ACNM Responds to ACOG’s 2010 VBAC Recommendations

On July 21, 2010, the American College of Obstetricians and Gynecologists (ACOG) released a revised practice bulletin on vaginal birth after previous cesarean section (VBAC). Today, ACNM released its response to the revised practice bulletin. Read on for an excerpt from the response, or read the full statement here [PDF].

ACNM’s philosophy is that all women—including those who have had a prior cesarean birth—should have access to information, counseling and birthing options provided by vigilant, skilled clinicians within a coordinated maternity care delivery system. While integrated resources should be made available in all settings, immediate access to emergency delivery solely to safeguard against the potential risks associated with TOLAC (trial of labor after cesarean) should not be the focus. Rather, risk associated with TOLAC should be considered within the spectrum of perinatal benefits and risks associated with nulliparous women in labor. Uterine rupture, a rare, often unpredictable complication of both trial of labor after cesarean as well as repeat elective cesarean delivery, is a primary factor underlying the ACOG recommendations. Yet the risk of uterine rupture associated with TOLAC is similar statistically to that of other obstetrical emergencies for a woman experiencing her first birth. Furthermore, it should be noted that the benefits of labor and vaginal birth are often omitted from this discussion. The focus is exclusively on risk, which does not yield a complete picture. Provided with the latest evidence and comprehensive counseling, women must be allowed to make decisions regarding TOLAC and give birth in the settings that best meet their individual needs. It is unclear how these fully informed women will be at liberty to choose a TOLAC when facilities continue to refuse them this option, claiming compliance with the 2010 ACOG guidelines.

ACOG’s 2010 practice guidelines may help to expand access to TOLAC for women with certain clinical presentations. However, ACOG’s continued recommendation that TOLAC be undertaken at facilities capable of immediate emergency deliveries virtually assures that the 2010 guidelines alone will fail to appreciably increase access to TOLAC and VBAC in the U.S. The NIH VBAC consensus statement recommends that “hospitals, maternity care providers, health care and professional liability insurers, consumers and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor” (p. 37). Only a long-term, system-wide, concerted effort based on quality evidence and further research in all settings will accomplish this goal. ACNM welcomes this important and necessary collaboration.

Read more [PDF]

The Lowdown on Lawsuits: An Interview with Premier Speaker Mamie Guidera

Last month, a National Institutes of Health (NIH)-convened panel urged greater access to vaginal birth after cesarean (VBAC) for low-risk women. However, many clinicians have noted since that access to VBAC is not likely to expand until the “elephant in the room” is addressed—fear of malpractice lawsuits. ACNM Communications Manager Yolanda Landon had a chance to chat with Annual Meeting Premier Speaker Mamie Guidera, CNM, MSN, about this growing reality that affects midwives and access to midwifery care. Read on for an inside look at what to expect during Mamie’s co-presentation at the ACNM 55th Annual Meeting. And don’t forget—Early Bird Registration ends today!

Yolanda: Through the media, we keep hearing about an increase in lawsuits against both midwives and physicians. What do you think accounts for this increased attention?

Mamie: Suits are more public now. We need tort reform! The costs have gotten out of control….If you look at ACOG’s ongoing litigation surveys and studies, you’ll notice that nearly 90% of physicians have been sued at least once in their lifetimes. Bill McCool and I did our first midwives and litigation survey in 2005, and we recently wrapped up another one. Among midwives who responded to our surveys, the percentages are close to 30%.These numbers have increased only slightly over the past few years; however, lawsuits affect practice in a major way because of malpractice insurance costs.

Really, there are four factors that can predict the likelihood of a lawsuit: the number of years in practice (the more years of practice increases the likelihood of litigation), the number of births done, your age, and the region of the US where the midwifery practice is located. For example, I’m at high risk because of my years of practice…it’s all about exposure. It’s not about skill, it’s about numbers.

Yolanda: A midwife is there to help women and families. So, s/he might get discouraged after the threat of a suit. Any advice for midwives to stay in the profession and not give up?

Mamie: First, there is a professional liability resource packet posted on the ACNM website. Part 4 is called “What to Do If You Are Named in a Lawsuit,” and provides practical advice. One of the most important things midwives should do is process. By that, I mean they should share their feelings with a professional counselor or religious/spiritual leader or [share the] details of the event with a formal morbidity and mortality committee where they work. These three places are “non discoverable.”

Most literature suggests getting back on the horse, stay in practice, and keep moving forward. And this [being named in a lawsuit/litigation] is part of our practice. This is just part of what happens. It’s as basic as carrying a Blackberry/pager device or assisting with a birth in the middle of the night.

Lastly, remember that a lawsuit is not usually because you did something bad. It tends to be about money. We live in a country where the system doesn’t take care of disabled children well. People need money [to take care of their families].

Yolanda: What will attendees learn during your session?

Mamie: They will learn the results from the midwives and litigation survey, which was distributed to all ACNM members in 2009. We asked members how litigation has affected their practice and what helped them cope. Attendees will also learn some lessons from closed claims analysis, which means we will review cases that are closed and try to learn lessons from them.

Yolanda: What are the take-away messages from the presentation? Please provide 1 or 2 pieces of advice that our attendees should always remember.

Mamie: Understand litigation and embrace the issue! Know why midwives get sued, and what kind of malpractice insurance you need and have. Get involved in your professional organization or your hometown to support tort reform…and if you get named in a suit, know you are not alone.

Guidera will co-present the Joint Risk Management Session Monday, June 14, at 5 pm with William McCool, CNM, PhD, FACNM, Tina Johnson, CNM, MS, and Israel Teitelbaum of Contemporary Insurance Services. Look for the expanded version of this interview in On Location, the newsletter that will be distributed to attendees at the ACNM 55th Annual Meeting & Exposition in Washington, DC.

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!