A Midwife’s Take on the NIH VBAC Consensus Conference

by William F. McCool, CNM, PhD, CRNP, FACNM

This past week the NIH held a 3-day Consensus Conference examining the current situation in maternity care regarding vaginal births after cesarean (VBACs), which have diminished considerably in number over the past 10 to 15 years. I was able to attend, and urge everyone to read the consensus preliminary report. In addition, many news outlets have picked up the story, including The New York Times.

Midwifery was well represented at the conference. Midwife and ACNM President Melissa Avery was in attendance, as was ACNM Executive Director Lorrie Kaplan. Tina Johnson, ACNM director of Professional Practice and Health Policy, spoke eloquently to the NIH assembled panel during the Q and A session. Certified nurse-midwives (CNMs) Mary Barger and Judith Rooks also raised important issues for the panel to consider. CNMs Cathy Emeis and Mona T. Lydon-Rochelle were featured speakers who presented VBAC data to the panel. Most impressive was Tekoa King, midwife extraordinaire and deputy editor of the Journal of Midwifery & Women’s Health, who was one of the NIH panelists.

I felt that the conference was quite good, and the meeting was as close to “fair and balanced” as it could get, which is not always the case with these NIH conferences. The bottom line is that the panel believes VBACs need to be offered to women as a part of informed consent, and that the opportunities for VBACs need to return to where they were in the mid-90s before ACOG and other groups began cautioning women about this method of birth. Much more research needs to be done regarding outcomes, and as pointed out by several speakers, any change in policy will require some form of tort reform in order to remove fears of litigation from those practitioners involved in VBAC care. But all in all, this NIH statement is hopefully the start of reversing the trend away from VBACs.

Nice work, all you midwifery and birth advocates in attendance!

Hear more from Dr. McCool at the ACNM 55th Annual Meeting & Exposition.

Will the NIH Panelists read the blogs and Twitter feeds? And should they?

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International on March 8)

I spent the good part of today glued to the live webcast of the National Institutes of Health Consensus Develop Conference on Vaginal Birth After Cesarean (VBAC). The agenda was packed with expert testimony on the findings of a systematic review of 35 studies involving over 660,000 women with prior cesareans, prepared by the Agency for Healthcare Research and Quality.

So many important findings were presented that I would not begin to do them justice if I summarized them here. What amazed me as much as the incredibly enlightening science, though, was the remarkable involvement of consumers and consumer advocates, many of whom are very savvy users of social networking tools such as blogs, Facebook, and Twitter.

And another interesting thing happened: the NIH Panel acknowledged the bloggers. Gina from The Feminist Breeder posted this picture of a slide from their introduction…

…right around the time that I was tweeting this:

(for the Twitter-naive, FTW is “for the win” and #nihvbac is the “hashtag” for the conference.)

They are right: there is an active blog community on the internet. And we’ve been “actively blogging” about VBAC for several weeks now. The blogging effort was coordinated, too. The International Cesarean Awareness Network pulled together an amazing collection of links to posts all over the internet on the topic of “VBAC as a Vital Option.”

This all got me wondering: have the NIH panelists been reading our blogs? And should they?

The panelists are supposed to be independent and objective (as we have seen, this is rarely if ever the case). But does independence equate with impartiality? And do the rules of impartiality that govern, say, juries in courts of law (eg, don’t google the case!), pertain to independent scientific panels?

Surely they’ve read somewhat if not extensively in the the scientific literature on VBAC. After all, the NIH would want to choose panelists who would be able to effectively do their job: coming to consensus on VBAC, and doing so requires some familiarity with the research and clinical issues. All of those testifying have affirmed that the available literature for nearly every important aspect of VBAC decision-making is “thin,” “scarce,” or “limited” and that major areas for future research include emotional and mental health outcomes, quality of life, long-term health, and impact on mother-infant bonding and breastfeeding. So if the scientific evidence cannot provide answers, what about asking women themselves? Especially those of us who are eagerly sharing our perspectives and personal stories on blogs and Twitter?

I’m interested to hear others’ thoughts on the role (if any) of consumer advocates, connected via social media, on the scientific panels like the NIH meeting.

