VBAC bans - x-posted in Birth Professionals Forum - Mothering Forums
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#1 of 44 Old 10-29-2007, 08:12 PM - Thread Starter
 
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I am so frustrated and angry today. Recently, my hospital has decided to stop providing VBACs. This was not provider driven. We are a small, rural community hospital and only do aroun 210 births a year. We are required to a have a perinatal agreement with a larger hospital with a NICU and other specialized services. This agreement includes all sorts of stipulations, like when we are required to consult a perinatologist and when we are required to transfer care. The powers that be in the bigger hospital don't want us to do VBACs because we don't have 24 hr in house anesthesia or OB. I have practiced here for 6 years and have attended around 20-25 VBACs, with over a 90% success rate. I am a family doc and don't do cesarean deliveries, so up until now, I would have all my VBAC clients meet my back up OB once in the third trimester. During labor, I would notify anesthesia and my OB back up that a VBAC client was laboring, and they would then keep themselves available, which in our hospital wouldn't necessarily mean sitting in house, but would mean staying ready. I stay in house during the entire labor. I've not had a problem, nor has my OB back up who has practiced here 30 years. Not every prior cesarean birth client I care for chooses to VBAC, but those that do, I've felt confident that we could assist them in making their own decision and then supporting them well. Since this policy is in effect, I'm not supposed to attend any VBACs at all. My OB back up has been making off the record exceptions for my repeat VBAC folks, but not for primary VBACs, and frankly, I'm worried that if this policy becomes more strictly enforced that I won't be able to do that even for my repeat clients. I'm supposed to tell them all they have to schedule a cesarean or deliver somewhere else.
Today, I had not 1, but 2 very excited women in my office in early pregnancy for new OB visits. Both were thrilled to be starting care with me because they had heard I'd help them VBAC. I had to tell both that I could no longer attend primary VBACs, even though they are both great candidates. After telling them where they could go to VBAC (hospitals an hour away or more, with less supportive labor environment, but no outright VBAC bans), one woman said to me "And what if I just continue my care with you and then refuse to have a c-section at the end?" I told her that was absolutely her right to make any decision she wanted to and we'd have to abide by it. To tell the truth, though, I think I'd probably lose my privileges pretty quickly if I had too many of those, and I'm not sure I wouldn't be required to turn the client in labor, even, since I don't do surgery to begin with and now have no back up to provide VBAC.

My question for both all the VBAC mamas and the birth attendants out there, is what can I do about this? Does anyone know if there is an active ICAN of IL chapter doing anything about VBAC bans? Do any birth attendants have experience with this type of situation? Where can I point these women so they get good counsel and information (besides myself)? Anyone else face a VBAC ban? I'm so upset about this I'm actually considering leaving the community over it (dh is not liking that one, we are settled and happy here) but I cannot participate in either forcing women to have a surgery they don't want, or guilting or persuading them into it by manipulation of facts. Any thoughts, ideas, or even just commiserations would be greatly appreciated!
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#2 of 44 Old 10-29-2007, 09:17 PM
 
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Wow ... you have a fantastic vbac rate ... if every woman that wanted a vbac were so lucky to have you in her town or nearby.

Can I ask where you are at? There are four chapters - Chicago, Kane County, Central Illinois and Rockford. There is also St. Louis, Mo.

Mom to Rooney (05/02) & The Bean (06/04)
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#3 of 44 Old 10-29-2007, 11:23 PM
 
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My question for both all the VBAC mamas and the birth attendants out there, is what can I do about this? Does anyone know if there is an active ICAN of IL chapter doing anything about VBAC bans? Do any birth attendants have experience with this type of situation? Where can I point these women so they get good counsel and information (besides myself)? Anyone else face a VBAC ban? I'm so upset about this I'm actually considering leaving the community over it (dh is not liking that one, we are settled and happy here) but I cannot participate in either forcing women to have a surgery they don't want, or guilting or persuading them into it by manipulation of facts. Any thoughts, ideas, or even just commiserations would be greatly appreciated!
IMO...if a hospital is "banning" VBACs b/c of this reason that hospital shouldn't be having ANYONE labor/birth there. If the hospital isn't equipped to handle UR then how are they equipped to handle a prolapsed cord? Same rate of risk...

Hmm...that's probably not much help for you (and I'm probably preaching to the choir, but that really irks me!). It stinks that they have so completely overreacted and misappropriated the risk for UR that they're doing things like this. Absolutely ridiculous that they limit women's choices.

