A VBAC is Safer on an Indian Reservation than in a Major US Hospital
March 10th, 2010NIH Consensus Development Conference on Vaginal Birth After Cesarean Section
For the past 2 days, the National Institutes of Health has hosted a conference to develop a consensus statement on Vaginal Birth after Cesarean Section (VBAC). In the United States, nearly one in every three births is via cesarean section, a number that is more than double the 15% cesarean section rate recommended by the World Health Organization. The high number of cesarean sections in the United States comes in large part from repeat cesareans. The current NIH discussion is to determine whether or not a woman who has had a prior cesarean section should automatically have cesarean sections with subsequent pregnancies, whether or not VBAC’s are safe and in what situations should they be performed.
Proponents of VBAC argue that VBAC’s are safe in women who are at relatively low risk and when the procedure is performed by competent labor attendants (midwives) in a mother friendly environment. (For more on mother friendly childbirth, see MFCI.) Opponents say that VBAC’s pose unacceptable risks to both the mother and baby due to the risk of uterine rupture, hemorrhage, and potential death of both mother and baby. So who is right? Ironically, both sides because the success of VBAC rests in large part with where it is done and who attends that birth.
One with nature-The Indian Health Service
The March 6, 2010 New York Times published an article by columnist Denise Grady reporting on the successful birth rates at the Tuba City Regional Healthcare System in Tuba City, Arizona. This hospital is part of the Indian Health Service, A federally funded healthcare program that serves Native American Indians and Alaska Natives, and is run by the Navajo Nation. This small hospital which delivers about 500 infants annually has a 32% VBAC rate and an overall cesarean section rate of 13.5%, despite the fact that many Native American women develop gestational diabetes and hypertension during pregnancy which, if they were being cared for by the conventional US health care system, would make them more likely to have cesarean section deliveries. How is such success possible?
Parameters that contribute to a low cesarean section rate overall and to high VBAC rates
To Fully understand the success of Tuba City and other hospitals like it, one must look at how the the overall system is structured. There are 5 specific things that Tuba City has in place that allows for their success.
1. Midwives attend most of the vaginal deliveries.
Midwives are more likely to “wait it out” if a woman is having a long labor and the baby isn’t in distress than to recommend a cesarean section. Midwives never induce labor, a process known to increase the likelihood of a cesarean section becoming necessary. Midwives are trained to assist women during childbirth process rather than to try to control it.
There is additional incentive amongst Native Americans to avoid cesarean sections. Many Native American couples wish to have more than 2 children and are educated about the dangers of repeat cesarean sections. Additionally, Native Americans believe that incisions are a threat to the spirit of the person being cut, so surgery is something to be avoided as much as possible.
2. Any and all family members are present and welcome.
In Tuba City as well as within any Navajo community, a laboring woman is never left alone. Not only will her partner be present, most likely her mother, grandmother, aunts, cousins and any other female relatives or family members. The laboring mother is constantly massaged and offered sips of water and small bits of food. With all of this support and her own prior exposure to labor and childbirth, the laboring mother has no fear whatsoever of her own labor and delivery.
3. Easier Adherence to ACOG VBAC Guidelines
The American College of Obstetricians and Gynecologists hs issued guidelines for VBAC’s. An obstetrician and anesthesiologist should be present or very quickly accessible while a woman who has had a previous cesarean section is laboring in the event that she requires and emergent cesarean section.
While many community hospitals have been unable to meet this criteria citing cost prohibition of maintaining professional staff on call at all times, hospitals on Indian reservations have had no such problem. The Tuba City Hospital is located within the property of the Navajo Indian reservation. Many of the physicians who work at the hospital either live on the reservation or within minutes of the hospital. Many doctors who are on call may actually go home while a midwife attends a birth because if they are needed, they can be at the bedside within minutes.
4. No Threat of Malpractice litigation
The Tuba City Hospital and its doctors are federally insured against malpractice because it is a federally funded facility. Hence the obstetricians are not as concerned about being sued if complications arise or about increases to or complete cancellation of their malpractice premiums.
5. No threat of wealth
The professionals that staff the hospitals in the Indian Health Services are paid flat salaries; $190,000 to $285,000 annually for the physicians and $80,000 to $120,000 for midwives. Since the staff is not paid per procedure, there is no incentive to do more and potentially unnecessary procedures.