I have to end it there to take part in a Blog Talk Radio Show with The Feminist Breeder and Debra Bingham, the president-elect of Lamaze International and the Executive Director of the California Maternal Quality Care Collaborative. Tune in!

Will Washington State Lead the Way for Improved Access to Midwifery Care?

by Heather Bradford, CNM, ARNP, Chair, ACNM Government Affairs Committee

In Washington State, we are working on legislation related to an access to care issue. The legislation would authorize pharmacists to fill prescriptions written by advanced registered nurse practitioners (ARNPs) in other states or in certain provinces of Canada. What does this have to do with midwifery? In Washington, certified nurse-midwives (CNMs) are licensed as ARNPs. The legislation would help CNMs in border states too, as the language considers those midwives to be ARNPs.

Current law authorizes pharmacists to accept prescriptions from physicians, osteopaths, dentists, podiatrists, and veterinarians licensed in any state or in a province of Canada that shares a common border with the state of Washington; however, ARNPs are not included. This can be problematic for women choosing an ARNP or CNM as her primary care provider. Most people need prescriptions filled locally so they have easy access to refills and consultation with their pharmacists. In our argument to legislators, we have shared that CNMs and ARNPs in our bordering states, Idaho and Oregon, have the same independent scope of practice and full authority to write prescriptions. The good news is the bill has passed unanimously in our state Senate and is moving forward through the House of Representatives.

Unfortunately, the language of the bill does not extend to prescriptions written by ARNPs across the country. Currently, only two other states (Kentucky and Texas) have limits on accepting prescriptions from ARNPs licensed in other states. In these states, pharmacists will not accept schedule II prescriptions for which their state’s ARNPs are not authorized to write. It is less clear which states have limits on accepting prescriptions written by CNMs licensed in other states. I received varying responses in an informal poll on the ACNM eMidwife clinical practice discussion group. There are some limitations with pharmacy laws in Texas and Kansas, both requiring a physician name on all prescriptions. However, with the use of a DEA or NPI number (which are essentially national license numbers), many states accept out-of-state prescriptions written by a CNM. Of the 15 or so responses I received, these states include Massachusetts, New Hampshire, New York, New Jersey, Virginia, Georgia, Mississippi, Arkansas, Missouri, and Alabama. Obviously, this is not a conclusive list, but it seems that the law needs to change in Washington State with hopes of others following suit.

Is anyone else advocating for or working on midwifery legislation in their state similar to this?

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.

Time Out for Good News

by Melissa Garvey, ACNM Writer and Editor

It’s a busy week at ACNM. We’re getting ready to open registration for our Annual Meeting and staying on top of a flurry of midwifery advocacy. In the midst of the activity, it’s been especially gratifying to see a hefty amount of positive press about midwives pop up in my inbox each morning. It feels great to have a chance to pause and revel in interviews well done, stories well told, and an inspiring midwifery mission making a difference in Haiti.

• Judith Rooks, CNM, MPH, FACNM, former president of ACNM, speaks up in the Portland Tribune about rising cesarean birth rates. It’s a balanced article that includes solid statistics and the midwifery perspective.
  
  
• Debbie Boucher, CNM, of Illinois is interviewed in an excellent Fit Pregnancy article titled “Home, Sweet Home.” Kudos to Fit Pregnancy for balanced coverage of home birth.
  
  
• ACNM Senior Practice Advisor, Eileen Ehudin Beard, CNM, FNP, helps women prepare for conception with straight-forward advice in the Vellejo Times-Herald, “Ready, Set Conception: 9 Steps to Prepare Your Body for Baby.”
  
  
• Nadene Brunk, CNM, explains the background and mission of Midwives for Haiti, an organization making a difference in Haiti before, during, and after the earthquake.
  

What Do U Think of Text4Baby?

by Melissa Garvey, ACNM Writer and Editor

ACNM has just signed on as an outreach partner of Text4Baby, a new service that sends free text messages (available in Spanish and English) to new and expectant moms. Launched by a DC-based mobile technology firm in cooperation with the National Healthy Mothers, Healthy Babies Coalition (HMHB), Text4Baby aims to encourage healthy habits and birth outcomes by delivering free texts on topics such as nutrition, flu prevention, substance abuse, and mental health. It also connects women with relevant support services.