Anyways...publicity is certainly helpful. ICAN's got a good whitepaper on what to do (as a consumer) if you encounter a VBAC banning hospital

There's also an FAQ and some tips on a mom's right to refuse. I don't know how much leeway you would have in being able to pass out handouts like this, but at the very least you can direct women to ICAN's website and tell them to look at the whitepapers.

There's also a good section on ICAN's website about advocacy. Not sure if you will find it helpful, but I've linked it just in case.
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#4 of 44 Old 10-29-2007, 11:26 PM
 
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Have you seen this?

http://www.midwiferytoday.com/articles/50ways_VBAC.asp

And..wow, thanks for being so supportive of VBAC, and all you're doing to support VBAC moms! We need more drs like you

dd (7) ds (5), ds (2) &3rdtri.gif hbac.gif and the furbabies cat.gifZeus, Dobby, Luna, & Ravenclaw
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#5 of 44 Old 10-29-2007, 11:33 PM - Thread Starter
 
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This is a great article, but one of the early suggestions is to file a complaint about your doc - cripes, I hope no one will file a complaint about me!
Also, I understand writing to a newspaper with the info about not having 24 hr anesthesia, but small hospitals like mine just cannot afford 24 hr in house coverage. We have 24 hr coverage, but our main anesthesiologist provides this during the week all by himself at night, and does so from his home when able, 2 blocks from the hospital. In a true, life or death, seconds counting emergency, we would do a cesarean under local with IV sedation - which would absolutely suck for all involved, but is possible. My OB backup has a done a few cesareans this way over the years when it was life or death and he didn't feel he could wait even a few minutes to get things going. Our hospital could not afford enough anesthesia personel to be in house 24/7.

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Have you seen this?

http://www.midwiferytoday.com/articles/50ways_VBAC.asp

And..wow, thanks for being so supportive of VBAC, and all you're doing to support VBAC moms! We need more drs like you
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#6 of 44 Old 10-30-2007, 12:06 AM
 
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I'm always inclined to take a statistical tack whenever I can. ;-) So, I wonder how feasible it would be to gather:

* Data on risk rates for VBAC UR under the conditions you have at your hospital
* Data on risks involved in VBACing with a hospital an hour or more away
* Data on risks involved with ERCS

...Which would combine to show that overall risk of mortality or morbidity is higher if your hospital may not perform VBACs?

Oooo! One thing you might be able to do is survey previous VBAC clients (anonymously), and find out how many would choose a homebirth or UC if this policy had been in place when they delivered. You can use a 1-10 type scale, so that you can gage how much more or less likely they would be to choose an out-of-hospital birth for their VBAC if they couldn't birth vaginally at your hospital. That might convince the right people that they're putting more lives at risk this way.

It might also be possible to contact the ACOG and ask them if their guidelines are intended to have this effect in this particular situation.

Do you know what's driving the other hospital's decisions? Did they change insurance carriers? Recently get audited or accredited? Get sued? Change managment?
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#7 of 44 Old 10-30-2007, 11:19 AM
 
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I just want to say thank you, for supporting your patients right to choose a VBAC.

It seems like everyone has given you good advice. Perhaps you could also contact the author of that article (Barbara Stratton) to see if she has any more advice. She is really the ICAN expert at fighting VBAC bans. Does the article list an email address for her?
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#8 of 44 Old 10-30-2007, 11:44 AM
 
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No advice, but thank you for doing all you can for VBAC mamas. We need all the support we can get.

One of the pp's brought up an excellent point about how many women would just stay home (possibly unassisted) if your hospital is no longer an option. Now, personally I don't have any problem with that, but it may open some eyes if the powers that be actually heard that. Unfortunately, in your case it's not like people are beating down the doors to birth there (VBAC or otherwise), so they're not losing a ton of money like some other hospitals might. They really shouldn't be doing any births if they cannot accommodate VBAC mamas. If it's good enough for a primip to have anesthesia 2 blocks away, then it should be fine for a VBAC'er to have the same.
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#9 of 44 Old 10-30-2007, 12:48 PM
 
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what part of Illinois are you in? I know it's rural, but that's all I know.....


