Tuesday, March 2, 2010

Six Reasons to Be Optimistic about the NIH Consensus Development Conference on VBAC

by Judith Rooks, CNM, MPH, FACNM

Many of you already know about the upcoming NIH Consensus Development Conference on Vaginal Birth After Cesarean (VBAC): New Insights, March 8-10, at the NIH Campus in Bethesda, Maryland. Many midwifery advocates, including me, have had a bad taste in our mouths about NIH conferences on cesarean sections based on the 2006 NIH “State-of-the Science” conference on Cesarean Delivery on Maternal Request. The people who did the review of the literature and prepared the background paper for the 2006 conference on elective cesareans seemed, in my humble opinion, to be biased and made ridiculous decisions about what evidence should be considered during the conference. They concluded that “no information exists,” thus asserting that no one knows anything about the relative risks of attempting to have your first baby vaginally compared to having an elective cesarean.

However, I’d like to draw your attention to the March 2010 conference tagline “New Insights.” I’m taking this as a hint that NIH is aware of the damage caused by unnecessary cesareans and would like to encourage more women to try trial of labor after cesarean (TOLAC). We don’t know if there will be a midwife on the panel that will have the final say on the report resulting from this conference. The identity of panel members will not be revealed until the conference opens. Nevertheless, there are lots of reasons to be optimistic about this conference.
  1. Mona T. Lydon-Rochelle, CNM, PhD, MPH, will present an important paper on the short-term benefits and harms to the mother of attempting a TOLAC versus having an elective repeat cesarean delivery and factors that influence maternal outcomes.
  2. Lucky Jain, MD, MBA will do a presentation on the short-term benefits and harms to the baby of its mother’s attempt to have a VBAC versus having an elective repeat cesarean delivery, and factors that influence short-term outcomes for the baby should be very good. Every pregnant woman who is faced with making this decision should know the information he will present.
  3. Emmanuel Bujold, MD, FRCSC, will explore differences between the American Congress of Obstetricians and Gynecologists’ (ACOG’s) VBAC guidelines compared to those of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and probably those of the OBGYN organizations of other countries.
  4. I expect that a paper by David Birnbach, MD, MPH, will be important, too. People need to know that there is a shortage of OB anesthesiologists and nurse anesthetists to provide epidurals. This is also relevant to the new ACNM Position Statement on Nitrous Oxide Analgesia During Labor.
  5. Howard Minkoff, MD, will present a paper on the “Immediately Available Physician Standard,” which should be very interesting and important.
  6. Ditto for a paper by Miriam Kuppermann, PhD, MPH, on understanding risk, patient and provider preferences, and obstetric decision making; a paper by Anne Drapkin Lyerly, MD, on the medical ethics of VBACs; and a medical reporter’s paper on mother’s stories.

Overall, this should be a very good and important conference. Please don’t be discouraged from registering and participating because you were so discouraged about the 2006 NIH conference on elective cesareans. Midwifery advocates need to be there in force, especially articulate midwives who are knowledgeable about issues related to VBAC and problems related to lack of access to TOLACs. This is an important issue for midwives, and we need to make NIH and the entire maternity care community see that we are actively engaged with the scientific and professional issues surrounding VBACs.


Samantha McCormick, CNM said...

I am a CNM, married to an OB who does VBACs. I think the only thing that could increase physician participation would be to change the reimbursement for physicians. Since most hospitals require OBs and sometimes Anesthesia to remain in-house during VBAC, doctors who attend VBACs lose money and personal time. They might have to cancel office hours and surgeries (my husband cannot leave the labor floor and may not perform any other procedures) to attend a VBAC, all to get paid pretty much the same as for a regular vaginal birth and less than he would be paid for a cesarean.

Since the total cost to insurance companies is higher for a repeat cesarean than a VBAC (including the higher rates of NICU and maternal readmission post op), physicians could be paid fairly for the extra time a VBAC takes and the insurance companies would still save money.

And, if VBAC (including attempted but failed) were reimbursed at a significantly higher rate than either regular vaginal or repeat cesarean, the docs would actually have an incentive to do them, rather than nothing but disincentives in the current situation.

At one point, insurers were convinced (pretty easily, as it saved them money) to reduce reimbursement for cesareans to close to that of a vaginal birth, to reduce the economic incentive for cesarean. Cesarean rates fell for quite a few years after that change.

We can't convince doctors to go against their own best interests. They work hard enough as it is. Costs go up, medicare rates go down, malpractice goes up, time with family is precious. Asking doctors to twiddle their thumbs on a labor floor for no extra compensation is idiotic.

You can present all the evidence about the benefits of VBAC and the dangers of repeat cesarean, but until we start fairly compensating physicians, nothing will change.

TheFeministBreeder said...

Samantha, I really appreciate your honesty and insight. It's interesting to hear about this issue from the wife of an OB. It's greatly disheartening, however, that the OB's pocketbook seems to be worth more than the uterine health (and future children) of the mother in question. Isn't the oath to "Do No Harm?" I don't think that means to the physician's pocketbook. It is sad that it costs the OBs more to "twiddle their thumbs" waiting for a woman to labor, but how does that give a doctor the right to put his finances ahead of his patient's well-being?

Seems to me that if money/time is a real issue for the family, that doctor would be better suited for a family practice position and not treating women who can/do have babies all hours of the night. At the end of the day, the patient is the one who has to live with (or suffer with) the consequences of these surgeries. Meanwhile, the doc closes up and goes home to his family. There's little justice in that.