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.
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.
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!
One of the highlights of the American College of Nurse Midwives (ACNM) Michigan Affiliate conference this past January was the presentation on Nitrous Oxide. The presenters, Michele Amstutz, RN, c-EFM and Laura Bozeman, MSN, RNC, CNL, c-EFM, from St. Joseph Mercy, enthusiastically described how they overcame obstacles through persistence, teamwork and education to bring laughing gas to their hospital.
From an historical perspective, the presenters explained that nitrous oxide was available for pain relief in labor in the United States up until the 1980’s, when epidurals grew in popularity. In recent years, the number of US hospitals offering nitrous oxide for women in labor has increased. Currently, two West MI hospitals, Spectrum Health Zeeland and Gerber Memorial offer it. Mercy Health Hackley responded to me on Twitter in January that they don’t have a start date yet, but their goal is to have it available within the next year.
When considering pain relief in labor, many women are concerned about the impact on the fetus. Fortunately, nitrous oxide is metabolized in the maternal lungs and clears rapidly, so only 80% of 1% of what the mom inhales reaches the baby. Studies have shown that there are no adverse effects on fetuses, including effects on fetal heart rate or apgar scores.
When it comes to maternal outcomes, nitrous also has advantages over other forms of pain relief. It does not require moms to receive intravenous fluids, have the fetus be continuously monitored, or restrict mobility, as with an epidural. The units can even be used with women who are in the tub! Unlike narcotics, it is non-addictive, which may be of concern to moms in recovery.
Something that I hadn’t considered was the many ways nitrous oxide could be used during labor and even postpartum. Because it is anxiolytic, or a medication that reduces anxiety, it can be used during medical procedures that may make a woman tense, like starting an IV, a foley bulb placement, or a vaginal exam. Although it cannot be used in conjunction with an epidural, it may be used during the insertion of one. Furthermore, many providers prefer it to local anesthesia for repairing tears after delivery because there is less distortion of tissues.
Nitrous oxide isn’t for everyone. Some women prefer a completely unmedicated experience. A small percentage of those who use it will experience side effects, most commonly dizziness and nausea. There are a few contraindications, including vitamin B12 deficiency. Finally, if a woman wants complete pain relief, she will probably not be satisfied with nitrous alone.
What about you? Have you used nitrous oxide for pain management during labor? I would love to hear about your experiences!