enrolled as Medicaid providers.  Our client fees are already low and many of us offer reduced fees to low-income women.  Our clients are choosing midwifery care and home birth because of our model of care and they will pay out of pocket, babysit our children, build us a shed, or trade chickens and eggs for the birth experience they want.  I do not know of a single Virginia CPM who would turn a woman away and force her to go to the hospital for a mandated c-section because her insurance will not reimburse for the birth.

Preventing CPMs from delivering VBAC babies would not end the practice of home VBACs, it would actually turn it from a very safe option to a dangerous one, with VBAC mothers having their babies alone at home with no monitoring whatsoever. This trend was the impetus for Delegate Hamilton’s efforts to pass licensure legislation for CPMs in the first place.  More and more Virginia women were choosing to birth unattended, rather than being forced to have their babies in hospitals.  Many of these women were and will continue to be women seeking VBAC.
 
Since providing a lesser quality of care to Medicaid clients than what would be available to them if they were insured or self-pay is against Federal guidelines, I sincerely ask that you pull this second bill as well and that we instead work together after the session to find a better solution to your OB’s concerns. We believe there are other more productive approaches that could be taken to increase access to hospital VBACs for women in the Harrisonburg area, and we’d like to engage in a dialogue with the stakeholder groups. I know that we ALL have the same goal in mind: optimal outcomes for mothers and babies.

Again, thank you so much for your time and consideration of these issues. As a reminder, as of January 19th I’ll be out of the country until February 1st.  In the interim, please contact Becky Bowers-Lanier, our lobbyist at 804-382-0991 or becky@macbur.com. If she needs the technical expertise of other CPMs, she will be able to access them quickly to provide you with answers to any of your questions.

Respectfully,

Brynne

p.s. As you may have noticed, I inserted links to a couple of very useful resources about C-section and VBAC.  You can also review the full text of numerous studies regarding VBAC and the risks of Cesarean delivery on the resources section of my practice website, many of which were published in ACOG’s Journal. I would strongly encourage you to ask your OB for the evidence on the position she is asking you to take regarding VBAC safety.

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.

Intervention Rates for Low-Risk Women in the United States and among Births Attended by Certified Professional Midwives, 2000

Average Facility Labor and Birth Charge by Site and Mode of Birth, United States, 2003–2005National U.S. Midwifery Credentials: Certified Nurse-Midwife, Certified Midwife, and Certified Professional Midwife

Is the Most Resource-Intensive Care the Best Care?

The Evidence about Vaginal Birth after Cesarean (VBAC)

What an incredible resource.You can download the PDF or request a beautiful bound copy for free. We need to make sure every maternal-child health policy maker in Virginia has a copy!

Exciting stuff