I wish you could come to St. Louis!! Sadly, the ob's have locked out fp docs (other than those in the fp residency program) from getting privileges at the local hospitals. It sucks. BUT, you can still homebirth. There is a hb doctor here who has done over 5,000 hb. We'd love to have you!!!
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#10 of 44 Old 10-30-2007, 12:51 PM
 
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Oooo! One thing you might be able to do is survey previous VBAC clients (anonymously), and find out how many would choose a homebirth or UC if this policy had been in place when they delivered. You can use a 1-10 type scale, so that you can gage how much more or less likely they would be to choose an out-of-hospital birth for their VBAC if they couldn't birth vaginally at your hospital. That might convince the right people that they're putting more lives at risk this way.
Hmm....I'm not so sure I'm comfortable with this type of idea. I get that it would work with the medical types, but using this tactic is precisely the way to alienate would be supporters if one were to go the PR route.
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#11 of 44 Old 10-30-2007, 01:03 PM
 
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In Houston, Tx the same thing is going on. One thing that is happening is getting a petition signed to give to the board in hopes they will change their mind.

http://www.thepetitionsite.com/1/sto...AC-ban-at-WHMC

Maybe someone in your community can start with this and organize letting media know womens right to make their own informed choice is being taken away.
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#12 of 44 Old 10-30-2007, 03:36 PM
 
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Would you loose your privileges at the hospital if you attended births at home? I know that's more of what a midwife does, but it may be an option if you are able. In the meanwhile, collecting statistics that a previous poster mentioned and presenting an evidence based letter, etc. is also a good idea. I'm sorry that you've been put in this position. Thank you for being VBAC friendly.

Anna
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#13 of 44 Old 10-30-2007, 09:10 PM - Thread Starter
 
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I know gathering data and proving safety sound like a good idea - but frankly, this is not about data or evidence. It is about CYA and legal mumbo-jumbo. ACOG says you shouldn't VBAC in a hospital without 24 in house OB and anesthesia. We don't have that, and aren't going to get it. ACOG doesn't care if that means once a section always a section, that is perfectly okay with them. Our perinatal network feels the same way. No amount of evidence is going to change that.

Meanwhile, last wednesday I attended a lovely second VBAC for a client who I attended for her first VBAC 3 years ago. She was admitted in labor shortly after 7 in the morning, walked in our halls, sat in our tub, then labored on her side and in hands and knees on the bed with her sister holding her and talking to her and telling her she could do it. Eventually, she started to push, and her little boy was born over an intact perineum, passing quickly from my hands to hers, all before 10 in the morning. In less than an hour, she walked to the bathroom and then to her room. In the morning, she went home.
If this policy was in place 3 years ago she would instead have been scheduled for an unnecessary surgery instead!
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#14 of 44 Old 10-30-2007, 10:36 PM
 
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I know gathering data and proving safety sound like a good idea - but frankly, this is not about data or evidence. It is about CYA and legal mumbo-jumbo. ACOG says you shouldn't VBAC in a hospital without 24 in house OB and anesthesia. We don't have that, and aren't going to get it. ACOG doesn't care if that means once a section always a section, that is perfectly okay with them. Our perinatal network feels the same way. No amount of evidence is going to change that.
I think your answer lies in this here.

You see to have two choices.

One is to obtain 24/7 OB and anesthesia coverage.

Two is to work on ACOG changing their recommendations for VBAC.

Seems to me that trying to convince a hospital and/or doctor to deviate from ACOG recommentations would be a wasted effort, and for good reason. But ACOG can and does change their standing on issues as new information arises.

If it could be shown that the current recommendations are actually doing more harm than good, that would be information that ACOG should take into account.

As for what you can do in your daily practice, I cannot advocate going against hospital policy if you have any desire to keep your job. I can only imagine the outcome of a malpractice lawsuit should a woman under your care, or any of the OB's 'secretly' doing VBACs, actually rupture while in labor. I wonder if your malpractice carrier would even cover you if you were attending a VBAC in a hospital with a known ban on VBAC?
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#15 of 44 Old 10-30-2007, 11:58 PM - Thread Starter
 
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I frankly don't really give a crap what ACOG says. I'm a family doc. Their guidelines are frequently not evidenced-based, but based on "expert opinion." There is not adequate evidence that having in house anesthesia makes a significant difference. Catastrophic rupture is rare, and when it happens every second counts, but even with anesthesia and OB standing by outcomes are usually awful. Less catastrophic ruptures usually need urgency, but we routinely hit reasonable guidelines for timely cesarean delivery even in our non-VBAC clients who we aren't standing by for. Another professional organizations are not given the ability to determine policy and ACOG, who doesn't even base theirs on actual evidence shouldn't be any different.
I happily support any woman making a VBAC decision, and I've had a few feel not having in-house anesthesia was a deal breaker, so they either chose a repeat or went elsewhere. Some women will add up the risks and benefits and make that decision, and others will fell that being close to home and in a supportive environment is important and will choose to stay with us.
Many of the VBAC lawsuits that drive this fear by doctors are pretty impressive if you read them: clients who were forced to have trial of labor by their insurance company, clients who were never informed of the risks of VBAC, and clients whose complaints of pain, bleeding, or wanting to go to cesarean where ignored and cases where there were multiple signs that mom and baby were in trouble but any care at all was delayed. There is not evidence that well informed women are suing for bad outcomes.
I have no intention of risking my malpractice insurance or privileges over this, thank you very much, but if someone does not take a stand and argue in favor of women having the right to make this decision themselves, how many more women will be coerced into surgery?
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#16 of 44 Old 10-31-2007, 12:37 AM
 
