A year ago, I wrote a blog about how hospital bans against vaginal birth after cesarean (VBAC) limit options for Muskegon families. I used birth data from the Michigan Department of Health and Human Services to compare percentages of people with low-risk pregnancies who have a cesarean after a prior cesarean in Muskegon and surrounding counties. Not surprisingly, VBACs are more common where hospitals support them.
The data available that I used was from 2008 to 2014. Since then, 2015 data has been released. I wanted to update this information to see if there were any changes, explore what might be impacting this change and predict how this situation might change in coming years based on current developments in healthcare policy and services.
Statewide, there has been improvement. In 2015, a total of 2,006 people had VBACs, compared to 1,882 in 2014, an increase of 124. When we look at West Michigan counties, however, only Muskegon County and District Health Department #10, which includes Oceana, Newaygo and eight other counties, saw an increase. Kent county births included 40 fewer VBACs and Ottawa county had 3 fewer than the year before.
There are a few issues with this data and that make it difficult to draw conclusions from. First, the two-to-three-year lag time from when the year ends until the data becomes available makes it less useful. We can reflect on what may have happened two years ago to impact these changes, but it is less relevant than being able to access real-time data. Secondly, the online database only provides this particular piece of information by county. In a large county, like Kent, it would be interesting to see how being in an urban, suburban or rural area or proximity to a specific hospital may impact access.
When applying this information to our doula practice, we see clients make a lot of different choices when it comes to choosing a provider and location for their planned VBAC. While some Muskegon area families are happy to travel to Spectrum Health Butterworth in Grand Rapids to deliver, others prefer the intimacy of the small practice at Gerber Memorial Women’s Health, also under Spectrum, in Fremont. Still others have decided to stay in Muskegon and show up in labor at Mercy Health Hackley, while home birth after cesarean (HBAC) is a clear choice for others.
Things may change in 2018. Dr. Tami Michele, who has practiced at Spectrum Health Gerber Memorial for many years, is switching over to Spectrum Health Medical Group Ob/Gyn, with locations on 68th St. and on Mid Towne in Grand Rapids. Some say the move is to help increase the access to VBACs at Butterworth, which serves more patients. Dr. Michele is former doula, whose advocacy for those who wish to plan a VBAC has earned her a national reputation. What is less known at this time is how her moving from a small, rural hospital to a large metropolitan one will impact access to VBACs for those outside of Grand Rapids. Some will surely follow her, while others may feel that they lost a resource.
Another recent change on the national landscape was the publication of the American Congress of Obstetricians and Gynecologists updated guidelines on VBAC, which appeared in the November issue of Obstetrics and Gynecology. According to Mark Turrentine, MD, chair of ACOG’s Committee on Practice Bulletins-Obstetrics, the guidelines are meant to ensure delivery at the safest facility, “However, this absolutely should not result in women having limited access to VBAC.”
According to Jen Kamel, founder of VBACFacts.com, the guidelines are an improvement over those released in 2010. She quotes the new guidelines, “Available data confirm that TOLAC [trial of labor after cesarean] may be safely attempted in both university and community hospitals and in facilities with or without residency programs.” She interprets this to mean that if a hospital can handle deliveries, they should offer VBAC, because an emergency cesarean may be required in any birth, even a low-risk one.
How local staff changes and changes in the ACOG guidelines will impact local access remains to be seen. Will more people be able to access VBACs at Butterworth, or will support at Gerber decline? Will the 2017 ACOG guidelines result in a reversal of bans at Mercy Health Hackley, North Ottawa Community Hospital and Spectrum Health Gerber Memorial, or will the liability concerns prevail? Time will tell, but we won’t be able to see the data until 2020!
In the meantime, we will continue to support families in all their choices, whether they choose a repeat cesarean, a VBAC at a hospital or birth center of their choice, or at home.
“Although this moment is bittersweet, it’s one of my favorite photos and I’m glad it was captured. Just before I was taken into surgery, after 24 hours of hard labor at home. My #doula, Faith, never left my side.”
— Ottawa County client, after a homebirth transfer to hospital
“[Faith] provided me with many resources, and I also really appreciated the teas she made me. Her evidence based approach was very unbiased and nonjudgmental. I felt like I could be honest about my needs with her… She really proved herself when the birthday came. She was my knight in shining armor! She made me feel so confident and comforted through my labor. Her knowledge of a birthing woman’s body and need for support was obvious. I credit my smooth labor and delivery to her…”
— Norton Shores mom, of her homebirth with Birth Quest
When I tell people that I’m a birth doula, the most common response I get is, “Oh, so you help women having their babies at home?”. To which I reply, “Yes, doulas support women at homebirths, but all of the women I’ve supported have given birth in hospitals”.
