Healthy People 2020 (HP2020) is a national initiative through the Centers for Disease Control (CDC) to improve the health of all Americans by creating targets for improving leading health indicators in a specified time frame. Increasing vaginal births after cesarean (VBAC) for low-risk women is one of those indicators.
There is no way to measure progress on these outcomes without data. Data is essential to any process to improve health. If we don’t know where we’re starting, we have no idea if our interventions are having the intended impact. For this reason, the Michigan Department of Health and Human Services (MDHHS) started collecting and sharing information by county on the percentage of women with a prior cesarean who have a repeat cesarean (to calculate the opposite, or percentage of women with a prior cesarean who did not have a repeat cesarean, subtract the percentage given from 100).
Not surprisingly, when compared to surrounding counties, Muskegon ranks last. In fact, in 2014, the most recent year for which data is available, only 16 women in Muskegon had a VBAC! This was not always the case. When women were encouraged to plan VBACs and deliver at local hospitals in 1999, this number was 83! VBAC bans make a difference.
Kent County leads West Michigan in the percentage of women having VBACS. When it comes to options, Kent County women can choose from three hospitals, Metro, Spectrum Health Butterworth and Mercy Health St. Mary’s. All of these hospitals allow VBACs.
Why does this matter? Why should women be concerned about their access to options for giving birth after a cesarean? The truth is that laboring and attempting a VBAC is less risky for most women than having major surgery. Family size also matters. The risks decrease with each successful VBAC and increase with each subsequent cesarean.
While many providers inform women of the risk of uterine rupture when attempting a VBAC, women are almost never informed of the risks of repeated cesarean surgeries. Every year in the month of October, the International Cesarean Awareness Network (ICAN) works to educate women about one of those risks: accreta. Accreta is a condition in which the placenta attaches too deeply into the uterine wall. According to their website, in the presence of placenta previa, the risk of accreta is 3% with the first repeat cesarean and increases to 67% for fifth or higher. Seven percent of women with placenta accreta will die from excess blood loss. Many women are encouraged to have a repeat cesarean without ever being informed of the risk of accreta. In fact, many women first learn about what accreta is when they are diagnosed with it!
When I speak with women in Muskegon about what influences their decision on how to birth after a cesarean, most tell me that the distance to travel to a hospital without a VBAC ban is just too far. They don’t want to travel for care or risk having a baby in their car. Some don’t have reliable transportation or gas money to make it to a hospital that allows VBAC. Most women want to give birth in their own community with the providers they know and trust. This is where their support system is and they don’t want to accept additional challenges by having a baby far from home.
One of the roles of doulas is educating the public on their options. If you are pregnant or planning a pregnancy after a prior cesarean, hiring a doula may be a first step in learning about your available options.
At Birth Quest, we’d like to hear from you! Are you a Muskegon woman who planned a VBAC? If you chose a repeat cesarean, what were the factors that influenced your decision? Your experiences may help another woman in a similar situation. Thanks for sharing!
As a birth advocate, supporting the rights of women who plan a vaginal birth after cesarean (VBAC) will likely keep me busy for the duration of my career. My heart goes out to women who have to navigate their healthcare options for childbirth after a cesarean one facility, practice and provider at a time. At the end of their inquiries, many find that their options are limited by their individual histories, provider decisions, hospital policies, insurance reimbursement and even politics.
Since October, I’ve been working through the West Michigan Better Birth Network, the local chapter of the non-profit, Birth Network National, to address the official VBAC ban at Spectrum Health Gerber Memorial. We have collected stories of women who have had VBACs there in order to stress to administrators that, despite being counseled that the main hospital campus, Spectrum Health Butterworth in Grand Rapids, is the safest place to labor and deliver, they have legitimate reasons for choosing a community hospital setting. [Link to a sample letter from Rebekah Thompson of New Life Doula Services. Link to my own letter from the perspective of a Substance Abuse Prevention Specialist.]
I was recently attending an event at Amanda Holbert’s yoga studio, Renew Mama. While discussing the work of the WMBBN, Amanda brought up the “ban” on CNMs attending VBACs in West Michigan hospitals. Amanda inspired me to look into this restriction further. Why could CNMs attend VBACs in some hospitals, like Borgess in Kalamazoo, but not at Spectrum Health Butterworth (the only hospital in West Michigan that both allows VBACs and has CNMs who deliver there)?
I called Spectrum Health to ask about their policy on CNMs attending VBAC deliveries and was referred to Charmaine Kyle, Clinical Nurse Specialist in Women and Infant Services. Right away, she informed me that the hospital does not have an explicit policy banning CNMs from attending VBAC deliveries. I checked in with Jen Kamel of VBACfacts, an advocate for greater access to VBACs nationwide, who suspected internal politics to be the culprit.
Before hearing back from Charmaine with a definitive answer, I attended the American College of Nurse Midwives (ACNM) Michigan Affiliate conference in Kalamazoo. There, I met midwives from across the state, most of whom are supported in attending VBACs at the hospitals where they work. Meeting these midwives made me even more determined to find out what is causing the restriction and advocate for overcoming it – West Michigan women deserve all possible options!
This past Wednesday, I received a reply: “a midwife is available through the residency clinic and would be able to establish care with a patient antepartum. When it comes time for delivery the midwife would partner with an obstetrician and co-manage the care during labor. The only problem right now is we don’t have enough midwives to provide 24/7 coverage. Our hospitalist (core faculty) obstetricians would manage the care during the night and on weekends.” In other words, a woman could see a midwife for prenatal care, but could only have one in attendance at her birth if she happens to deliver during normal business hours.
