The Business of Being Born Message Board

Dear Ricki Lake and Abby Epstein,

Thank you so much for what you are doing! You are changing thousands of
women’s lives (babies too). The Business of Being Born is absolutely the
best birth film I have ever seen. I am on a number of VBAC support groups
on-line and I see messages daily from pregnant women with prior cesareans
who are being denied care, who are being forced into a repeat c-section
against their will, who are frightened and unable to find help anywhere. I
am deeply troubled by not just the culture of birth in hospitals, but by
the blatant violation of a woman’s right to go into labor and make medical
decisions for herself. A woman should have the right to go into labor and
enter a hospital for care without the fear of a court ordered c-section.

Below is my initial letter to ACOG about the lack of availability of VBAC
services, ACOG’s response (with grossly inaccurate information), and my
response to their response, cc’ed to you. You have my permission to post
this if you think appropriate (minus my contact info) – I think ACOG needs
to hear from many, many concerned citizens.

Thank you again,

Amber

My response to ACOG:

Office of the Executive Vice President
Ralph W. Hale, MD, FACOG

rhale@acog.org
American College of Obstetricians and Gynecologists
PO Box 96920
Washington, DC 20090

July 28, 2008

Dear Dr. Hale,

First, thank you for taking the time to respond to my concerns about lack of
obstetrician support for VBACs. I am glad to hear that ACOG is an advocate
for VBACs. I truly hope that after reviewing accurate VBAC benefits and
risks, and taking into account the needs of birthing women in America, you
and fellow ACOG administrators will do everything possible to reverse the
restrictive VBAC guidelines, encourage VBACs again, work with insurance
agencies to enable VBAC support, and condemn any hospital attempting to
“ban” VBACs (and consequently force women into surgical birth against their
will).

I am disappointed and a little surprised by the inaccurate risks that you
listed in your letter – I shared your letter with ICAN officials and a few
other birth advocacy groups to help gather data on the risks of VBACs.
Neither I, nor anyone from these birth advocacy groups, was able to find
recent studies or statistics confirming some of the information you
provided. In your letter you state that uterine rupture occurs in about 2%
of VBACs. For lower transverse cesarean sections, all of the research we
were able to find points to a general risk of less than 1% for VBAC women,
and much lower when induction agents were not used. ACOG’s 2004 practice
bulletin lists rupture risk as less than 1%.[i] Here are a couple of the
recent studies on VBACs and their uterine rupture rates:

Landon, et al (2006) - .7% for single prior cesarean, .9% for multiple prior
cesareans[ii]

Lydon-Rochelle (2001) – .52% (spontaneous labor) .77% (induced without
prostaglandins)[iii]

Regarding your statement that in cases of uterine rupture, “death of the
baby is almost certain and death of the mother is probable,” I was unable to
find any study confirming this. In a 2004 Landon study, of the 124 uterine
ruptures, there were 2 fetal deaths.[iv] In the Lydon-Rochelle study, there
were 5 fetal deaths out of 91 ruptures. Obviously any fetal death is a
tragedy, but fetal death from uterine rupture is rare, not “almost certain,”
and fetal death can be a consequence of repeat cesareans as well.

Another surprising statement in your letter about maternal risk is
“virtually 100% will lose their childbearing ability” if they don’t die. In
the Lydon-Rochelle study, 4 women needed hysterectomies out of 91 ruptures,
again the overall risk is low, not “virtually 100%.” The 2004 Landon study
also concluded that the risk of hysterectomy and maternal death was about
the same for both the trial of labor group and the elective repeat cesarean
group.

I am troubled that information on VBAC risks is not combined with
information on repeat cesarean risks. Only providing information on VBAC
risks does not allow prior cesarean women to weigh the risks and benefits of
each birth option. The Nisenblat study on multiple cesareans found a
hysterectomy rate of 1.1%, and an overall “major complication” rate of 4.3%
for second cesareans and 8.7% for a third or higher number of cesareans.[v]

One of the most troubling things for me personally about ACOG’s current
guidelines is the statement that women with two prior cesareans are not
candidates for a trial of labor. All women have the right to attempt labor.
As listed above, the medical literature shows that VBACs after multiple
c-sections are a safe option. I had a fabulous, completely uncomplicated
VBAC (homebirth) after two prior cesareans.