Because the word doula is not a part of everyday vocabulary for most people, I think many confuse a doula with a midwife. This is usually the second thing I have to explain to people about my job. I don’t catch the babies; I hold space for mom and support her through the process.
The next question usually revolves around why doulas attend more hospital births than homebirths. Several factors impact a woman’s decision on whether or not to hire a doula. For the woman choosing to give birth at home, the biggest factor is likely financial. Homebirths are generally paid for out-of-pocket, as are doulas. Since doulas don’t provide the clinical support a pregnant woman needs and they don’t catch babies, women who desire a homebirth are often faced with the decision to choose between hiring a midwife or a doula. In this scenario, the midwife is usually chosen because of the necessity of her services.
But what if having a doula AND a midwife were an option?
It’s true that your midwife will spend more time with you while you labor and provide a different model of care during pregnancy and delivery. It’s also true that she will likely have assistants who can attend to some of your needs. However, with their focus primarily on the clinical aspects of care, there are other elements left unaccounted for.
Generally, a doula will meet with you in your home at least a couple of times before you have your baby. She’ll be familiar with you and your surroundings. It’s during these meetings that doula and mom become acquainted and comfortable with one another. If there are pets, the doula will get to know them. If there are other children or family members, the doula will get to know them, too. This process is vital in developing a safe relationship as the mother will depend on the doula to cover the non-clinical elements that are a part of the birth process. It’s during these visits that mom can share her hopes and her fears. While she’s probably also done this with her midwife, the doula provides more time for mom to process and plan. The more informational and emotional support a woman receives during her pregnancy, the better.
And in the event of a hospital transfer?
Your doula will be with you. Your midwife probably will be, too, but if your doula is the one you’ve been leaning on emotionally during your pregnancy and labor, her presence is vital. Odds are, she was with you earlier in your labor than your midwife was, as well. That’s the beauty of a doula: no shift changes and present with you from the beginning to the end. Another benefit is that a doula is likely to be very familiar with the hospital environment and maybe even some of the staff, so she can help to explain what is going on and bridge the gaps between a homebirth and a hospital birth.
Regardless of the outcome, whether you had your baby at home or had to transfer to the hospital, your doula will be there postpartum for you to process the experience. Your midwife will, too, but depending on how the birth went compared to how you had envisioned it, your doula provides added space and opportunity to share things that you might not wish to share with your midwife. I know for me, I’m no good at confrontation and had I been upset with my midwife or disappointed, there’s no way I could have told her that (fortunately, that wasn’t the case for me!). A doula is trained to listen to your grievances and your joys. Validating your feelings and helping you to pick through the pieces and put them together, a doula can offer perspective, encouragement, and reassurance.
Birth is one of the most unpredictable events in nature. No matter how much you know about it, curveballs often appear in the form of all the little things that surface in the midst of the limbo of labor that no one had planned on.
I think back to my last pregnancy, when I had finally planned the homebirth I’d always wanted. It honestly was an amazing experience to labor at home and push my baby out the way I wanted with a supportive group of women (midwives, assistants, my mom and mother-in-law) and my husband. All of it was golden. I was even doing “doula talk” in my head, like focusing on the words soft and open. You see, I’d had my birth doula training through DONA only a few short months before the birth. So at the very least, I was able to focus and feel pretty in control during the more intense moments of labor. Super proud of myself for that!
However, the entire day leading up to my precious little one’s arrival, my anxiety and the negative self-talk going on in my head was relentless. Fourth baby, longest labor. Why? Was I not moving around enough? How long was it going to take? Why were the contractions that woke me in the wee hours of the morning that were 4 minutes apart and very uncomfortable spacing out to 15 minutes and not as painful? And there went my thoughts for the better part of an entire day. It’s the one part of my labor I look back on and wish I’d had a better attitude about. As helpful and supportive as my husband was physically for me that last time around (so grateful for the counter pressure and back rubs!), I needed someone to help ease my mind. I needed someone to remind me that every labor is different and that what I was experiencing was normal. I’d fed my fear of waking in labor and things moving quickly, as they had in the past (with my third baby, I went from 5cm to holding my baby in under a couple of hours after painfully relentless contractions). Instead, I spent the better part of the 24 hours that I was in labor anxious, discouraged, and feeling guilty for having sent my kids away first thing in the morning because I was sure “this is it!”. I wasn’t mentally prepared for a long labor. I’d never had one.
