Childbirth After Cesarean: Lakeshore Women Have Options

From module 12 of the VBAC Education Project (VEP).

From module 12 of the VBAC Education Project (VEP).

Women in Muskegon and elsewhere along the West Michigan lakeshore have several options for childbirth after cesarean. What are some of these options?

Repeat Cesarean

The majority of women in Muskegon County who have a prior cesarean have a repeat cesarean section (RCS). This may be because they decide this is the safest option for them based on their medical history, while others prefer the certainty and convenience of scheduling their birth. Other times, women don’t realize that they have other options or don’t have the support to access them.

Vaginal Birth After Cesarean (VBAC)

I’ve heard Muskegon birthing people being prepped for surgery be told that they can deliver vaginally in the future, but that they would have to go to a Grand Rapids hospital. That’s only part of the story. While currently, all three of the hospitals in Grand Rapids, Spectrum Health Butterworth, Metro and Mercy Health St. Mary’s, offer VBAC, distance makes this option a challenge for many people. Holland Hospital also offers VBAC as an option.  Others are intimidated by the prospect of receiving prenatal care and delivering with a large practice and facility, which feels impersonal compared to the care they are accustomed to in their community. Despite the challenges, some Muskegon people will travel out-of-county for their VBAC.

Another option that appeals to some families is to deliver in a community hospital that has a VBAC ban, or policies that discourage VBAC, but is known to have supportive providers. Dr. Michele and her colleagues at Spectrum Health Gerber Memorial have an excellent reputation for supporting those who choose to have a VBAC. Others receive their prenatal care locally, put off scheduling a RCS or do not show to appointments, with the plan to show up in labor at their local hospital. Local community hospitals include Mercy Health Hackley in Muskegon and North Ottawa Community Hospital (NOCH) in Grand Haven. I have heard of people having VBACs at Hackley, despite the ban, but not at NOCH.

Free-standing birth centers are an option for women who want to deliver with a midwife in a home-like atmosphere outside of, but close to, a hospital. There is some evidence that choosing midwifery care through a free-standing birth center increases VBAC success rates. Simply Born Birth House is the only free-standing birth center in West Michigan. Sara Badger, a Certified Professional Midwife (CPM) is the provider there. Birth centers have criteria they use to screen women to see if they are good candidates for this type of care. If this is something you are considering, I recommend scheduling a consultation before pregnancy to learn more.

The final option is to plan a home birth after cesarean, or HBAC. In the event of a rare complication, like a uterine rupture, this may not be the safest option, but some people are willing to take the risk to birth on their terms, in the privacy of their own home, with a provider who believes in their body’s ability to birth. As with birth centers, home birth midwives have criteria for screening clients who are candidates for HBAC. You may have to interview several in order to find the right one for you.

As with any birth, there are many decisions to be made. Since providers vary a great deal in their support of VBAC, it isn’t a bad idea to do some research prior to your next pregnancy. A provider may also have good advice to increase your chance of having a successful VBAC, like the amount of time to wait between pregnancies and how to optimize your health.

While those in Muskegon and along the lakeshore may not have all of the options available to birthing people in large, metropolitan areas, they do have possibilities. Knowing what those are is the first step to choosing the course of care best for you and your family.

Top 5 Predictions for Childbirth in 2016

These are my predictions for childbirth in 2016.  What do you think? Please include your thoughts and your own predictions in the comments!

5.)           WHO changes their position on episiotomies

“Perhaps it is time to move beyond the question ‘What are the appropriate indications for episiotomy?’ to the more fundamental question ‘Is there an appropriate indication for episiotomy?’

— From D. Lyon, Global Library of Women’s Medicine

In 1996, the World Health Organization published “Care in Normal Birth: A Practical Guide,” recommending an episiotomy rate of 10%.  Since that time, episiotomy rates in most countries have declined.  The practice of selective episiotomies has continued despite the fact that there has never been a randomized controlled trial showing that they have any benefit whatsoever.

This has become a point of contention between some birthing women and their providers.  In fact, in 2015, an obstetrician in the United States surrendered his license after being caught on video performing a forced episiotomy on a patient.

In 2014, a study was undertaken in Brazil called, Comparison of Never Performing an Episiotomy to Performing it in a Selective Manner, or EPISIO.  Although the study is complete, the results are not yet published.  The researchers collected data on newborn, as well as maternal outcomes.  If this research shows that, even in cases of macrosomia and fetal distress, episiotomy holds no benefit, the World Health Organization may take a stand that even 10% is too high, with global implications.

4.)           ARRIVE study results increase elective inductions

In June of 2015, the Over the Moon Doula Group in Grand Rapids, Michigan, hosted Rebecca Dekker of Evidence Based Birth as a part of their Seminar Series.  The topic was due dates.

Dekker’s lecture introduced me to the A Randomized Trial of Induction Versus Expectant Management (ARRIVE) study, in which women would be randomly assigned to either induction at 39 weeks or expectant management.  Although some of the sites are still recruiting subjects, the data should be in by the summer of 2016 and results may become public by the year’s end.

Other than furthering the schism between the medical and natural childbirth camps, news that elective induction at 39 weeks prevents adverse outcomes could place a strain on hospitals.  As Dekker pointed out, if hospital maternity wards are full with women being induced, will there be enough room left for women who arrive already in labor?

3.)           US cesarean rates continue to decline

The cesarean rate for birth in the United States hit an all-time high in 2009, but has declined for most racial and ethnic groups since. This has not been an accident, but due to a concerted effort by consumers, researchers, hospitals and providers.

For example in 2014, the American Congress of Obstetricians and Gynecologists (ACOG) changed the definition of active labor from 4 to 6 cm, cause more women who present in early, or latent labor, to be sent home.

The coming year may also see changes in hospital policies on Vaginal Birth After Cesarean (VBAC), which holds the potential to further decrease the cesarean rate.  Many women choose to have their VBAC at home, not because that is their first choice, but because no other options are available. A study published in the Dec. 2015 issue of Birth showed that, although Home Births After Cesarean (HBAC) have high success rates, when a uterine rupture does occur, perinatal death is more likely.  As local work on perinatal regionalization, a system of designating where infants are born or are transferred based on the amount of care that they need at birth, continues, more community hospitals may reverse their VBAC bans.  This will make VBACs more accessible and safer for women who prefer a hospital birth closer to home.

2.)           Out-of-hospital birth rates continue to rise

While out-of-hospital births represent a small percentage of all birth in the United States, they have been on the rise since 2004. When it comes to home births in one West Michigan county, Kent, home births have increased 116% in the last 8 years!

According to the American Association of Birth Centers, the number of freestanding birth centers in the United States also continues to rise, from 170 in 2004 to 248 in 2013. There are currently two freestanding birth centers in West Michigan, Cedar Tree Birthing Suite in Grand Rapids and Midwifery Matters in Greenville.  As more birth centers continue to open, the number of women choosing this option will also grow.

1.)           More states will pass laws providing insurance reimbursement for doulas

All the research points to the potential healthcare savings if doulas become more widely available, due to the lower rates of cesareans, pitocin induction, medical pain relief and more.  At the present, only two states, Minnesota and Oregon, require Medicaid to cover the cost of a birth doula.

All that could change now if three national organizations, Choices in Childbirth, the National Partnership for Women and Families and Childbirth Connection, have anything to do with it!  Key Recommendation in an executive summary released in early 2016, include having congress mandate Medicaid coverage for doulas and state legislatures mandating private insurance coverage for doulas.  If policy makers take their advice, 2016 may turn out to be “The Year of the Doula”!