I’ve never sat in on anything as political or crucial to the birth community as last week’s National Institute of Health’s Consensus Development Conference on Vaginal Births After Cesarean. I’ve been to Medical Board meetings, participated in the California Association of Midwives’ board meetings and witnessed the surges of energy (meetings) that eventually turned into the (re-)creation of legalizing midwives in Florida. The opportunity to see the two day conference (spread over three days) is still there by clicking on the NIH link above; I highly encourage birthy folks to take the time to listen through at least some of the presentations. There are too many highlights to pick just one speaker; several shared information so profound as to bring me to tears or to clench my fists – they sure evoked emotion!
I’m pretty informed about VBACs. I know the statistics regarding uterine rupture (less than 1%) and that at least half the uterine ruptures documented were in women that had been induced or had augmentation with prostaglandins or pitocin. I knew that it was riskier to have a cesarean than a vaginal birth. I knew the physical and emotional differences between cesareans, vaginal births and VBACs. I knew that about 30% of hospitals have outright bans against VBACs and that even more don’t have a doctor on staff who will do one. I knew women were traveling or having unassisted births in order to get their VBACs.
I offer Home Births After Cesareans (HBACs) even though our California law says it is a contraindication for a homebirth (the words they use are “significant pelvic or uterine abnormalities, including tumors, malformations, or invasive uterine surgery that may impact on the current pregnancy”) However, with informed consent, the client has the right to “self-determination”… deciding for themselves if they are willing to accept the risks and continue on the homebirth path. “In recognition of the client’s right to refuse that recommendation as well as other risk-reduction measures and medical procedures, the client may, after having been fully informed about the nature of the risk and specific risk-reduction measures available, make a written informed refusal. If the licensed midwife appropriately documents the informed refusal in the client’s midwifery records, the licensed midwife may continue to provide midwifery care to the client consistent with evidence-based care as identified in this document and the scientific literature.”
If only it were that easy for VBAC women around the country.
I listened as speaker after speaker detailed the plight of women, begging for a VBAC, but being rebuffed by doctors and hospitals. Many Certified Nurse Midwives are also limited by rules and insurance. Women have been forbidden to VBAC in certified birth centers for several years. We’ve all heard the stories of women traveling hours, hundreds of miles and crossing state lines to exert their right to have a vaginal birth. Many of us already know that the only “choice” for women who cannot find anyone to attend is to have an unassisted birth, which is, while risky, I’d venture to say, probably less than the risk of a repeat cesarean. In the VBAC community, there is documentation of women who, even though they entered the hospital pushing, were forced… yes, physically… into the operating room and, even though they were screaming their objections (not a strong enough word), stating they were not consenting to the surgery, their abdomens and uteri were cut open and their babies pulled out of them. It sounds unreal, doesn’t it? Like this could never happen?
In one of my own experiences, with a client hoping to HBAC, we transferred to a highly regarded hospital due to “failure to progress” at 8 centimeters. All mom wanted was an epidural so she could think and figure out what she wanted to do. As we were admitted, we could see the baby’s head coming down, but mom was frantic, begging for an epidural. Matter-of-factly, the obstetrician said, “Sure, once we get you into the OR, then you can have the epidural.” Screaming “No!” he repeated the statement a couple more times. My client grabbed me and begged me to help her get the epidural and the anesthesiologist leaned down to her face and, sickly sweet, said, “It won’t take five minutes to get you out of pain. Let’s go back to the OR, okay?” My client, crazed with pain, asked me what to do. I was horrified that we could see how low the baby was, but they were threatening her, manipulating her, that if she wanted pain relief, she had to consent to surgery. I cried and softly told her, looking in her eyes, that if she wanted the epidural, she would have to go into the OR. I think she screamed, “Take me back!” and they were in the OR within a minute. A nurse came back after the surgery and said the baby had been so low in the vagina, she was told to push the baby back up into the uterus so they could deliver her. This story continues to make me sick to my stomach. And this was at a good hospital, one that has CNMs on staff and doctors who are decently supportive of VBACs. All we could figure was a resident needed to get another cesarean under his belt and was going to get one that night, even if he had to assault a woman to do so. (Oh, and this client was an NICU nurse at another hospital; now an L&D nurse.)
Even though I have personal experience with the disgusting way our medical system can assault women, physically and emotionally, I could not stop crying as I listened to those other women’s stories.
Intertwined with the stories was the blunt, copious information/proof that doctors and hospitals were not “allowing” VBACs because of insurance issues. Whether it was the doctor’s malpractice insurance that blocked them from helping women VBAC or the hospital’s insurance that blocked doctors, even those that wanted to help women, insurance companies were the lead puppeteers in this bizarre, topsy-turvy world of the limitation/elimination of a woman’s right to what happened to her body.