The restrictive ACOG VBAC guidelines are not based on the most recent
evidence, and they have not made VBAC women safer. I am on a number VBAC
support groups on-line. As I stated in my last letter, there are thousands
of VBAC women in America being refused care by obstetricians. Some of these
women have the option of planning a safe, midwife attended homebirth. Many
obstetricians and midwives who are supportive of VBACs cannot provide care
because of restrictive insurance, hospital and/or licensing policies –
policies influenced by ACOG guidelines – these policies must change.
Unfortunately, I know of a number of women in America who stay at home to
birth unattended because they were/are unable to find any doctor or midwife
to provide care if they VBAC, and they cannot go into a hospital to birth
because VBACs are banned at their local hospital(s). Many other women are
attempting to labor at home until crowning and only showing up at the
hospital after they are sure they can’t be forced into a c-section against
their will. There have even been some frightening cases of hospitals and
obstetricians seeking court ordered c-sections on women who have refused
them.

If a hospital is not safe for a VBAC labor, a hospital is not safe for ANY
laboring woman, as any birth can experience an urgent complication requiring
a cesarean section, such as placental abruption or cord prolapse. ACOG
guidelines must change to ensure that all VBAC women can enter a hospital to
labor and birth without fear of facing a forced c-section.

I am aware that part of the reason many hospitals have banned VBACs and
doctors refuse care is because of liability concerns. Insurance policies
and hospital liability policies are often modeled after medical organization
guidelines. ACOG needs to proactively make insurance carriers, hospitals,
and pregnant women aware of risks and benefits of both repeat cesareans and
VBACs. If ACOG’s restrictive guidelines are eased to recognize benefits and
encourage more VBACs, then insurance policies will follow suit.

The cesarean epidemic is out of control in America. One way to help reduce
unnecessary c-sections is to make VBACs more common and supported again.

To summarize, I implore ACOG to ensure that the rights of women to attempt
labor and make their own medical decisions are protected by:

1. Condemning any hospital providing maternity services that “bans” a
vaginal birth and requires a woman to undergo surgical birth against her
will

2. Denouncing the practice of court ordered cesarean sections for women
who have refused

3. Condemning any obstetrician that denies care for a pregnant woman
who refuses a surgical birth

4. Revising the current restrictive guidelines to allow hospitals more
leeway with management of VBACs (eliminating requirements such as
“immediate” anesthesia, etc…)

5. Revising the current guidelines to recognize that a trial of labor
after multiple cesareans is a safe option

6. Preparing a comprehensive statement about the risks of repeat
cesareans along with guidelines on VBACs.

Sincerely,

Amber

Cc: Douglas Kirkpatrick, MD, ACOG President

ICAN

Birth Action Coalition

The Business of Being Born network

_____

[i] American College of Obstetricians and Gynecologists, Vaginal Birth after
Previous Cesarean Delivery, ACOG Practice Bulletin, no. 54 (July 2004).

[ii] M.B. Landon, et al., “Risk of Uterine Rupture with a Trial of Labor in
Women with Multiple and Single Prior Cesarean Delivery.” Obstetrics and
Gynecology 108, (2006):12-20.

[iii] M. Lydon-Rochelle, V. L. Holt, T. R. Easterling, and D. P. Martin,
“Risk of Uterine Rupture during Labor among Women with a Prior Cesarean
Delivery,” New England Journal of Medicine 345, no. 1 (5 July 2001): 3-8.

[iv] M.B. Landon, et al., “Maternal and Perinatal Outcomes Associated with a
Trial of Labor after Prior Cesarean Delivery,” New England Journal of
Medicine 351, no. 25 (16 December 2004): 2581-2589.

[v] Nisenblat V, Barak S, Griness OB, Degani S, Ohel G, Gonen, R. Maternal
complications associated with multiple cesarean deliveries. Obstet Gynecol
2006; 108: 21-26.

ACOG’s letter to me:

Office of the Executive Vice President
Ralph W. Hale, MD, FACOG
rhale@acog.org
American College of Obstetricians and Gynecologists
409 12th Street SW
Washington, DC 20024

July 14, 2008

Dear Ms. Craig:

Your letter of June 23, 2008, to our President, Dr. Douglas Kirkpatrick, was
referred to me for response.

