Open Letter to Delegate Matthew Lohr, Virginia House of Delegates

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. 

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.