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I frankly don't really give a crap what ACOG says. I'm a family doc. Their guidelines are frequently not evidenced-based, but based on "expert opinion." There is not adequate evidence that having in house anesthesia makes a significant difference. Catastrophic rupture is rare, and when it happens every second counts, but even with anesthesia and OB standing by outcomes are usually awful. Less catastrophic ruptures usually need urgency, but we routinely hit reasonable guidelines for timely cesarean delivery even in our non-VBAC clients who we aren't standing by for. Another professional organizations are not given the ability to determine policy and ACOG, who doesn't even base theirs on actual evidence shouldn't be any different.
I happily support any woman making a VBAC decision, and I've had a few feel not having in-house anesthesia was a deal breaker, so they either chose a repeat or went elsewhere. Some women will add up the risks and benefits and make that decision, and others will fell that being close to home and in a supportive environment is important and will choose to stay with us.
Many of the VBAC lawsuits that drive this fear by doctors are pretty impressive if you read them: clients who were forced to have trial of labor by their insurance company, clients who were never informed of the risks of VBAC, and clients whose complaints of pain, bleeding, or wanting to go to cesarean where ignored and cases where there were multiple signs that mom and baby were in trouble but any care at all was delayed. There is not evidence that well informed women are suing for bad outcomes.
I have no intention of risking my malpractice insurance or privileges over this, thank you very much, but if someone does not take a stand and argue in favor of women having the right to make this decision themselves, how many more women will be coerced into surgery?
Well then.

I guess you told me.

Really, though, *you* may not care what ACOG says. And I get that. I really do.

However, your OP *seemed* to want advice on how to actually DO something about the problem. If you really just needed a place to rant, that's ok too.

But the fact is, addressing WHERE these bans are coming from is the only real option aside from obtaining 24/7 OB and anesthesia coverage. And the bans are arising from ACOG guidelines.

So, like it or not, ACOG is 'setting the bar' so to speak.

If they are doing so NOT based on research, NOT based on actual evidence that their recommendations improve outcomes, yet hospitals and malpractice carriers nationwide are taking what they say and running with it, doesn't it make sense to advocate change within ACOG?

If they are the ones saying 'You really ought to have 24/7 OB and anesthesia coverge' and that is what is driving the current trend towards banning VBACs everywhere you look, it doesn't take a rocket scientist to figure out that THAT is where it would make the most sense to focus efforts on education, research, evidence based medicine, etc.

If ACOG is truly pulling this 24/7 coverage concept out of their behinds, they need to be called on it. If enough providers got together and demanded answers as to why they are making recommendations that you say are completely unsubstantiated in research, perhaps it might do some good.

What other choices are there really? Demand that the hospital change their mind? They'll change their mind when ACOG changes the guidelines. Demand that individual doctors attend VBACs regardless of hospital priveledge and/or malpractice coverage? Good luck with that.

I stand by my opinion that there are really only two realistic options at this point. Get coverage or work on ways to change ACOG's stand.

I will also add that nowhere in my post did I suggest you NOT 'take a stand' or 'argue in favor of women'. On the contrary, I *do* think someone needs to rally the troops and figure out a way to insist on accountability within ACOG since it seems malpractice carriers and hospitals are just following their lead. That's exactly why I think it makes the most sense to focus efforts on ACOG.

Not once did I suggest that I believed it best if you would just throw in the towel and say 'Well, that's that, no more VBACs here.' You may not like what I suggested, and that's certainly fine, but please do not insinuate that I ever said anything to the effect of allowing women to be 'coerced' into surgery.