Within the first 24 hours of going live, 6500 people had subscribed to the service, and at a sign up rate of as many as 250 per hour, total subscription numbers continue to climb. From the beginning, ACNM staff members were impressed with the concept and execution of Text4Baby. With an estimated 90% of US adults carrying cell phones, this project has the potential to reach millions of women with positive messages. We’re especially pleased that HMHB staffers sought out midwifery input before going live.

Thanks to feedback from ACNM staff midwives, many of the texts contain provider-neutral, midwifery-inclusive language. One of the first texts subscribers receive is “You can choose who you see for pregnancy care. Midwives, family docs, OBs & nurse practitioners can all provide care. Call 800-311-2229 for free/low-cost care & to find a provider who's right for you.”

What do you think? Do you expect Text4Baby to make a meaningful difference in the lives of women and their babies?

Becoming a Critical Reader: Bias, Bias Everywhere!

by Andrea Lythgoe, LCCE (Originally published on Science and Sensibility for Lamaze International)

Pretty much everyone would agree that there is bias in research. Most people would say that bias is inherently bad. While it absolutely can be a bad thing, it can’t be completely eliminated. So what can be done about bias in research?

There are many kinds of bias:

• Researcher bias: researcher sets out wanting to the study to prove something, and intentionally or unintentionally manipulates the study to make sure that happens
• Sponsor bias: The organization that sponsors the study either encourages researcher bias or manipulates the publication of the data. Some studies might be completely suppressed, some might have overly inflated press releases touting minimal results.
• Publication bias: Journals must be selective in what they publish due to space limitations, but I think it is fair to say that some journals may choose not to publish a study that might anger its audience.

But today I want to focus on READER bias:

Your first job in the critical reading of an article is to check your bias. We are all human, and so we all have bias. Sometimes it is hard to see your own biases. Take a look at the pictures below. In the first picture, we can tell that there is something there, but it is difficult to see. In this case, the letters are lined up with our angle of vision.

In this second picture, the letters are running the opposite way as our line of vision, and as you can see, suddenly that bias is crystal clear!

The same is true with our reading of the research. The biases that we have act as a filter that alters our reactions to the research. If we already have our minds made up that induction of labor = bad, then any research on labor induction is going to be seen through that filter. Any research that seems to place induction in a favorable light will be seen has highly suspicious. Any minor flaws will be exaggerated. Any research showing bad outcomes from inductions will likely get a “free pass” and flaws may be overlooked.

Murray Enkin, author of “A Guide to Effective Care in Pregnancy and Childbirth”, said this:

Perhaps the most important bias of all resides in the (potential) reader, who determines how (or if) the results will be read and interpreted.

I would agree with him. I have, over the years, seen the best and worst of research used to back up various points, ignoring the quality (of lack of it!) as long as it agrees with them. This is a normal human tendency, and one that is at the heart of many discussions about the available research.

But the good news is that reader bias isn’t impossible to overcome.

The solutions? Awareness of bias and a change of perspective! As you read, consider how this research might be read and understood by someone with a completely different perspective. When you read a study that really resonates as a great study with you, play “devil’s advocate” and pick it apart. Be merciless in looking for flaws, weaknesses and the other types of bias listed above. The same is true of seeing an article you disagree with. Look for strengths and solid evidence. Have an open mind to other possibilities. Sometimes when doing this, you’ll be able to see some aspects you would never have noticed otherwise.

So, here’s an exercise for you. Take a few minutes, and write down what your biases are when it comes to research. Which kinds of research, which methods, which topics do you particularly feel drawn to? Which ones seem silly or useless? For inspiration, you may want to read a personal commentary article written by Murray Enkin (2008) where he goes through his own personal biases. The things he feels a bias for or against may not be the same for you. I know I have a disagreement with one of his stated preferences. But taking the time to carefully think through your own personal biases, to clearly acknowledge the filters through which you view the research, can only help you as you try to step back and make a critical analysis of the research.

Reference: Enkin, M. W. (2008) Biases in evaluating research: Are they all bad? Birth: Issues in Perinatal Care. 35(1). 31-32.