What you need to know to “Just Say No”

What you need to know to “Just Say No” to medically unnecessary cesareans:

Ten important documents to have when planning a VBAC.

1. ACOG’s Statement on Maternal Decision Making, Ethics and the Law can be downloaded here. Now, why is the Committee on Ethics Opinion Statement from the American Congress (formerly College) of Obstetricians and Gynecologists (ACOG) from 2005 important in a world where women are regularly denied informed consent?  It’s more ammunition to fight back against care providers who are behaving UNethically.  While the entire document is worth reading to know where and how the committee came to its opinions, the opening abstract hits on the most important parts:

“ABSTRACT:  Recent legal actions and policies aimed at protecting the fetus as an entity separate from the woman have challenged the rights of pregnant women to make decisions about medical interventions and have criminalized maternal behavior that is believed to be associated with fetal harm or adverse perinatal outcomes.  This opinion summarizes recent, notable legal cases; reviews the underlying, established ethical principles relevant to the highlighted issues; and considers six objections to punitive and coercive legal approaches to maternal decision making.  These approaches 1) fail to recognize that pregnant women are entitled to informed consent and bodily integrity, 2) fail to recognize that medical knowledge and predictions of outcomes in obstetrics have limitations, 3) treat addiction and psychiatric illness as if they were moral failings, 4) threaten to dissuade women from prenatal care, 5) unjustly single out the most vulnerable women, and 6) create the potential for criminalization of otherwise legal maternal behavior.  Efforts to use the legal system to protect the fetus by constraining pregnant women’s decision making or punishing them erode a woman’s basic rights to privacy and bodily integrity and are not justified.” – ACOG Committee Opinion, November 2005.

While ACOG does not expect us to use this document against them, the reality is that in and of itself, ACOG expects its member providers to live within the bounds of these types of opinions.  If a provider follows the “immediately available” standard which is NOT law in any state, then it reasonably follows that you can show them this committee opinion and ask them to hold themselves to the same standard.  VBAC is not a procedure and this document would also apply to any hospital offering obstetric care and refusing to allow a woman to vaginally birth (VBAC) within their hospital.

2. The National Institutes of Health (NIH) Consensus Development Conference Statement and their recommendations regarding VBAC can be downloaded here.  This document is most useful for pointing out the research that backs up VBAC as a safe and reasonable choice for mothers to make and has comparative risks to a primipara (first-time) mother.  There is a problem with these documents being only recommendations, without force of law and/or protocol on obstetricians but it’s still a re-affirmation of the same information that we knew thirty years ago with the force of thirty more years of research to back it up.  If you don’t want to print the abstracts, then you can print only the conclusion.  Watching the actual consensus development process is worthwhile to understand the science that the panel was hearing and to further understand the true underlying causes of cesarean.

3. Federal Emergency Medical Treatment and Labor Act (EMTALA)

A good link to what is entailed in EMTALA is http://emtala.com/law/index.html.

Does EMTALA work to allow VBACs in hospitals that claim to have vbac bans? There is some dispute as to whether or not EMTALA would work in the case of a woman presenting in labor who wants a VBAC.  It’s a valuable document to have considering that a woman who is far enough along in labor does reserve the right to refuse treatment (cesarean) and right to refuse transfer if her birth is imminent but the hospital is still required to provide appropriate care under this law.

There is one section of a current recommendation that exists that may be somewhat helpful despite any debate over EMTALA’s total usefulness for VBAC moms:

“Individuals who present at these locations and request examination or treatment for a medical condition or have such a request made on their behalf must be screened under EMTALA and, if an emergency medical condition is determined to exist, provided necessary stabilizing treatment, because these locations are dedicated emergency departments.”

In the language of a normal mom, this could mean that a woman in labor with imminent delivery is expected to be treated with only stabilizing treatment and therefore, has the right to refuse a cesarean despite the hospital’s objections and without being told she must leave and find another care center.

4. ACOG’s Statement on VBAC (2010) which emphasizes that VBAC or Trial of Labor (TOL) is a reasonable choice for women who have had a cesarean under certain conditions. It should be noted, however, that these are simply guidelines by the obstetrical trade union and do not necessarily apply to other providers and/or their organizations. Many providers find that with informed consent, very FEW restrictions should be placed on VBAC and those reasons would almost all overlap with requirements for cesarean birth overall, such as a complete placenta previa.