Although I understand your concern about support for emergencies that occur
during labor, patient safety is and should always be our number one concern.
VBAC is potentially an extremely dangerous procedure for both mother and
infant. Although 98% of women can potentially have a successful VBAC, in
two percent of cases the result can be a rupture of the old scar. If this
happens, then death of the baby is almost certain and death of the mother is
probable. Even if the mother does not die, virtually 100% will lose their
child bearing ability. To prevent these disasters, the ability to perform
immediate surgery is critical.

ACOG is an advocate for VBAC. We believe it is an acceptable alternative to
repeat cesarean in a woman with a non-recurring problem. The issue that you
identify with hospitals is based on the hospital’s fear of litigation if a
patient or her baby has a uterine rupture. Another problem is the hospital
insurance carrier. Some of them are not willing to cover VBAC, even if
coverage is available.

We have had our Committee on Obstetric Practice review our guidelines. They
have had input from many sources and carefully reviewed the incidence and
severity of complications. Based on this review, the Committee and our
Executive Board have decided to keep the current statement as they are
written.

Thank you for contacting us.

Sincerely,

Ralph W. Hale, MD, FACOG
Executive Vice President

Cc: Terrie Gibson

My initial letter to them…………………….

Douglas H. Kirkpatrick, MD, President

The American College of Obstetricians and Gynecologists
PO Box 96920
Washington, DC 20090-2188

June 23, 2008

Dear Dr. Douglas H. Kirkpatrick:

In the summer of 2007, I chose to have a VBAC homebirth after two prior
cesareans. It was a fabulous, completely uncomplicated, and easy homebirth
VBA2C. If I had followed standard protocol and ACOG guidelines, I would
have had a third major surgical birth, and all the significant risks that
come along with major surgery instead of the quick and easy recovery I
experienced. My wonderful VBA2C has heightened by concern regarding current
ACOG policies that I believe are harming women and stripping women of a
basic reproductive right – the right to attempt a vaginal delivery.

I ultimately chose a homebirth because I was scared of laboring and
attempting delivery in a hospital given the current completely unsupportive
climate among OBs for vaginal birth after cesarean, especially multiple
cesareans. The truth of the matter is that the written policy at my local
hospital, at least at my time of delivery (July 2007), clearly stated that I
“was not a candidate for a trial of labor” simply because I had two
cesareans. Plus, that is the official policy of ACOG. I didn’t know who I
would face in labor, or what pressure I would receive to be forced into an
unnecessary cesarean if I actually came into a hospital. So I chose to stay
home to have my baby. I am not alone. I am on a number of VBAC e-mail lists
and discussion groups, and there are thousands of women in America choosing
a VBAC homebirth because ACOG policies make VBAC hospital births extremely
difficult or impossible.

I am writing to ask for your assistance in getting ACOG to reverse their
draconian VBAC policies that have NOT improved the outcomes of mothers or
babies[i], but:

1. Led to an alarming increase in unnecessary cesareans by virtually
eliminating VBACs (latest VBAC figure is an astonishingly low 9.2%)[ii]

2. Led to over 300+ hospitals in America “banning” VBACs[iii]

3. Led to malpractice insurance carriers not covering doctors who
perform VBACs – this has caused a particularly dire situation in Oklahoma
where the vast majority of doctors in the entire state have stopped taking
VBACs

4. Maternal death is on the rise in America for the first time since
1977 – the increase in cesareans are one possible cause[iv] [v]

5. More women being forced, against their will, into major surgery, and
consequently, being forced to accept the risks of major surgery whether they
want to or not

6. VBAC homebirths have dramatically increased – thousands of women are
being forced to birth at home, unattended, because no obstetrician is
willing to attend their VBAC births

