Monday, February 23, 2009

The Importance of One Little Word....

The recent TIME article on VBAC bans ("The Trouble with Repeat Cesareans") made a number of good points.

But one of the most important points the article made was on the impact the change of ONE little word had on women's access to VBACs.

In their 1999 Guidelines on VBAC, the American College of Obstetricians and Gynecologists (ACOG, the trade union for OBs) changed one key word, suggesting that OBs and anesthesiologists had to be "immediately available" instead of "readily available" during a VBAC labor.

That one-word change completely obliterated VBAC as a choice from basically half the hospitals in the country.

A Change in Guidelines

ACOG used to require that OBs and anesthesiologists be "readily available" (meaning they had to be within a few minutes' drive from the hospital). When they re-wrote the guidelines in 1999, the wording became "immediately available."

This ONE-WORD change in the guidelines was the death knell for VBACs in many communities. It means that OBs and anesthesiologists have to be IN the hospital the whole time a VBAC mother is in labor....."just in case."

Most doctors won't do this, both because they don't like to "labor-sit" and because it crimps their ability to see other patients. And smaller, more rural hospitals simply don' t have the personnel to provide 24/7 coverage like that.

Was this change in guideline based on good solid evidence? No. As ICAN's recent press release about VBAC bans notes:

The ACOG guidelines stipulate that a full surgical team be “immediately available” during a VBAC labor, though the stipulation is a “Level C” recommendation, which means it is based on the organization’s opinion rather than medical evidence.
Dr. Marsden Wagner, neonatologist and perinatal epidemiologist, criticized the change in guidelines in this way:

This recommendation, "VBAC should be in institutions equipped to respond to emergencies with physicians immediately available," has no data to support it--no studies showing improvements in maternal mortality or perinatal mortality related to the characteristics of institutions or availability of physicians.
A Different Standard for VBACs

"Immediately available" sounds good on paper, but it puts a level of demand on VBACs that no other birth has.

For every other birth, it's fine to have doctors on call but not right there---but VBACs got a different standard when the guidelines were changed. "Immediately available" coverage is now a requirement only for VBAC births.

Why the requirement for 24/7 coverage in VBACs? Because there were some infamous cases of uterine rupture in the 1990s. Doctors practiced unsafely, widely inducing VBACs but not monitoring them closely, and some babies died or were harmed. Some parents sued (and rightly so). As a result, doctors became gun-shy about VBACs.

The problem was really not the VBAC itself, but how the doctors were mismanaging the VBAC, and sometimes also the lack of timely response to emergencies. As a result, ACOG suggested that all of their members be immediately available ON-SITE during a VBAC labor, ostensibly protect the mother and baby from harm, but also to protect themselves in lawsuits from the charge of lack of timely intervention.

ACOG guidelines are only guidelines, not laws, but because they are considered "standard of care" in the community, few hospitals dare to defy them. If a hospital lets doctors be merely "on call" during a VBAC labor and something bad happens, they risk a huge malpractice award to the parents because they permitted the doctors practice outside the "standard of care" from their parent organization.

Thus, the "immediately available" requirement was interpreted as requiring 24/7 surgical and anesthesia coverage; without it, hospitals felt they were vulnerable to lawsuits. Since only the very largest hospitals are able to do 24/7 coverage, VBAC was effectively wiped out for half the country, all from the change of one little word.

The 24/7 Dilemma

It's everyone's ideal to have someone standing by at all times in hospitals, ready to intervene in case of an emergency (and not just in maternity units; car accidents can happen at any time of the day or night too).....but it's simply not practical or workable to have 24/7 coverage in most institutions. On-call coverage is good enough for everything else. Why isn't it good enough for VBACs?

VBACs should not be held to a stricter standard just because they are VBACs. All births have potential risks; VBACs do have the risk of uterine rupture, but while this is serious, so are some of the other very rare complications that can happen during non-VBAC births. To say that it's not safe to do a VBAC without 24/7 coverage means that it's not safe to do ANY births at that hospital.