Unfortunately, until ACOG changes their guidelines, I'm shocked there are still hospitals and docs out there are willing to open themselves up to the liability of NOT complying. Fair or not, you and I both know that all it takes is ONE lawsuit. If the patient's attorney can show that the hospital and/or doctor weren't following current guidelines set forth by ACOG...well, how do YOU think that's going to end up?
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#17 of 44 Old 10-31-2007, 01:00 AM
 
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I know gathering data and proving safety sound like a good idea - but frankly, this is not about data or evidence. It is about CYA and legal mumbo-jumbo. ACOG says you shouldn't VBAC in a hospital without 24 in house OB and anesthesia. We don't have that, and aren't going to get it. ACOG doesn't care if that means once a section always a section, that is perfectly okay with them.
Hmmm... OTOH, ACOG has goals for lowering the overall section rate, and they're NOT getting anywhere near meeting them.

My question for them would be what the intended purpose of the in-house OB/anesthesia rule is. Is it to get hospitals to hire these people? Or is it to get patients to choose hospitals who can? I'm guessing that, whatever the purpose is, it's NOT to get women to choose between an hour or more drive while in labor or a repeat section.

That's the thing about policy... the hope is that policy shapes behavior in a desirable way for a particular outcome. The outcome that the ACOG wants is for babies to not die because mom chose to VBAC instead of an ERCS. But a secondary desired outcome is to have fewer cesareans performed.

Also... the ACOG guidelines do not say "in-house" or "24 hours" or any of that wording. They say "immediately available" to respond to emergencies. The common interpretation is "24 hour in-house." However, a hospital an hour or more away is NOT "immediately available" in ANY sense. So if a client with a previous cesarean goes into labor and suffers a rupture early on (before she can get to the other hospital), your hospital will be responding to the emergency *anyway*. Were that patient planning on birthing at your hospital, you'd already be on standby for them, they'd be pre-admitted, etc. But since she has to be sent soooo far away, you'll have to respond and will be less prepared for it.

That's why I think that a dialog with the policymaking agency might be in order. It sounds like their policy is being abused for purposes that don't match those of the ACOG. A "ruling" from them might help the larger hospital's lawyers see that they're darned if they do, darned if they don't (because if a VBAC client suffers a uterine rupture on the highway halfway to the hospital, and finds out that they might have been ok had that larger hospital allowed yours to take their birth, hello lawsuit).
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#18 of 44 Old 10-31-2007, 02:26 AM
 
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ACOG doesn't care if that means once a section always a section, that is perfectly okay with them. Our perinatal network feels the same way. No amount of evidence is going to change that.
Absolutely! I'm thinking "Born in the USA" by Marsden Wagner here.

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I frankly don't really give a crap what ACOG says. I'm a family doc. Their guidelines are frequently not evidenced-based, but based on "expert opinion." There is not adequate evidence that having in house anesthesia makes a significant difference.
I was actually amazed when I started reading ACOG guidelines at the number of their current practices that were based on level C reccomendations - i.e. those that are "based primarily on consensus and expert opinion." Again, Marsden Wagner anyone?

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I have no intention of risking my malpractice insurance or privileges over this, thank you very much, but if someone does not take a stand and argue in favor of women having the right to make this decision themselves, how many more women will be coerced into surgery?
Exactly! So far there really aren't all that many folks who are willing to do that. Grass-roots movements can be very powerful, but I can't help but think that with some other folks involved we can actually make some headway in this issue. Of course, it would take a radical change in the medical culture. (ala Robbie Davis-Floyd)

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But the fact is, addressing WHERE these bans are coming from is the only real option aside from obtaining 24/7 OB and anesthesia coverage. And the bans are arising from ACOG guidelines.

So, like it or not, ACOG is 'setting the bar' so to speak.
Yes...and this sentiment exactly begs the question - why is a trade union whose primary purpose is to look out for the best interests of their members allowed to "set guidelines"? You don't see other professional membership organizations/trade unions setting guidelines for other areas of society.

The ACOG's really a trade union gone amock is what it is. How about actually wrestling the power from organizations like the ACOG who should stick to what they do best, protecting their members, and leave guideline setting and policy making to those who would actually recognize evidence if it smacked them in the face and understood the value of what the WHO has gone about doing by stating that the actual medically indicated c/s rate should be somewhere near 10-15%?

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ACOG has goals for lowering the overall section rate, and they're NOT getting anywhere near meeting them.
It may just be my jaded self, but I actually think this is nothing more than a PR maneuver than it is about actually wanting to do something about the overall c/s rate. It's more like they can then point to their "goals" and say - see what we've done? See how much we care about laboring women?