Don’t get me wrong; my birth team was incredible! I’d depend on them again in a heartbeat for their care and support during pregnancy and birth. Looking back, though, I know I needed more in those long hours before my little guy finally made his arrival.
Doulas meet so many needs that are maybe overlooked or not considered.
I know when my son was born, my house was a mess. Pretty sure there were dishes and laundry that needed to be done. I didn’t feel like cooking and no one brought food while I was in labor. It was a long, lonely day. I struggled to find distractions. There were so many things during that entire day of early labor that a doula could have helped me and my husband with. We were both so tired.
When I was in active labor and pushing, I soaked up every encouraging word and touch my birth team provided me. They were tender, attentive, and confident. In hindsight, I realize I had needed that all day to better cope with my apprehension about the imminent arrival of my baby. I needed someone to hold that space for me and remind me that everything would be okay. I needed someone to tend to the things my husband and I couldn’t get to while I tried to rest.
My other children were born in the hospital, where food and laundry weren’t an issue. While the hospital environment is not my personal favorite for giving birth, those two things ended up being huge oversights for me with my homebirth. I don’t have sisters or super close girlfriends that I would have felt comfortable having with me while I labored; and I wanted my mom and mother-in-law present for the birth, not running around my house cleaning and cooking. While having my son at home was truly a dream, waking up the next day to the reality of…well, real life, wasn’t. Looking back, I hadn’t planned for how to handle those seemingly tiny details. Who knew that while I did the hard work of bringing life into the world that my house wouldn’t clean itself or cook a meal for me! Or take care of my other children when they returned home the very next day (totally needed a postpartum doula, too).
My business partner and Birth Quest founder, Faith, also had her last baby at home. Her labor, which was the complete opposite of mine, was quick and intense. Despite her doula training, she found herself in need of one and speaking the words women the world over often say when it’s become too much…“I can’t do this! Make it stop!”
I needed a doula; but even if I’d wanted one, I couldn’t have afforded one anyway.
At least, that’s what I thought. I know better now. I could have asked family to help with the expense or sought a doula out that would take my finances into consideration and work with me to make it affordable. Our vision is to increase access to doulas for every person who wants one, so please contact us if you have a financial hardship, especially if that is due to the unreimbursed expense of an out-of-hospital birth. Everyone deserves a doula!
As one Birth Quest client of her having a doula for her homebirth said, “My parents paid for my doula as a gift for our Homebirth. If they hadn’t, cost might had been an issue but I definitely would choose to hire a doula again. Their knowledge and support are so priceless if you can find one you love!”
My story and Faith’s are just two of many stories. Doulas do so many things. If any one part of your labor and birth could be considered customizable, it’s who you choose as your doula. With you from the moment you feel like you need her, she’s the one you’ll have expressed your desires to about labor and birth. Whether you need someone behind the scenes – doing your dishes, folding laundry, or getting a meal ready – or someone to be a part of the action – holding your hand, taking pictures, or showing your partner where to apply counterpressure – your doula is the one person attuned to your wants and needs. And if at any time you want what your doulas doing to change, just say the words…that’s what she’s there for.
What does a doula do at a homebirth anyway?
At a homebirth, a doula is going to do everything she’d do for you in a hospital, except that she is in your space where there are more personal elements that might need tending to. Because the list could go on and on, here are a few examples:
- Ideally, she arrives earlier in your labor to provide support (informational, emotional, physical, etc.)
- Support for your partner (in the form of breaks, encouragement, direction on how to apply pain management techniques, etc.)
- Support for others present during your labor and birth (friends, relatives, children, etc.)
- Light household chores (dishes, laundry, etc.)
- Meal preparation
- Tending to the needs of pets
- Taking pictures
- Crowd control (making sure mom has the space and privacy she desires)
- Immediate postpartum support
- Assistance with breastfeeding
- Preparing a place to rest postpartum
- Meeting needs specific to the individual
- Hold space for the woman in labor
- Create/maintain a peaceful and calm environment
Who could use a doula at a homebirth?