Remember, there's no proof that 24/7 coverage improves outcomes. Before instituting such restrictive guidelines that potentially impacts the health of women so deeply, it is important to have research showing that such coverage makes a difference, that any improvements from such coverage would balance the women that would be harmed from being forced into thousands of repeat surgeries in the smaller hospitals.

The American Academy of Family Practice Physicians took on this "immediately available" requirement in their 2005 Trial of Labor After Cesarean (TOLAC) guidelines. It is uncommon for major doctor organizations to come out and contradict each other like this; the fact that the AAFP did so is a major reprimand to ACOG. Yet in the four years since the AAFP statement came out, ACOG still has refused to modify its guidelines.

The AAFP stated in its TOLAC guidelines [emphasis mine]:

TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes....

Current risk management policies across the United States restricting a TOL after a previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence...We could find no evidence to support a different level of care for TOLAC patients.

What this change in guidelines is really about is protecting ACOG members in lawsuits, not improving outcomes in VBACs.

VBAC Is Only For Rich Urban Women

One side effect of the "immediately available" rule is that VBAC has become available only to a select few--those who have excellent insurance coverage and who live in a large urban area near a major regional hospital that can afford 24/7 coverage. (Note: Even there it's not always allowed.)

If you live in a rural area, forget it. If you are on Medicaid, forget it. If you don't have a lot of money, forget it. Chances are, you are not "allowed" to have a VBAC. You are not "allowed" control over your own body or say in your own choices.

Doctors in rural areas excuse this blatant discrimination by telling women they can just go to an urban hospital if they really want a VBAC....but the reality is that this is simply not feasible for most families. Most people in rural areas or small cities simply can't afford to drop everything and move to The Big City for several weeks around a birth, nor do most women want to drive several hours to The Big City while in labor.....especially in uncertain weather seasons like wintertime.

So basically, women from smaller towns and rural areas are, in effect, being forced into repeat cesareans by the "immediately available" rule.

Some smaller hospitals "permit" occasional VBACs....if the mothers pay an additional fee for having an anesthesiologist come baby-sit on site while they labor. In effect, they are making it so that only rich women have the choice for VBAC.

Even in large urban areas, access to VBAC is not guaranteed. A number of hospitals in big cities have stopped doing VBACs because some malpractice insurance companies charge more for doctors doing VBACs.

Other hospitals stopped doing VBACs because they are looking at their profit margins, which increase as cesarean rates go up. More cesareans create more billable services, require less staffing (no hands-on labor support), make it easier to schedule personnel, and fills their hospital beds predictably. Hospitals make more money from banning VBACs and increasing cesarean rates.

The sad fact is that it's not about what's best for moms and babies; it's about what's best for their bottom line.

Even if you live in a large urban area and have a local hospital that does accept VBACs, you are still not home-free. If you are on Medicaid, you don't get a lot of choice in your birth attendant. You have to take whomever accepts Medicaid, and many of those doctors don't "do" VBAC. So even if you have everything else going for you, if your Medicaid-approved doctor doesn't do VBACs (and many do not because they can't afford to sit in the hospital 24/7 with you), you're out of luck.

So now there are distressing and deeply troubling patterns of discrimination starting to emerge. All because ACOG decided to change "readily" to "immediately" in their 1999 guidelines.

Speak Up About It

The point is that ACOG needs to change their guidelines. A lack of 24/7 surgical and anesthesia staffing should not be a requirement to "permit" VBAC. Bottom line, VBAC should not be held to a different standard than all other births.

Doctors and hospitals and elected officials MUST start pressuring ACOG to restore the "readily available" wording to their guidelines. We consumers have been pressuring ACOG for years to change the wording but they could care less about the chilling impact their guidelines have had on women and childbirth choices all over the country. It's all about protecting their members from lawsuits instead.