Quote:
Originally Posted by Ironica View Post
That's the thing about policy... the hope is that policy shapes behavior in a desirable way for a particular outcome. The outcome that the ACOG wants is for babies to not die because mom chose to VBAC instead of an ERCS. But a secondary desired outcome is to have fewer cesareans performed.
Again, I really don't think this is in line with what the ACOG's actual purpose is. It's purpose is to first and foremost look out for it's members. The primary purpose of the ACOG is not to look out for pregnant/birthing moms.

From one of their own publications:

Quote:
Founded in 1951, ACOG became the specialty’s first
enduring, nationwide, democratic, professional membership organization.
(emphasis mine)

and

Quote:
ACOG works closely with the media to promote the specialty and keep the public informed of new research and current guidelines for women’s health care.
(emphasis)

and from their Strategic Plan:
Quote:
The American College of Obstetricians and Gynecologists, the pre-eminent authority on women’s health, is a professional membership organization dedicated to advancing women’s health by building and sustaining the obstetric and gynecologic community and actively supporting its members. The College pursues this mission through education, practice, research, and advocacy. ACOG will emphasize life-long learning, incorporate new knowledge and information technology, and evolve its governance structure. To achieve its strategic goals, ACOG will develop an operational plan that includes appropriate metrics.
(emphasis mine)

Anyone want to take a gander about what happens when supporting women in labor or supporting women in general conflicts with "building and sustaining the obstetric and gynecologic community and actively supporting it's members"? Which one will prevail?

Seriously...in this day and age with all that we've seen do we really believe that the ACOG is all that unbiased or altruistic?

I'd skip trying to "work with" the ACOG at all and focus instead on the publicity aspect. Hospitals, espcially for profit ones, don't want their share of the pie to shrink when it comes to labor/birth. Why not exploit that and put the spotlight back on them. If they truly believe that their customers will take their dollars elsewhere it can provoke change. It's worked well in other areas where they have succeeded in reversing bans like these.
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#19 of 44 Old 10-31-2007, 07:07 AM
 
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I was actually amazed when I started reading ACOG guidelines at the number of their current practices that were based on level C reccomendations - i.e. those that are "based primarily on consensus and expert opinion." Again, Marsden Wagner anyone?
Can you tell me how to access their policy page without a password? I'd love to read it, but you have to be a member... : Things that make you go Hmmmm...

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#20 of 44 Old 10-31-2007, 02:12 PM
 
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Can you tell me how to access their policy page without a password? I'd love to read it, but you have to be a member... : Things that make you go Hmmmm...
I haven't ever looked at them on their website, just the applicable ones at www.guideline.gov.
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I'd skip trying to "work with" the ACOG at all and focus instead on the publicity aspect. Hospitals, espcially for profit ones, don't want their share of the pie to shrink when it comes to labor/birth. Why not exploit that and put the spotlight back on them. If they truly believe that their customers will take their dollars elsewhere it can provoke change. It's worked well in other areas where they have succeeded in reversing bans like these.
Totally agreed..... Obviously your hospital wasn't all that concerned about ACOG guidelines up until now. Weren't those guidelines put in place around 2004 or before? It's not like this is brand new information causing them to react.

I mean this comment with the upmost respect but if the ACOG is looking out for it's members, why would it listen to a family doctor who isn't throwing intervention with no medical evidence (other than "expert" opinion) at birthing women. It seems like there are better avenues for your energy.

So it's back to determining support women birthing in your hospital. The suggestions that I have are not going to be the easiest to implement but I truly believe they will be the most effective. Would it be possible to solicit the help of local ICAN groups, birth groups, doulas, etc to raise awareness to this issue? Do you know of any clients or other mothers that might be willing to take a stand and organize a rally, notify the media, call in, etc? Even if someone on the ICAN list can bring this to the attention of other women and ask them to call in (could you provide contact information?). The ICAN women have done call-ins before to doctors offices in order to protest vbac bans. Is there a mother who would be willing to contact or talk to the media, even local newspapers? A good reporter would want to talk to affected women as well as doctors and hospital personnel to get the full story.

I know those aren't easy but we've been doing stuff liket his in NJ to protest the high c-section rate in this state. I know change won't be immediate since we are talking about a statewide epidemic but the information is getting out there. Hospitals don't want bad publicity and some are getting it. Others are clearly losing patients due to the word getting out.

I'm so happy to hear your concern and frustrated to hear that another hospital is banning vbacs. I just hope that others can join in.

Proud mommy 9/2004 ribboncesarean.gif , 11/2007 vbac.gif, 2/2011 ribboncesarean.gif
ICAN of New Jersey --> find 2010 NJ hospital birth stats here!