“Conventional” Wisdom
In conventional western medicine, childbirth is a procedure to be managed and controlled. In most US hospitals, laboring women are not allowed to move freely because they are hooked up to fetal monitors. They labor in bed and primarily on their backs-the least comfortable position in which to labor.
A woman is not allowed to have anyone she pleases at her side and many times is alone during her labor process when the doctor or nurse needs to “check her progress.”While many women hire doulas, many US hospitals still try to and successfully block their presence in the labor and delivery rooms.
Many more interventions are involved; from intravenous fluid administration, to epidural anesthesia, to labor induction with oxytocin, an episiotomy (a surgical incison in the perineum to allow passage of the baby without tearing. Not usually needed but frequently done “just in case.”), to forceps and/or vacuum extraction of the baby to cesarean section. The natural process of labor and delivery is now seldom allowed to “play itself out.”
Why is there such a disparity between the two methods?
In this era of Health care reform and in the midst of this contentious debate, the Navajo nation is a blatant example of less being more. The United States spends more money than most industrialized nations for health care and yet we have some of the sickest, most obese citizens in the world. We also have some of the highest maternal and infant mortality rates in the industrialized world. We are in no way, shape or form getting what we are paying for.
If the United States truly wants to lower cesarean section rates to be more in line with WHO recommendations, if it wants to improve VBAC rates and if the US truly wants to improve maternal, fetal and infant mortality, we have to change how we do things.
- Births should be attended to by the most qualified attendants-midwives.
- In uncomplicated situations, labor and delivery should be allowed to progress naturally at their own times.
- Women should be allowed to move freely during labor and to have anyone they need present. Cultural and religious traditions should be respected.
- Treatments and interventions should be administered on a case by case basis and not as standards of care. Interventions should be kept to a minimum and not be performed as a defense against litigation.
- Monetary incentive should not be given to providers for more interventions, yet providers should be assured of adequate compensation for their skills.
Most physicians in our current health care system would balk at these recommendations because these would represent sweeping changes in the way they are trained, how they practice medicine and most especially in the way that they are paid. However we Americans, especially we women, have to ask ourselves how much longer are we going to put up with and pay into a system that clearly does not have our best health at its core?
It will be interesting to see what the NIH consensus comes up with. Quite frankly I am not all that encouraged that much is going to change, but the fact that there was even the discussion means that we are moving, ever so slowly, in a more positive direction.
Let’s Make Mother Friendly Childbirths available for Mamas on Bedrest
March 4th, 2010The Coalition for Improving Maternity Services (CIMS) is dedicated to improving the care provided to women and their families during the child birth process. They advocate a midwife model of care which accentuates freedom of movement while in labor, the ability to eat and drink freely while in labor, the freedom to choose where to deliver a baby (at home, in a birthing center or at a hospital) and who to have present at the birth (the partner as well as a doula or female labor support partner). While I am totally in favor of all that CIMS is doing, I am dismayed that little is being done to extend this same type of care to “mamas on bed rest” or high risk pregnant women.
I attended the Coalition for Improving Maternity Services (CIMS) annual forum for the first time this past weekend. I learned a lot about new research in pregnancy, labor and delivery and delivery of care for pregnant women and their families. But the one thing that kept nagging at me throughout the conference was that many of the findings and initiatives, including the Mother Friendly Childbirth Initiative (MFCI), are not available to “mamas on bed rest” or high risk pregnant women. While I wholeheartedly agree with the initiative, I kept wondering to myself, “What about mamas on bed rest?”
In my opinion, high risk pregnant women need mother friendly childbirths more than women having uncomplicated childbirths. When that red “High Risk” is stamped on a woman’s chart, she automatically loses the bulk of her power to choose the course of her pregnancy. She is told if she has to go on bed rest-there isn’t choice not to. She is told when she will deliver and where (often in a hospital operating room with a cesarean section). She will have medications and interventions-often without being told or asked if she wants to have them and all the while she will be told that if she wants to have a baby to bring home at all, this is how it has to be. Mother Friendly? Not in the least.
I don’t dispute that when a woman is having a high risk pregnancy that more medical intervention may be needed to sustain the pregnancy or to deliver the baby. What I am railing against is the powerlessness that high risk pregnant women have to succumb to in order to have a child. While many of us may already be humbled by infertility and conception difficulties, and threatened miscarriages and preterm labor, doesn’t it stand to reason that we need the support and comforting atmosphere of a mother friendly environment even more so? Can’t we apply even a few of the MFCI points to high risk pregnancy right now?
