Sunday, March 7, 2010

Action Alert: VBAC Ban in FL Birth Centers

On Wednesday, March 24th, the State of Florida's Agency for Health Care Administration will move to permanently ban Vaginal Birth after Cesarean (VBAC) in Florida birth centers. Currently, women who choose to give birth normally after surgery must do so in a hospital that will allow it, which encompasses only half of those in the state, or at home with a Licensed Midwife and physician consult sign-off. VBAC's are currently not permitted in birth centers, but only because of a 'de facto ban' due to outdated language in the regulations. After a request that the language be updated to include legalized VBAC's at birth centers with Licensed Midwives and physician consultation, the State used the opening to move to make VBAC's illegal in state licensed birth facilities.

This is a dangerous proposition. The State has evidenced already this year its assumed position as medical surrogate, in the January case of a Tallahassee woman who was confined to a hospital bed and subsequently court-ordered to have a c-section. This sort of treatment completely negates a patient's right to informed consent. Further, if the State feels women should have VBAC's in hospitals, then by the same medical surrogate token, they should mandate that AHCA hospitals allow women adequate trial of labor and welcome VBAC's. If fewer than half of Florida hospitals 'allow' VBAC, and fewer than 1% of obstetricians 'allow' VBAC candidates as patients, and Florida women are limited in their choice of birth place and care provider...well, you do the math. Our primary c-section rates aren't getting any lower (Florida's average is around 37%). The best way to begin to chip away at these epidemic and very dangerous numbers is to increase the VBAC percentages. Women who attempt to VBAC are successful over 75% of the time without necessity for intervention, yet at Sarasota Memorial Hospital, for example, only 1 to 3 women have successful VBAC's each month. Why? Because they cannot find supportive care providers. Many providers, pressured by insurance and medical malpractice concerns, scare (for lack of a better word) women into believing they are making an unsafe choice (read this thorough comparison to learn for yourself). While it is true that a uterine rupture (the primary concern of providers hesitant to accept VBAC patients) can be a devastating obstetric event, it occurs in fewer than 1% of VBAC candidates, and is responded to by emergency c-section--a procedure our hospitals are fully equipped to execute effectively. For those undergoing repeat c-sections, rates of serious placental complications, infections and NICU admission for the babies of those sections are rising rapidly. Women should and are legally obligated to receive balanced information that includes the risks and benefits of VBAC as well as the risks and benefits of repeat surgery. Allowing the pursuit of VBAC at home or at a state licensed birth center with a Florida Licensed Midwife will keep healthy, safe options open for Florida's families, and will dramatically reduce taxpayers' investment in unnecessary surgery.

There is virtually no difference in medical equipment between a birth center and the gear of a homebirth midwife. If the state considers VBAC with a Licensed Midwife at home safe, it is literally contradictory to ban VBAC's in birth centers. Many women would feel more comfortable in a birth center than in their homes, for a variety of reasons, and should be offered this opportunity. Physician consultations for VBAC's take into account several factors regarding the woman's previous surgery(s) and current health risk factors. Once again, we should be striving toward a collaborative model, one in which normal, healthy woman can choose the safe, cost-effective, nurturing care of midwives, and be reassured that obstetricians are available to provide their expertise and intervention if necessary--and only if necessary.

For these reasons, I urge you to sign the following petition and make your voices heard in support of legalizing VBAC's in Florida's licensed birth centers:

To: Florida Agency Health Care Administration

While we recognize the need to change outdated language in the rule, it is our position that the state consider similar language to that of F.S. 467. Such language would work to insure the patient received competent care from a licensed practitioner and respects the right of the patient to make an informed decision. We ask the State of Florida to remain a regulatory body and not take on the role of medical surrogate.

This is a very timely discussion, as tomorrow begins the first conference from the National Institutes of Health on VBAC issues. The conference will address the following key questions:

--What are the rates and patterns of utilization of trial of labor after prior cesarean, vaginal birth after cesarean, and repeat cesarean delivery in the United States?
--Among women who attempt a trial of labor after prior cesarean, what is the vaginal delivery rate and the factors that influence it?
--What are the short- and long-term benefits and harms to the mother of attempting trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
--What are the short- and long-term benefits and harms to the baby of maternal attempt at trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
--What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean?
--What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?

I am hopeful that the findings of this conference will further support the safety, cost-effectiveness and good common sense of allowing women to make their own informed decisions about VBAC, and will encourage the practitioners in attendance to do everything possible to combat the primary c-section rate. We wouldn't be holding conferences or discussing legislation regarding VBAC policies if the primary c-section rate were at an appropriate, healthy level.

1 comment:

  1. Yes, the de facto ban allows for VBACs at homebirths, and only allows VBACs at birth centers if they are involved in a certain research study. The center I was at was involved in the study, (and the outcomes were favorable, as far as I know) and continued to allow VBACs, with a physician consult that included the op report from the prior cesarean (or any other uterine scar). Until they were told they couldn't anymore.

    Now I think they try to arrange homebirths for VBACs. It doesn't make sense to me. It seems that most women at that practice preferred a birth center birth (I know this doesn't reflect national numbers, but that may reflect the availability of homebirths vs. birth center births).

    I think the availability of cesarean is the same at a birth center and at a homebirth. In most cases, it is the same as it would be at a hospital. I have been involved in numerous transfers from birth center to hospital, including one involving a VBAC patient. It's not the lack of being in a hospital that is the limiting factor. Just like the response to an in hospital complication of labor, the limiting factor is usually how far away and how busy the physician is, and they are rarely in house.