It's been TEN YEARS since that wording was instituted and they still haven't changed it back. They don't care what we think. They don't care about our needs. They only care about their own narrow self-interest.

Still, we consumers must keep up the pressure and intensify it on doctors, hospitals, and elected officials, for the wording will only change when the big guns start pushing ACOG back.

Outraged yet? Want to take action? Link to the Time article on your blog, or email the story to someone (from the TIME website preferably).

Or read more about the Time author's own bumpy journey to VBAC and give it some link love too. Even at a hospital that "allowed" VBAC and in a practice that was supposedly "VBAC-friendly," she was given the ole "bait and switch" routine and strongly pressured to schedule a repeat cesarean about 2/3 of the way through the pregnancy. (Remember, the outright bans are only the tip of the iceberg.)

Or click on this link for ways to start making your views known to your elected officials; ICAN's made it easy for you. You can do a lot of it by email.

Make some noise before VBACs disappear from the country altogether.


Jill Arnold said...

Not only did the families affected suffer, but women everywhere pay the price for the iatrogenic uterine ruptures that occured as a result of obstetric mismanagement.

Anonymous said...

This is a fantastic piece and you hit the nail right on the head! Now if only someone would hit ACOG right on the head and knock some sense into them!

Anonymous said...

It drives me nuts that instead of recommending that doctors use safer practices, ACOG's recommendation is to increase surgery (having surgeons and anesthesiologists immediately available means go straight to surgery). They never even consider that the doctors' methods ARE the problem, instead they label the VBAC as the problem, with the solution being more of what caused the "problem" in the first place (more c-sections). I wish we could get legislation requiring doctors to give their patients informed consent that actually shows the statistical risks of procedures, and do it for inductions, tests, surgeries, everything. This problem is not just within the OB community, it's a problem in many fields (I'm currently nursing a knee that has had so many new problems since the knee surgery I had 4 years ago, directly caused by the knee surgery, that are natural effects of what was done, yet the doctor never mentioned these as a possibility--if I had known I would have just suffered with the knee pain I had to begin with, because this is so much worse).

Enjoy Birth said...

Wonderful, wonderful post! Thanks for saying it all so simply. Let's work together to encourage ACOG to change that word back!

Anonymous said...

I read this long article from The New Yorker today and was wondering what you thought of it:

I have become more radicalized by your bringing the full scope of these issues into view, thank you.

Well-Rounded Mama said...

Wellroundedtype2, thanks for pointing me to that article. I hadn't seen it before.

I have mixed feelings about the article. Some parts of it are excellent, some parts overblown scariness. Typical childbirth really isn't that dramatic, and although all those things he lists CAN go wrong, they actually are pretty rare events. 90% of women will birth just fine, given reasonable nutrition, a reasonably healthy body beforehand, and a supportive attendant. Even more will be fine with just a little extra help. The scary problems like he lists are really uncommon, esp in a typical low-risk population.

A lot of problems (like the infection rates he cites) actually come largely from mishandling of labor, like lots of vaginal exams after the woman's water breaks. Don't do vaginal exams and the rate of infection drops significantly. But that gets left out of the mix because it's standard of care and they have a hard time not automatically evaluating that, even when it increases risks significantly.

I was fascinated by the history of Dr. Virginia Apgar. That was a great part of the article. I'm familiar with Apgar scores, of course, but I didn't know much about its inventor. That was really fascinating. Sounds like a cool chick! And it's a very useful tool, I agree. Definitely worthwhile.

I could have told the doctors, though, that the laboring woman in the story had a malpositioned baby. She had all the classic signs....and ALL her doctors missed them until very late in the process when she was already beat.

That's one thing doctors these days are lousy at.....detecting the obvious signs of a poorly positioned baby and knowing how to fix that without resorting to a c/s. That's another future blog post....but you can read more about it on my website if you just can't wait!