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#22 of 44 Old 10-31-2007, 09:59 PM
 
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Yes...and this sentiment exactly begs the question - why is a trade union whose primary purpose is to look out for the best interests of their members allowed to "set guidelines"? You don't see other professional membership organizations/trade unions setting guidelines for other areas of society.
Oh, yes you do.

The ABA and its state versions do a LOT of setting guidelines and regulating practice of attorneys. They are the licensing organization and provide a major enforcement role. They take complaints, fine those not meeting standards, suspend licenses based on misconduct... a whole lot of regulatory stuff.

For another example, the MPAA is a private trade organization that provides a rating system that has *no* force of law... only the force of theaters knowing that they won't be able to show any of the big releases if they don't abide by the rules.

In both cases, they do it because the *other* choice is governmental regulation. The MPAA ran afoul of this with the Hayes Act, and didn't want to see a repeat. I know less about the history of the ABA's role in regulating attorneys, but the reasoning is similar: if they don't self-regulate, then someone else will do it for them.

This is very relevant to the current birth crisis. There's a health care crisis going on right now, and the 2008 election will feature the issue strongly. There's more and more sentiment for some type of Universal Health Care. So if the ACOG wants to continue to be in a position to protect its members, they'll need to be seen as useful in protecting the public, too.

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I'd skip trying to "work with" the ACOG at all and focus instead on the publicity aspect. Hospitals, espcially for profit ones, don't want their share of the pie to shrink when it comes to labor/birth. Why not exploit that and put the spotlight back on them. If they truly believe that their customers will take their dollars elsewhere it can provoke change. It's worked well in other areas where they have succeeded in reversing bans like these.
I'm not suggesting "working with" the ACOG. I'm really more suggesting putting them on the spot. ;-) They may not respond at all... I'm sorta expecting they won't :-/ but it's worth a shot. If they do respond, either they're going on the record as basically saying that they really don't give a d*mn about the c-section rate, and totally support CYA policies (which undermines their larger position)... or they remove the larger hospital's "excuse" for prohibiting VBACs at the smaller one. Either way, it can't hurt to get a "ruling" from them on this, because either they're hypocrites or they have to admit their guidelines aren't being applied correctly in this case.
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#23 of 44 Old 10-31-2007, 10:34 PM
 
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I mean this comment with the upmost respect but if the ACOG is looking out for it's members, why would it listen to a family doctor who isn't throwing intervention with no medical evidence (other than "expert" opinion) at birthing women. It seems like there are better avenues for your energy.
Or even better...why not just let you go on as you were figuring from their point of view that you'll just end up hanging yourself thereby reducing the competition? (I really only mean this half seriously)
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#24 of 44 Old 11-01-2007, 11:14 AM
 
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I found this interesting...

Quote:
QUALIFYING STATEMENTS

* These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.
* Despite thousands of citations in the world's literature, there are currently no randomized trials comparing maternal or neonatal outcomes for both repeat cesarean delivery and vaginal birth after previous cesarean delivery (VBAC).
Emphasis mine...

OP, this could be a powerful weapon to take to the hospital admin to argue that the ACOG isn't mandating impossible standards and that variation is acceptable.

Thanks Pampered_Mom for the link. I'm glad I was able to find out exactly what "The College" has to say rather than just taking my doc's word for it.

Anna
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In both cases, they do it because the *other* choice is governmental regulation. The MPAA ran afoul of this with the Hayes Act, and didn't want to see a repeat. I know less about the history of the ABA's role in regulating attorneys, but the reasoning is similar: if they don't self-regulate, then someone else will do it for them.
I've been mulling this one over in my head trying to clarify my thoughts so they'd make sens when I set out to write them down. I guess my biggest issue with the way the ACOG goes about doing it is the fact that the guidelines (and those of other medical professional organizations) are hosted on a government website - www.guideline.gov. That's what really rubs me the wrong way about it - because they aren't evidenced based and they aren't backed up by epidemiological studies. I think these kind of "regulations" need to be from a third party organization whose express purpose isn't to look out for the best interest of their members - the OB/GYNs. Make sense?

