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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

ICAN President's Letter to California Medical Board about VBAC

I'd like to share with you what I wrote to Senator Figueroa today on behalf of ICAN.

I've encouraged the women on all of the ICAN lists to let the Senator know that they cherish their right to autonomy and free choice.

Here is my letter:

April 20, 2005

Senator Liz Figueroa
State Capitol, Room 4061
Sacramento, CA 95814

Dear Senator:

I am writing in reference to the midwifery standard of care issues that are currently before the Medical Board of California.   I am not advocating any particular document or position.   I am writing to emphasize the importance of a woman's choice when it comes to place of birth as well as caregiver for pregnancy and birth.

Pregnant women have the right to choose a licensed midwife to provide her prenatal and labor and delivery care-even if her resulting choice may be medically unpopular with the American College of OB/GYNs.  This is particularly true if a woman has twins, a breech presentation or a prior cesarean delivery.

There are two areas of concern. The first is in avoiding a cesarean birth.  For most obstetricians, the standard of care for a breech presentation or multiple babies is a cesarean.  Most young doctors are no longer trained in the art of breech or multiple delivery-but they are trained surgeons.  While in certain situations a cesarean can be lifesaving for mother and baby, the World Health Organization has said there is no reason for any region of the world to have a cesarean rate above 10-15%.  Right now, our state is very near the 30% mark-double what the WHO considers safe for mothers and babies.

A cesarean increases the mothers risks of hemorrhage, infection, rehospitalization, and death-and that is just with the surgery.  She also faces greater likelihood of future infertility, ectopic pregnancy, miscarriage and dangerous placental abnormalities in future pregnancies.  One study even linked prior cesareans to future unexplained stillbirths.   Cesarean born babies have greater risks of respiratory distress, childhood asthma,  and 1-2% of them are cut during surgery.  The goal in our state should be to avoid unnecessary cesareans, and having licensed midwives as an option for women furthers that goal.

The second area of concern is women with prior cesareans, VBAC mothers.  The weight of medical evidence shows VBAC to be a reasonable choice to mothers.  There are slightly increased risks of uterine rupture, but the most recent study in December 2004 showed that risk to be 4 out of 1,000 if the mother did not have a labor that was artificially augmented or induced.   The risk of a miscarriage after an amniocenteses is approximately 2%, yet those are routinely ordered and that risk is accepted by the medical establishment.

Because of  ACOG's approach to VBAC, over 300 hospitals in the country have banned VBAC altogether.  My organization has documented over 50 California hospitals that no longer allow women the choice of  normal birth if she has had a cesarean-even if she has had multiple prior VBACs.  The ACOG "recommendation" that a physician be "immediately available" has now been adopted  and interpreted by medical malpractice insurers to mean that a hospital must have around the clock staffing of an operating room, complete with anesthesiologists and obstetricians.  Many smaller hospitals cannot afford that and the economic decision has been to require all women in that situation to submit to a repeat cesarean.  Sadly, in the rural areas of our state, that is the only hospital in the area.

For the medical establishment, it is not about scientific or evidence-based practice, or even the best care for pregnant mothers and babies, it is about economics.  The original 1999 ACOG recommendation on its face admits that it is in response to "medico- legal" concerns, and is a Level C recommendation.  Unlike Level A and Level B recommendations which are based at least in part on scientific evidence, Level C guidelines are based on consensus and opinion.  It is a travesty.  ACOG has backed even well-meaning physicians into a corner on VBAC.

VBAC women should have the option of a licensed midwife available to them.  Otherwise, they and their  babies are literally doomed to the operating room and subjected to unnecessary risks.  This was my personal choice in 2001, and if I ever am fortunate to expect another baby, I want that choice available to me again.  Each additional cesarean increases the risks of placenta previa, abruption, accreta exponentially in future pregnancies. Any standard of care or protocol that "risks out" VBAC women will deny them their civil rights and autonomy of choice.

Any standard of care or protocol that "risks out" women with breech babies or multiple babies puts them in the uncomfortable and difficult position as a VBAC mom the next time around.

I urge you to consider and continue to champion the rights of women in our state to have the right to make informed choices when it comes to their own health care, even if ACOG does not like those choices.

I would be happy to provide you with any additional information that you may need.

Sincerely,
TONYA JAMOIS
President, International Cesarean Awareness Network, Inc.

Cc:  Dr. Fantozzi, Chair, Midwifery Task Force, MBC

ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean (VBAC).