There’s no denying that as a doula, I feel the benefits are universal and for all women. With that being said, specific reasons a doula is perfect for a homebirth include:
- Women whose family/friends are not near enough to provide support
- Women without a partner or whose partner might not be available for support
- Women with anxiety or other health issues that might impact their confidence in their ability to give birth
- Women who want to be prepared in the event of a hospital transfer
- Women who know they need a lot of support
- Women who don’t want to worry about meals or cleaning during labor and after birth
- Women who know their partners will need additional support
- Women who want support but aren’t comfortable with family/friends present
- Women who have specific wants and needs
- Women who have other children that will be present that need support
- Women who want someone to promote and maintain a calm, peaceful environment
- Women who want a safe person to hold space for them
Since doulas aren’t as commonly present at homebirths as they are for hospital births, we did a little investigating into why.
Thanks to the women who took part in our Facebook poll (@birthquestservices) to find out why they, women who’d had homebirths, didn’t have a doula. Not surprisingly, the leading reason was cost. A close second were women who felt they already had enough support while the third reason was a desire for privacy.
However, because women were allowed to choose more than one option, some chose both cost and sufficient support as their primary reasons for not hiring a doula. This leaves us to wonder…which was the biggest factor?
Answers to a 2017 Muskegon-area Facebook post asking, “If you had a homebirth and didn’t hire a doula, why not?”
— Blog written by Beth Singleton, DONA-trained Birth Quest birth doula and photographer,
who had her fourth child at home in Muskegon
Advocates for women’s health hold a vigil in Nov. of 2015 in Muskegon
“It’s so great to be around friends. The work we do is so hard.”
— Participant, 2016 Society of Family Planning’s North American Forum
In November of 2016, I had the honor of attending to the Society of Family Planning’s North American Forum, a life-changing experience, not so much because of what I learned, but because of what it made me feel. I knew this conference was going to be different from any other I had attended when I went to register and realized that I needed two personal references to even complete the online form.
This was heavy. It’s heavy because healthcare providers are risking their lives every day to provide comprehensive reproductive healthcare services to women. It’s heavy because by being in the presence of so many abortion doctors at one time, I was myself at risk for being murdered. Every conference attendee received a name badge, with a photograph that had to be scanned every time we entered the conference area. We were to turn off the location-finders on our electronic devices. We were to take off our name badges if we left the conference area. We were not to take photographs with other attendees and share them.
I’ve been to a lot of conferences before, but nothing with this level of security. One might think that I would be afraid for my own safety, but the measures taken were reassuring. A lot of people don’t understand the sacrifice people make to perform abortions. Often, it is the only work a doctor can do, due to stigma. This can result in social isolation. Going into the work is not taken lightly and is often the consequence of life-changing experiences, some of which were shared with tears and great conviction at the microphone. Sharing space with such brave people opened my heart to a small taste of what they experience daily. I can read about statistics and danger, but this experience brought me closer to a more personal understanding.
Doctors weren’t the only ones in attendance, though. There were also attorneys, researchers, academics, students, and advocates, but I think I was the only doula and childbirth educator present. I’ve shared a lot of the resources I gathered, but I haven’t written about some of the things that I learned that may be useful in my work. Here are some highlights:
- Catholic Healthcare:
- Although there are over 600 Catholic hospitals in the US, over 1/3 of women surveyed did not correctly identify the hospital where they sought care in terms of religious affiliation.
- Most women believe that hospitals should never be able to restrict care.
- Residents who graduate from programs at Catholic institutions report dissatisfaction with their training. Although they may not be able to provide abortions, they can still be taught how to do them, through online modules and off-site collaborations.
- Zika Virus:
- Many of the countries affected by Zika also have some of the most restrictive abortion laws in the world.
- Zika is not transmitted through breastmilk
- Men should wait 6 months after potential exposure before trying to conceive. Women should wait 8 weeks.
- We don’t yet know what the outcomes will be for infants who were exposed, but are “normal” at birth.
- Vertical (mother-to-fetus) transmission is less likely in the first trimester, due to the impermeability of the placenta, but if contracted, outcomes are worse. Later in the pregnancy, the fetus has a more mature immune system and the mother has transmitting immunity, so the outcomes are better.
- Affected countries are advising that women avoid pregnancy, without giving them access to contraception and abortion, which is an unfair and unreasonable expectation.
- Immediate Postpartum Long-Acting Reversible Contraception (LARC)
- LARCs can be inserted immediately postpartum.
- 50% of women ovulate and 60% resume sex before their 6-week postpartum visit
- Up to 35% of women never attend their postpartum visit
- Subdermal implants inserted 1 to 3 days postpartum have shown no negative impact on infant health or breastfeeding.