Based on the comments I read on the numerous VBAC discussion lists, there is
a general feeling among many women desiring VBACs that the current ACOG
policies have nothing to do with protecting the best interest of women, but
rather, are based on protecting the best interests (time and money) of
ACOG’s doctors. A growing number of women believe the ACOG policies are
intended to make birth more convenient for OBs, as scheduled cesareans are
usually less time and occur during weekday business hours, and also generate
far more money than a vaginal birth. I certainly don’t believe this is the
case for most OBs, but again, the current policies of ACOG do not seem to
reflect the medical literature available showing that VBACs are safe, even
after multiple c-sections, and that increasing number of c-sections carrying
alarmingly higher risks for women. The Landon study (2006) showed a uterine
rupture rate of .7% for single prior cesarean women and .9% for multiple
prior cesarean women, statistically insignificant.[vi] The Nisenblat study
(2006) showed that women undergoing a third or higher cesarean faced an 8.7%
risk of a “major complication.”[vii] A number of studies also show that
many ruptures are linked to induction[viii], and that uterine rupture rates
in women who go into spontaneous labor are only about .4% - an extremely
small risk.[ix]

When I was pregnant with my third child, I was sure that given the new
research, ACOG would be issuing a new VBAC policy statement easing their
restrictive guidelines, and even encouraging VBACs in otherwise low-risk
women, even those with multiply prior cesareans. My VBA2C baby is almost a
year old, and this still hasn’t happened.

There are two very ironic things about the current ACOG policies that
restrict VBACs for women –

1. ACOG seems to support a woman’s right to “choose” when it comes to
elective cesareans, yet it does not support a woman’s right to “choose”
vaginal birth, and

2. Uterine ruptures, albeit very rare when induction agents are not used,
can usually be medically managed in a hospital setting, yet the restrictive
policies are forcing thousands of women to birth at home, without access to
immediate care in the very rare event of an emergency.

Ultimately, ACOGs policies are not helping women. I believe they are
reducing patient access to care, stripping women of a basic reproductive
right, and they are making women less safe.

It is my sincerest hope that you will work to reverse the restrictive VBAC
policies, bringing true birth choices back to prior cesarean section women,
and ultimately improving the health and well being of women seeking VBACs.

Please consider sharing my letter and story with any ACOG officers and
fellows you feel might be willing to help improve the situation for VBAC and
VBAmC women in America.

Sincerely,

Amber Craig

ambercraig@nc.rr.com

_____

[i] J. Zweifler, et al., “Vaginal Birth after Cesarean in California: Before
and After a Change in Guidelines,” Annals of Family Medicine 4, no. 3
(2006): 228-234.

[ii] Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2005.
National Vital Statistics Reports 55, no. 11. December 28, 2006.Available
at:
ril%2021>
ril%2021> www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_11.pdf. Retrieved April
21, 2008.

[iii] International Cesarean Awareness Network. Hospital VBAC Bans Push
Record-High Cesarean Rates Bans Force Women into Unnecessary Surgery.
November 23, 2004. Available at:

http://www.vbac.com/pdfs/ICANrecordhughcesareanrates.pdf. Retrieved April
21, 2008.

[iv] Miniño AM, Heron MP, Murphy SL, Kochankek, KD. Deaths: Final Data for
2004. National vital statistics reports; vol 55 no 19. Hyattsville, MD:
National Center for Health Statistics. 2007. Available at:
%2021> http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_19.pdf. Retrieved
April 21, 2007.

[v] Ogburn Jr. P. Deadly Deliveries. New York Times. October 14, 2007.
Available at:

http://www.nytimes.com/2007/10/14/opinion/nyregionopinions/14CIogburn.html.
Retrieved April, 21, 2007.

[vi] Landon MB, Spong CY, Thom E, Haut JC, Bloom SL, Varne MW, Moawad AH,
Steve N. Caritis SN, et al. Risk of uterine rupture with a trial of labor in
women with multiple and single prior cesarean delivery. Obstet Gynecol 2006;
108:12-20.

[vii] Nisenblat V, Barak S, Griness OB, Degani S, Ohel G, Gonen, R. Maternal
complications associated with multiple cesarean deliveries. Obstet Gynecol
2006; 108: 21-26.

[viii] D. J. Ravasia, S.L. Wood, and J.K. Pollard, “Uterine Rupture during
Induced Trial of Labor among Women with Previous Cesarean Delivery,”
American Journal of Obstetrics and Gynecology 183, no. 5 (2000): 1176-1179.

[ix] G. C. S. Smith, et al., ”
Outcomes Associated
with a Trial of Labor after Prior Cesarean Delivery,”
New England Journal of Medicine 352, (21 April 2005):1718-1720.