I know well how using even just a few of the MFCI points can make a huge difference. When I had my daughter, I went into preterm labor and all hell broke lose! I was admitted emergently by one of my OB’s partners because she was off. Since I was scheduled for a cesarean section I was admitted and prepped in a surgical anteroom. My husband was present at times, but for the epidural and other procedures, he was asked to leave and I was all alone to endure the clang of instruments being opened and laid out, bright lights directed at the OR table and draped and masked “blue people” I didn’t recognize telling me everything would be okay. It was unnerving to have my belly bared to a room full of strangers; some to care for me and some to “take” care of my baby .
Once the epidural was administered, I began vomiting profusely and little was done to stop it except adding things to the IV bag. When my husband came into the delivery room there was so much commotion he was completely overwhelmed. When my daughter was born I asked him what she looked like and he was completely undone by the “crater” they had created in me to get her out. My daughter was quickly whisked out for more “intensive” care due to breathing difficulties and was only paused briefly by my face. My husband went with the baby and once again I was on my own. I was alone in the recovery room, vomiting and in pain for 2 hours before being transferred to the post partum floor. A neonatologist briefly stopped by to tell me that my daughter was okay, they were checking her out and that I would see her shortly. She did not arrive while I was in recovery. We did roll by the nursery on my way to the floor. I still hadn’t held my baby and by now 4 hours had passed since her birth. On the floor I continued to vomit until 2 am when the anesthesiologist finally graced us with her presence and gave me something in the IV bag to stop the vomiting and put me to sleep. It was the next morning, 12 hours later, when I held my daughter for the first time before she was transferred to the neonatal intensive care unit.
The picture was completely different when I had my son 3 1/2 years later. First and foremost, he was nearly term, born at 39 weeks. I actually had him at a different hospital because I wanted to have my tubes tied and the first catholic hospital did not allow the procedure. The second hospital tried to make the surgical suites more friendly. It may seem strange, but a nice color and curtains at the windows does a lot to warm up a place. Every room was tastefully decorated with a place for a partner to sleep and a place for the baby’s bassinet. My OB delivered my son and I felt so much more comfortable with her attending the birth. My husband was so shell shocked from my daughter’s birth that we agreed he wouldn’t be present at my son’s birth. We flew my older sister in to be with me instead. She was by my side at all times and we were laughing so hard at one point, my OB had to ask us to stop giggling so she could stitch me up!
When my son was born, my doctor held him up so that I could see him. She did suction him (a midwife care no no) and then she laid him on my chest. He nursed with a vigor I didn’t know a newborn could muster! The nurses wiped him off and wrapped him up to go see my husband. That was the only time he was away from me. He and my sister rode with me to the recovery room where my husband, my parents, my sister and baby were all present. My son nursed at will and also rode with me to my room and stayed with me in my room until I was discharged.
One could argue that my second delivery was so much better because my son was a healthy term baby and my daughter was preterm and had breathing complications. I did not have lots of choices regarding my care or treatment for either birth. But even within those parameters, I believe that the “warmer” , friendlier environment, having my OB who tended me throughout my pregnancy deliver my child and having a friend/family advocate always at my side keeping my spirits high and making sure I had what I needed went a long way to making my second delivery much calmer, more memorable (in a positive way) and more “Mother Friendly” than the first. Small changes such as these and a few others would go a long way towards making “mother friendly” births for mamas on bed rest.
CIMS is Hard at Work for Mamas on Bedrest
February 25th, 2010
I’m so excited! The Coalition for Improving Maternity Services (CIMS) Annual Meeting and Forum will be held in Austin this weekend, February 26-27th and I’m going to be there! Some of the most prominent experts in mother and baby care will be presenting and relating data from their latest research. I know that I am going to learn a lot about how to better care for and serve mamas on bed rest. Of course I will be sharing all that I learn with you.
CIMS defines itself as,
“The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and well-being of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.”
What does CIMS do for Mamas On Bedrest?
“How does this pertain to me? I have a high risk pregnancy and all of those “natural” treatments and birthing options won’t work for me. There will be lots of medical intervention in my birth-there already has been!” CIMS is dedicated to ensuring that all mamas have as natural and as safe a pregnancy, labor and delivery as possible-whether they are considered “high risk” or an “uncomplicated” pregnancy.
Why is CIMS’ work so important?