Slowly creeping over me, I realized that it was fear –fear of lawsuits and the fear of losing money- that loomed over the VBAC bans more than any other single reason. (Addendum: An OB stated that the lawsuit issue had more to do with losing their livelihood, spending years in litigation and the terriblt trauma to their families' being sued caused as more important than the thought of losing money through increased malpractice insurance. This is, of course, one person's perspective.) Tucked in there is the American College of Obstetrics & Gynecology’s 2004 statement that VBACs should only “be attempted in institutions equipped to respond to emergencies with physicians immediately to provide emergency care.” Of course, ICANers have known this for ages. I knew it peripherally, but what horrified me was the reality that doctors were willing to risk a woman’s life by doing the more risky cesarean in order to save themselves from litigation or censure. Put another way, it is more important for them to take care of their wallets (and their insurance companies’ wallets) (see what I said above) than it is to keep a woman alive. I let the layers of distress lay one on top of the other, understanding, seemingly for the first time, the selfishness and greed some/most doctors and all hospitals and insurance companies have and to what extent they were willing to go to keep their asses out of hot water. Speaker after speaker exposed/disclosed the financial bottom line and how women were being made to suffer (and die!) so they could be comfortable.
Because of ACOG’s requirement to have doctors and anesthesiologists at the ready, a great many docs decided to eliminate VBACs from their practice so they didn’t have to sit around waiting for a woman to have her baby. One speaker told the story that at one hospital, the rule wasn’t just the doctor had to be in the hospital at the ready, but in the Labor & Delivery unit itself. No cafeteria. No sleeping in the doctor’s lounge. Sitting and waiting. Could the hospital have been more clear in saying, “The hell if we’re going to have VBACs here.”?
Wondrously, OBs, CNMs, RNs and the women themselves spoke out about the state of VBACs in our country. Over and over, men and women said they were helping women VBAC, often with intense anger coming from other doctors and hospitals. Some of the providers were so busy, women traveling from hundreds of miles to have assisted births, they begged the board to revise their recommendations so more physicians could give women what they were scrambling to have – their VBACs.
Layer upon layer of obstacles stretched out a thousand miles. What do we tackle first? The speakers each had their recommendations. The insurance industry; forcing them to stop dictating what doctors and hospitals do. The malpractice insurance companies; stop assuming every labor is a potential lawsuit. Doctors; stop allowing insurance companies to run your lives… oh, and stop doing cesareans for convenience’s sake. Hospitals; allow women the right to their choices and doctors the right to support/attend VBACs. Nurse-Midwives; lobby for the right to attend VBACs again. Women; start suing for wrongful cesareans.
Looking over the enormous amount of work that needs to be done, it seems insurmountable, but we who support VBACs, we who want VBACs, we who demand the right to our bodies… we cannot quit.
The NIH’s recommendations, as most of us already know, was that the cesarean rate is too high in this country and that VBACs, with all the research, is proven safer than a repeat cesarean and should be encouraged. They had no comment on how that was supposed to be done.
While those of us watching hoped for this exact recommendation and were thrilled with the announcement, one parting stab was made that almost deflated the whole conference. Rebecca Spence from RHRealityCheck says, “Panelist Laurence McCullough, the Chair in Medical Ethics and Health Policy at Baylor College of Medicine, spoke for the panel during the public comment session and in a press briefing, taking the position that a physician has an independent obligation to protect a fetus, which, it is claimed, is not dispensed by a laboring woman’s refusal to consent. The panelists’ comments indicated that a conclusion regarding the ethical question was beyond their scope, yet stated to the press and to the audience that the body of law and ethics that protects the right to refuse surgery was not written for, and may not include pregnant patients.” (emphasis mine) It took me asking several women and reading a few blogs before I understood what they were saying: that pregnant women might not/do not have the right to refuse a cesarean… that doctors can still force women, whether through the courts or even strong-arming them, into the operating room.
I don’t know if the panel knew exactly what they were implying, but we all heard it nonetheless. Even though the recommendation was to allow more VBACs, it was ultimately in the doctor’s hands to decide when the woman could no longer make her own choices. He (or she, of course) could sail along with the status quo, not pressing ACOG to change their oppressive “recommendations,” not to change his view that VBAC is unsafe, that he has free rein to lord a scalpel over a woman’s abdomen. It was almost as if the panel said, “We recommend VBACs, but it’s absurd to expect it because, you silly girls, you can’t possibly make a sane decision when you’re pregnant and in labor. We’ll make that decision for you.”
After what seemed like a positive, productive and informative three days, I learned that The System really is rooted in misogyny, it’s values deep in the concrete of control and manipulation and left wondering if anything we ever do makes any difference at all.