Can CNMs attend VBAC deliveries in West Michigan hospitals? The answer is: it depends!

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!

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”!