5. Your state’s Patient’s Bill of Rights or Pregnant Patient’s Bill of Rights.

While not every state has one, if your state does, this could be a legal statute that binds providers to act ethically despite their personal wishes for care.  In some states, this document reiterates a woman’s right to informed consent and refusal, giving grounds to refuse the procedure of a non-medically indicated cesarean.  Check out our State By State page to see if your state has one listed.

6. A VBACFacts.com calling card or Quick Facts Sheet. These handy little cards describe your risks or non-risks in a quick, easy to produce form.  They are ideal for recalling what the studies break down to and include citations for those studies as well.  Not to mention, if you share…you will be helping other women break the cycle of myths about VBAC.

7. The “Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery” Study (Landon, et al NEJM 2004). If you are a mom who has had multiple cesareans, a copy of Landon’s study is a must.  This landmark study is the best ammunition for mothers of unknown/unusual scar types or multiple cesareans.  The study reaches conclusions about the relative safety or risk of uterine rupture that shows that even after multiple cesareans, VBAC is not an unreasonable choice for mothers.  The wording on this study is actually very medically inclined but for those who want to understand the real risks of cesarean and how it affects every labor thereafter (Uterine rupture is NOT a risk of vaginal birth, it’s a risk of prior cesarean.  VBAC is not to blame, the first cesarean is, which is why prevention is VITAL) should check out this study’s conclusion, excerpted here:

“Among 17,898 trials of labor and 124 ruptures, we found two neonatal deaths, for an overall rate of rupture-related perinatal death of 0.11 per 1000 trials of labor.  A recent review of 880 maternal uterine ruptures during a 20-year period showed 40 perinatal deaths in 91,039 trials of labor, for a rate of 0.4 per 1000.

8. The American Association of Family Physicians’ (AAFP) Statement on VBAC.  This particular document is interesting because it does not agree with the ACOG recommendations for VBAC.  Several family physicians went even further with editorials regarding the controversies here and another, additional document under the AAFP also shows that maternal and infant outcomes do not improve under ACOGs “immediately available” guideline.

9. The Northern New England Perinatal Quality Improvement Network document set.  This includes a sample consent form, VBAC guidelines and a patient education document.  While this document set does not clear all women with prior cesarean for VBAC, the guidelines are just that, they provide a framework for understanding relative risk and factors that may contribute to risk and to help a mother and provider choose appropriate care.  A favorite quote is the last paragraph:

“If our goal were to prevent all cases of fetal injury due to uterine rupture, approximately 7.5 million dollars would be spent for each case of fetal injury from rupture that was prevented.  This is based on a general risk of uterine rupture of 0.5%, a 10% incidence of significant fetal injury when rupture occurs, and the cost of cesarean delivery listed above.  In addition to the economic costs, substantially more children would be require intensive care services due to respiratory complications at birth, some of them severe.  The price of discontinuing VBAC services is thus substantial.”

10. The March of Dimes statement on “Why the Last Weeks of Pregnancy Count” (2009).  This page emphasizes NOT doing cesareans before 39 weeks unless absolutely necessary (in the case of a medically indicated cesarean) due to the increased morbidity (harm) and mortality (death) in these infants.  Another page on the March of Dimes site that is important is “Cesarean Birth By Request”.

I truly wish that any and/or all of these documents could protect women from an OB/GYN or hospital facility violating her rights to bodily integrity by trying to force her into a cesarean.  The only way this will truly be overcome is by women filing complaints, going to newspapers and other media outlets and presenting our cases to our state attorneys offices in the hope they will take up the case or filing private lawsuits.

In the case of Florida, the state attorney and the state insurance commissioner both stated, “We simply don’t get enough formal complaints about these subjects.”  And they don’t.  Many women are either still pregnant and search out other providers or simply cave to the planned cesarean or they are new mothers caring for an infant and a healing wound and possibly, other children at home.

Filing complaints is something BirthAction is trying to make easier on our State By State and Advocacy pages.  There are also templates on the site for approaching insurance companies or other interested parties.  If you are confronted by an unfriendly provider who refuses to allow VBAC or who refuses to acknowledge your right to refuse a cesarean, we suggest you do something about it.  We do not have to remain victims of this system, we can learn and grow and fight back for our births and our babies.  Birth IS Action.  Arm yourself.

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