Anna - No problem! I too found it incredibly enlightening becayse the OB I was seeing while pg w/my son lead me to believe that the guideline said one thing when in fact quite the opposite was true. The unfortunate part is that the aspects that you highlight really are quite the opposite of the way the guideline is put into practice IRL.
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I've been mulling this one over in my head trying to clarify my thoughts so they'd make sens when I set out to write them down. I guess my biggest issue with the way the ACOG goes about doing it is the fact that the guidelines (and those of other medical professional organizations) are hosted on a government website - www.guideline.gov. That's what really rubs me the wrong way about it - because they aren't evidenced based and they aren't backed up by epidemiological studies. I think these kind of "regulations" need to be from a third party organization whose express purpose isn't to look out for the best interest of their members - the OB/GYNs. Make sense?

Anna - No problem! I too found it incredibly enlightening becayse the OB I was seeing while pg w/my son lead me to believe that the guideline said one thing when in fact quite the opposite was true. The unfortunate part is that the aspects that you highlight really are quite the opposite of the way the guideline is put into practice IRL.
What I found even more disturbing was that if you go to the ACOG website, you have to be a member to review their policies. : I guess they figure that if the general public gets a hold of this malarkey, then the OBs can't have that power over relationship with their patients. And I have no idea if they host any studies on their website, but just about every other medical professional organization at least has the abstracts to their peer reviewed journal articles and studies on the web for public consumption. You would think something as fundamental as a policy statement would be made public and without charge directly from the source. :

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Since the hospital is implementing a no VBAC policy because of pressure from your larger backup hospital, would community pressure from consumers do any good? Would your small hospital even have a choice even if they *wanted* to provide VBACs? Or would consumers need to turn the heat on to the larger backup hospital and demand that the perinatal agreement be based on real evidence (such as the AAFP's recommendations for VBACs)? C

Could you really lose privileges for advocating for patient's rights to refuse treatment? Who would make the decision to withhold/revoke privileges if this ever came up?

Sorry, more questions than answers...
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#28 of 44 Old 11-05-2007, 10:16 AM
 
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I'm wondering if it would be possible to mobilize other organizations that aren't totally birth-related, such as NOW. Two years ago it passed a resolution opposing VBAC bans, and I think the "patient's right to refuse treatment" and "woman's right to choose" arguments could be very compelling.
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#29 of 44 Old 11-08-2007, 01:42 AM
 
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I've been mulling this one over in my head trying to clarify my thoughts so they'd make sens when I set out to write them down. I guess my biggest issue with the way the ACOG goes about doing it is the fact that the guidelines (and those of other medical professional organizations) are hosted on a government website - www.guideline.gov. That's what really rubs me the wrong way about it - because they aren't evidenced based and they aren't backed up by epidemiological studies. I think these kind of "regulations" need to be from a third party organization whose express purpose isn't to look out for the best interest of their members - the OB/GYNs. Make sense?
Hmmm... I see guideline.gov as more of a clearing house/public service than an endorsement. The Federal government has no mechanism or power to set or enforce medical protocols, of course. In the case of the ACOG, the service is very valuable, since unlike the other professional organizations (AAP, AAFP, for example) they don't make their guidelines public on their own website. The AAFP's guidelines on VBAC (well, TOLAC is how they put it) are also on guideline.gov, even though they differ from the ACOG's guidelines in some details. And they even host a guideline from the Alzheimer's Association, which is a private volunteer non-profit organization (I'm sure it's not the only example... I was just going in alphabetical order ;-).

These aren't regulations. They're basically suggestions, and hospitals set policies based on them either closely or loosely. From looking at what the ACOG actually *says*, it's clear that most hospitals use a lot of other material in making policy too, usually that provided by their lawyers :-/. The real problem is the attorneys practicing medicine, not the professional organization creating the rules!

Now, this all does inspire one other idea: can the OP make the point to her hospital (and then, hopefully, up the chain to the other hospital) that the current policy is asking her to go AGAINST the guidelines for TOLAC set forth by her own professional organization? Recommendations 1 and 4 clearly say that she SHOULD be offering TOLAC to many clients currently not eligible under the policy.
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#30 of 44 Old 11-08-2007, 05:19 PM
 
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These aren't regulations. They're basically suggestions, and hospitals set policies based on them either closely or loosely. From looking at what the ACOG actually *says*, it's clear that most hospitals use a lot of other material in making policy too, usually that provided by their lawyers :-/. The real problem is the attorneys practicing medicine, not the professional organization creating the rules!
They're considered the rules to follow and are really the foundation of the way most obs practice in this country. Since they have a monopoly on childbirth and historically do everything they can to prevent competition I don't really think one can shift the blame to attorneys.

Seriously...defending the ACOG by blaming lawyers? Sounds like a page from their own playbook. The lawyers aren't to blame here - the present birthing culture is very firmly rooted in the ACOG and it's members.
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