Mostly because of the poor maternal and infant mortality rates in the United States. According to the March of Dimes 2003 data , infant mortality rates in the US are at approximately 6.8 deaths per 1000 births. This is a sobering number given that in the US, we have some of the most technological treatments available. Despite our technological advances and our ever rising medical costs, the United States lags far behind most industrialized nations and many developing nations in infant mortality. For all we do, many American infants still die well before their first birthdays. The statistics are worse or African American babies. Black babies die at a rate of 13.5/1000 according to the March of Dimes.
Maternal mortality is not much better. According to the US Department of Health and Human Services Health Resources and Services Administration, in 2006 13.3 maternal deaths occurred for every 100,00o births. This may not seem like a lot, but in 1n 1987, that number was 6.6 per 100,000. We’re going backwards, not forwards. What is most alarming to me, an African American woman, is that the vast majority of deaths occur in African American women and babies. African American mothers are 3 times more likely to die from complications of pregnancy or childbirth than their white counterparts.
Part of the problem is that for all of our technology and advanced treatments, they are not readily available to everyone. Women from lower socioeconomic groups, women without insurance and women whose insurance dictates caregivers or place of birth are at the mercy of whatever care their providers choose to give them.
And in many cases, that means cesarean section. The United States has one of the highest rates of cesarean section delivery in the world. Nearly a full 34% of babies born in the United States are born via cesarean section. While cesarean section is a necessary procedure in certain cases, often in the United States cesarean sections are elected based on convenience or to avoid the potential for a poor outcome and subsequent litigation. The World Health Organization (WHO) clearly states,
“Countries with some of the lowest perinatal mortality rates in the world have cesarean rates of less than 10%. There is no justification for any region to have a rate higher than 10-15%” (From the International Cesarean Awareness Website, www.ican-online.org)
CIMS is working with ICAN and other organizations to push tougher regulations on cesarean sections so that mamas and babies won’t be put at unnecessary risk.
CIMS is also at the forefront when it comes to education, especially regarding breast feeding. It has long been established that breastfeeding is the best way to nourish an infant and has been endorsed by the WHO and the American Academy of Pediatrics. Yet a small percentage of American women and their babies have established breastfeeding by 6 weeks. CIMS’ members work diligently to provide breastfeeding education resources to underserved areas and to assist mamas who want to breast feed to do so.
CIMS is working to change the way American clinicians provide prenatal care to pregnant women. They advocate for the midwifery model of care which sees a woman as the primary driver of her health care and as an active participant in all decisions regarding her prenatal care.
The Mother Friendly Childbirth Initiative (MFCI)
With all of these interests, CIMS has issued The Mother Friendly Childbirth Initiative (MFCI). MFCI clearly states the position of CIMS on maternal, child and family birth and health care and what they are doing to change our current maternal health care system. The entire consensus statement can be read here.
CIMS is not a bunch of loud mouths hippies calling for everyone to have home births, and unfortunately, that is how some of their opponents try to portray them. On the contrary, CIMS is an organization whose members and advocates research pregnancy and child birth while adhering to the most stringent medical research methods currently required. Any treatment or procedure that they advocate is endorsed because there is clearly defined evidence that the treatment is effective and beneficial and works with minimal or no inhibition to the natural course of pregnancy, labor and delivery. As we all know there are a number of treatments and procedures performed today during the course of “normal” prenatal care, pregnancy, labor and delivery that while they “get the job done,” they are often detrimental to mama and baby either physically and/or emotionally. CIMS raises awareness about such procedures while at the same time advocating for alternatives that are more supportive, nurturing, and equally beneficial and effective for mama and baby.
CIMS is an advocate for safe, natural pregnancies and births. No, they are not going to reem you for being high risk and needing intervention such as bed rest. But they are going to advocate that you be offered all possible options for your situation, that you get the support that you need while you are on bed rest regardless of your economic or insurance situation, that you be allowed to at least try vaginal birth in the absence of an evidence based contraindication, that you be close to your baby as soon as possible after delivery and that you have all the education, assistance and support that you need to skillfully breastfeed your newborn.
I’ve said it before and I’ll say it again. Being on prescribed bed rest with a high risk pregnancy does not mean that you, a mama on bed rest, lose all rights to decide your course of care. Nor should it prevent you from receiving the best care for you and your baby; care that supports you, nurtures you and results in both of you. CIMS may advocate for vaginal births and a midwifery model of care, but at its heart, CIMS seeks to defend and advocate for the health and well being of mothers and babies.
