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