The whole planned c/s at 39 weeks thing for everyone to MAYBE prevent a very few stillbirths was scary, because if you do enough of those, those very rare complications everyone dreads (anesthesia accidents, blood clots, DIC, major hemorrhage) will become more and more common. It's just a statistical fact of enough of procedure xx and even the rare complications will start piling up. And the research does NOT support that a c/s is safer for the mother; not at all. Most shows just the opposite. That was a little research cherry-picking on his part.

I also disagreed with his contention that obstetrics is really good at trying something and looking to see if results improve. That's true of a few procedures, but SO NOT TRUE of so many more, like episiotomy, external fetal monitoring, use of Cytotec to induce VBACs, yadda yadda. They really are still not very evidence-based, or they'd be doing a LOT of things differently. I really think obstetrics would be improved if they actually critically evaluated new things more thoroughly before jumping on the bandwagon and using them quickly.

However, I think his idea for an Apgar score for the mother is RIGHT ON THE MONEY. Cesareans are so common because drs focus on the baby's condition at the expense of the mom's, and really downplay the effect of surgery on the mother's health (short- and long-term). An Apgar for mom would really improve immediate and longer-term post-op care and might get them to really focus on how best to improve maternal outcomes as well as fetal outcomes.

Thanks for the link to the article. It was a mixed bag, with both pros and cons in the story, but a really interesting read.

Christie CC said...

Hi Kmom,

Do you know if there has ever been a well-organized letter campaign to ACOG?

I'll admit I'm not optimistic that it would make a difference, but I do think we need to at least make an effort in that regard as well.

Moreover, I can't help but wonder if with all of the great pressure going on from consumer organizations, if now might be a better time than most.

I'd love your thoughts!



Well-Rounded Mama said...

Christie, I don't know if there's been a really organized huge effort to write to ACOG. I know ICAN members have written to ACOG before and basically gotten blown off; just recently one of our board members wrote the VP of ACOG on some incorrect data he cited in arguing against VBACs and he basically blew her off. So I honestly don't hold a lot of hope for ACOG being responsive to us.

Instead, I hold hope for pressuring local drs and hospitals and elected officials and getting THEM to put pressure on ACOG to change the wording. If a change ever happens, it will come from pressure from within, from other doctors and hospital administrators etc.

I think we start that process with pressure from without, though, so they understand we're not just passively knuckling under and lying down on the operating table. So in a roundabout way, consumer pressure will work, but not so much directly.

At least, that's what I think. I'm sure others feel differently.

Christie CC said...

Hi Kmom,

Yes, I was aware of the blow off by the VP to Lisa's questions, which certainly adds to the argument for pessimism.

On the other hand, the bottom up approach has many challenges as well. It can be overwhelming at times.

Random idea, but what if every time a woman left a practice that was pulling the bait and switch, ICAN sent a note saying "you've been dumped" for non-supportive care. I'm partially kidding of course, but it's just that Drs. need to understand that it does matter and women will walk.

It seems to me that women are usually so wrapped up in finding support (understandably so) that the follow-up often doesn't happen, so they just disappear, and the practice never knows why.

I know lots of women do write letters to providers after, but the ones I've seen are not about why they dumped them, yk?

Okay, I'm rambling.


Anonymous said...

Any chance of a million woman march on Washington? Waving signs that say "First Do No Wrong" and giving statistics. The C-section rate is a great cause to rally around. The first man I mentioned it to said his daughter had an artery cut during C-section... There could be "First Do No Wrong" t-shirts and motorized sofas and of course men would be welcome too. I'd join in a heart beat. Give me Freedom Of Choice to refuse "healthcare". I'm sick of Obama pretending folks like me don't exist, would a million of us be enough to get some airtime?

Anonymous said...

Seems wrong to argue about risk/benefit to mother vs. baby. They are literally connected! Another facet of the same attitude; the quack who referred to pregnancy as "a medical problem". I wanted to tell him "it's a baby!" but he was so clueless I just stared at him instead.