After speaking with a CNM in private practice who delivers at Spectrum Health Butterworth, I learned they are in a similar situation. The hospital’s laborist (salaried staff Ob/Gyn) will not cover them in the event a cesarean becomes necessary, so an obstetrician from their practice has to both be available and willing to stay at the hospital until the mom delivers without being paid to do so. Since they cannot guarantee that this requirement will be met, the midwives who practice at the hospital cannot advertise their ability to take on pregnant women planning VBACs.
Several changes could move West Michigan toward increased access to CNM-attended VBAC births in hospitals. First, Spectrum Health Butterworth could hire more midwives so that those working in their residency clinic could be paid to cover births occurring 24-hours a day. Secondly, the hospital could further find creative solutions to overcome the liability fears of the laborist which lead to the unwillingness to cover the midwives working in private practice. Thirdly, other hospitals that allow VBACs could hire midwives. Finally, smaller community hospitals who already have midwives delivering there could remove their VBAC bans.
Are CNMs able to attend VBACs in hospitals in your area? What worked to increase access in your community? Do you wish you had this option? I want to hear from you!
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”!
At the last West Michigan Better Birth Network meeting, the other co-leaders and myself discussed lack of access to vaginal birth after cesarean (VBAC) at lakeshore hospitals. Mercy Health Hackley, North Ottawa Community and Gerber Memorial hospitals all have official policies banning VBACs. Despite the ban, doctors at Gerber have a national reputation for supporting the birthing decisions of moms who desire VBACs there, but not without resistance from administration. We decided to take up their cause through a letter-writing campaign.
Although I do not have a personal story about VBAC, I do have the insight of a preventionist. This is the letter I will send:
Richard C. Breon, President and CEO
100 Michigan St. NE
Grand Rapids, MI 49503
October 6th, 2015
Dear Mr. Breon:
I am writing concerning the official policy of Spectrum Health that does not allow women to have a trial of labor after a cesarean at Gerber Memorial Hospital, despite the fact that many women do safely have vaginal births after cesarean (VBAC) there. I am a birth and postpartum doula, childbirth educator and Certified Prevention Specialist through the State of Michigan. Prior to becoming self-employed, I coordinated the Muskegon County Fetal Infant Mortality Review for seven years. During that time, I abstracted over 150 cases of fetal and infant death, compiling the data that informed Muskegon’s infant mortality prevention efforts, which I also spearheaded.
The Spectrum of Prevention, developed by Larry Cohen based on the work of Dr. Marshall Swift, places policy and legislation on the highest rung of influence, with the most potential to impact the strategies below it. For this reason, policies that prohibit women’s access to VBAC at community hospitals, despite ACOG’s recommendation that this decision should be made by the patient and her provider, have widespread implications far beyond the health risks of repeat surgery. VBAC bans undermine women’s autonomy by taking the decision for where and how they will give birth away from them and their providers and placing it in the hands of administrators. The underlying message is that women cannot be trusted to decide what is best for themselves and their families.
Groundbreaking research has recently been conducted that examines how structural and institutional policies impact individual behavior. Several such studies have been published in the September 2015 issue of The American Journal of Preventative Medicine. In “A First Look at Gender Inequality as a Societal Risk Factor for Dating Violence,” researchers show that there is a relationship between the Gender Inequality Index (GII) and adolescent dating violence. While VBAC access is not an indicator on the GII, policies that respect the decisions of women and their providers in childbirth, so long as they are demonstrated to be safe, may reduce gender-based violence. Domestic violence is not only one of the leading cause of pregnancy-associated injury deaths, it is also a risk factor for tobacco, alcohol and other drug use in pregnancy.
The official ban on VBACs at Spectrum Health Gerber Memorial should be lifted, not only for the health and safety of birthing women in West Michigan, but to improve gender equality, reduce gender-based violence, and prevent perinatal substance use and the resulting maternal and infant mortality.
Thank you for your time and consideration. Feel free to contact me if you have any questions.
Faith Groesbeck, BA, CCCE, CPS
cc: Dr. Tami Michele, DO
Dr. Stephen Rechner, MD
Randall J. Stasik
 The Prevention Institute. “The Spectrum of Prevention: Developing a Comprehensive Approach to Injury Prevention.” Accessed online at: http://preventioninstitute.org/component/jlibrary/article/id-105/127.html on 10-6-15.
 American College of Obstetricians and Gynecologists. “Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115.” Obstet Gynecol 2010;116:450–63.
 Gressard, Lindsay A. et al. “A First Look at Gender Inequality as a Societal Risk Factor for Dating Violence.” American Journal of Preventive Medicine, Volume 49 , Issue 3 , 448 – 457.
 Chang J, Berg CJ, Saltzman LE, Herndon J. Homicide: A Leading Cause of Injury Deaths Among Pregnant and Postpartum Women in the United States, 1991–1999. American Journal of Public Health. 2005;95(3):471-477. doi:10.2105/AJPH.2003.029868.
 Bacchus, L., Mezey, G., & Bewley. “Domestic violence: prevalence in pregnant women and association with physical and psychological health.” European Journal of Obstetrics & Gynecology and Reproductive Biology. 113: 1 (2004): 6 – 11.
 Project CHOICES Research Group. “Alcohol-exosed pregnancy: Characteristics associated with risk. American Journal of Preventative Medicine. 23 (2002): 166 – 173.
 Martin, S.L., Acara, J., & Pollock, M.D. (2012, December). Domestic Violence During Pregnancy and the Postpartum Period. Harrisburg, PA: VAWnet, a project of the National Resource Center on Domestic Violence. Accessed online at: http://www.vawnet.org on 10-6-15.