- Male Contraception
- There are 3 options for male contraception:
- Acceptability determines if men will use available options.
- Surveys show 44 – 83% of men would use, if available.
- Lowest acceptability is in Indonesia; highest is in Spain.
- Women play a role in acceptability – men are more likely to participate in studies when encouraged by their spouses.
- A barrier is that men don’t have a designated healthcare provider for birth control, but family planning clinics may be the most logical place for them to go.
- Methods exist, but are not yet labeled for use as male birth control.
- LARC methods exist for men, but are hindered by lack of precision and research.
- There is likely to be less of an environmental impact with male hormonal contraception methods than female methods because those are excreted into the waste-water and impact fish reproduction.
- There are potentially non-contraceptive benefits to male hormonal contraception, such as an increase in lean mass, decrease in fat mass and decrease in bone loss.
Overall, I left the conference feeling that the training of most doulas in family planning is inadequate. Doulas and childbirth educators play a role in reducing infant mortality, poor birth outcomes and perinatal mood disorders when we have knowledge of family planning to decrease unplanned pregnancies and increase interpregnancy intervals. We can also help educate clients about the wide range of birth control options and their potential impact on breastfeeding and future fertility. As a full-spectrum doula, it’s important to provide information and support that is respectful of the values of the families I serve, across the wide-range of reproductive health decisions they face.
If you are planning a pregnancy after a cesarean, you may be considering a vaginal birth after cesarean, or VBAC. For people in Muskegon and along the West Michigan lakeshore, you may not know anyone who has ever chosen this option, so finding support is key. I have compiled this list of VBAC resources to help you educate yourself about your choices.
Research shows that having a doula reduces the risk of having a cesarean and increases the chances of a successful VBAC. As with a primary cesarean, the biggest factors to influence the success of a planned VBAC are the provider and facility. Doulas are aware of all of available options, so find one early in your pregnancy.
Only 6% of birthing families hire a doula, so it may be hard to start your search. When asked why they chose a specific doula, most people say that they clicked, or had a good vibe. For this reason, most doulas, including myself, offer a free consultation in your home or the location of your choice.
Resources for finding doulas in your area include your healthcare provider, DoulaMatch.net, birthingnaturally.net and Doulas.com. The Facebook page for the Lakeshore Doula Network includes a list of doulas that practice in the greater Muskegon area.
International Cesarean Awareness Network (ICAN)
ICAN of Grand Rapids, the nearest chapter, supports pregnant people who are looking to avoid an unnecessary cesarean, those who are recovering from cesarean surgery and those who are planning to have a VBAC. People gather once a month to share their stories, increase their knowledge and get support.
As a doula who has only had vaginal births, I attended a couple of meetings to listen and learn more about how to support my clients who have cesareans and are planning VBACs. While the focus of birth is often on the physical health of the birthing person and infant(s), ICAN is a nonjudgmental space to get support for the emotional aspects of birth. Knowing they are not alone and being able to tell one’s story is often a first step toward healing.
Here are some of my favorite resources for learning more about VBAC:
- VBAC Education Project (VEP): VEP was created by Nicette Jukelevics, MA, ICCE to “empower women to make their own decisions about how they want to give birth after a cesarean and to provide VBAC-friendly birth professionals and caregivers with the tools and resources to support them.” All materials are downloadable for free. I had the pleasure of meeting Nicette at the 2016 ICAN conference and she was very passionate about getting her materials to people who can benefit from them. I’ve used VEP materials in my own teaching and am grateful for such an accessible resource!
- Vaginal Birth After Cesarean (VBAC): Informed and Ready: This is a Lamaze childbirth education online class for parents. Curious about the content for my own teaching, I paid the $29.95 and watched it myself back in May of 2015. It covers the emotional aspects of a cesarean, factors affecting VBAC success, the risks of repeat cesareans for moms and babies, the risks of VBAC, how to choose a provider, resources for parents and more! Not a bad deal to receive guidance in childbirth after cesarean from the comfort of your own home.
- VBACFacts.com: Jen Kamel founded this website, which provides “realistic, powerful, non-biased, research-based, trustworthy and balanced” information on VBAC for parents and professionals. Her online course for parents, “The Truth About VBAC for Families,” is $299 and includes many resources. Jen Kamel is more than an authority on VBACs, she is a strong advocate for childbirth choices! Her current work helping to reverse hospital VBAC bans will positively impact many.
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?
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.