Grassroots Network: NIH Consensus Development Conference on VBAC

Dear Friends,

As most of you know by now, the National Institutes of Health (NIH) convened a Consensus Development Conference on VBAC (vaginal birth after cesarean) in Bethesda, MD on March 8-10, 2010. I felt privileged to represented CfM and be one of the voices for consumers, trying to keep the focus on what is best for women and babies rather than the concerns and pressures that hospitals experience.

It was clear that many of the presenters really understood the problem of VBAC bans, especially Rita Rubin who gave a powerful presentation of women's stories. There was plenty of frustration, too, especially near the end when the panel ethicist refused to acknowledge a pregnant woman's right to refuse surgery, even when she has appropriately weighed the risks to herself and her baby.

All in all, I think the conference really moved the VBAC conversation in the context of other problems in maternity care. It remains to be seen just how much medical practice - and culture - will change as a result of the panel recommendations.

This Grassroots Message includes CfM's response to the NIH Consensus Report on VBAC. At the bottom, I've included links to the NIH conference documents, media coverage. Happy reading! Citizens for Midwifery on the 2010 NIH Consensus Development Conference on VBAC

Our overall assessment of the NIH report can be found below and links to much of the media coverage below that. A full analysis can be found here.

The NIH panel recommendations urge two courses of action that, if implemented, would go a long way toward improving the situation for women with prior cesareans. They state that their goal is to "support pregnant women with a prior transverse uterine incision to make informed decisions about TOL [trial of labor] and ERCD [elective repeat cesarean delivery]". To do that, they (1) urge evidence-based practice, and they (2) urge ACOG to reconsider "ACOG #5". CfM agrees. We would also like to see the following actions:

* All hospitals and OBs should start supporting VBACs, not just "offering" and "encouraging". CfM believes the Midwives Model of Care represents that support of physiologically normal birth.

* ACOG should rescind "ACOG #5" immediately. In doing so, insurance companies would no longer have a basis for dropping or threatening to drop malpractice insurance or raising insurance rates on practitioners and hospitals that offer VBAC, as those individuals and institutions will merely be responding to both the evidence and the guidelines. By rescinding "ACOG #5", ACOG and its members would be taking a step toward earning back the trust and confidence of the women they serve.

* Informed consent must be based on an honest risk assessment, including information about provider outcomes, provider bias and conflicts of interest, as well as the research evidence, in order to support all women, not just VBACing women, to have healthy births.

Willa Powell

CfM President

---
The NIH documents can all be reached from their press release, including the full report, the full evidence report, and recorded webcasts of the conference:

http://www.nih.gov/news/health/mar2010/od-10.htm

There has been a great deal of news coverage, including:

http://www.nytimes.com/2010/03/11/health/11birth.html

http://www.npr.org/templates/story/story.php?storyId=124542025

http://www.msmagazine.com/news/uswirestory.asp?ID=12295

Many organizations are developing press releases and responses including ICAN and Lamaze:

http://ican-online.org/print/node

Lamaze

A running blog discussion from the conference can be found at

http://thefeministbreeder.com/once-a-cesarean-rarely-a-choice

http://thefeministbreeder.com/nihvbac

and several blog postings with ongoing discussion can be found here:

http://www.theunnecesarean.com/blog/2010/3/10/nih-vbac-consensus-development-conference-gift-horse-or-troj.html

This article anticipated the NIH conference and very much supports CfM's philosophy:

http://www.nytimes.com/2010/03/07/health/07birth.html?partner=rss&emc=rss

A fairly comprehensive list of articles on this conference is available at:

http://birthaction.org/Blogs/tabid/66/EntryId/64/Articles-and-blogs-on-the-NIH-VBAC-Consensus-Panel.aspx

There's even a petition: http://www.petitiononline.com/VBAC2010/petition.html

Birth Book

My review of the classic book Birth Book by Raven Lang was posted on the CAPPA blog this week.

Just a reminder that the book is available in a limited edition reprint from CFM here! The book is very hard to find on the secondary market.

--
Molly
CfM Blogger

Reminder about CfM Survey!

It isn't too late to share your feedback with Citizens for Midwifery via our online survey. It is open until April 2nd and we would dearly love your contributions! This survey is being conducted as part of an effort to strengthen the direction of the organization as goals are set for the coming years.

Please take the opportunity to share your voice with CfM!

--
Molly
CfM Blogger

Grassroots Network: “A Victory for Mothers and Babies”

Dear Friends,

The CfM Board is celebrating the improvements for mothers, babies and families that are part of the health care reform bill passed last night! Read below the latest from the MAMA Campaign lists those improvements. We are proud of our work with the MAMA Campaign, which will continue to work for increasing access to Certified Professional Midwives!

Sincerely,
Susan Hodges, “gatekeeper”


From the MAMA Campaign:

A Victory for Mothers and Babies!
Midwives and mothers, babies and families, are victors today! With the passage of the Senate health care reform bill in the U.S. House of Representatives on Sunday, March 21, and the signature of the President in the coming days, several provisions that will significantly benefit mothers and babies will now be the law of the land! These provisions will increase access to birth options for low-income women across the country, and will improve the quality of maternity care for all women in the years to come. The MAMA Campaign is proud to have had a role in improving conditions for midwives and mothers in this landmark legislation.

The following are now law:

• MAMA Campaign’s “partial victory”: Senator Cantwell’s provision that will have the effect of requiring Medicaid reimbursement for licensed CPMs offering services in licensed birth centers
• American Association of Birth Center’s provision that mandates Medicaid reimbursement of the birth center facility fee
• Childbirth Connection’s provision requiring quality assessment and improvement measures specific to maternity care
• American College of Nurse Midwives’ equitable reimbursement act for Certified Nurse Midwives
• And: giving birth, having a cesarean section, or being the victim of domestic abuse will no longer be considered pre-existing conditions and used to deny insurance coverage to women!

What Happens Now With This Legislative Process?
Last night, the House of Representatives passed the Senate health care reform bill that contains the above provisions and the President will sign this bill into law in the coming days. The House also passed a companion reconciliation bill, popularly called a “side car" or "fix it”, to address the House’s concerns about the Senate bill. This companion bill now goes to the Senate for consideration. It is expected that debate will begin in the Senate on Tuesday, and that Republicans will introduce a number of amendments, with debate taking several days. The Senate will be considering this bill under the reconciliation process which requires a simple majority to pass, and Democrats appear confident that they have the votes to pass this bill in the Senate.

Thank You for Your Role in This Victory!
Thank you to each and every one of you who supported the MAMA Campaign and these provisions for women and families. Every letter that you wrote and every dollar that you gave made a difference! We look forward to working with you this year as the MAMA Campaign continues the effort to cover all CPM services in all settings in the Federal Medicaid program.

Moving Beyond Health Care Reform- MAMA Continues to Fight for CPMs
MAMA continues to be on the move for midwives and mothers in Washington, D.C! The MAMA Campaign Steering Committee met in Washington, D.C. two weeks ago, March 5th – 7th, to evaluate the campaign to date and to re-commit to working together to achieve our central goal: to amend the Social Security Act to require the reimbursement of all CPM services in the Federal Medicaid program. On March 5th, 8th & 9th, steering committee members met with 35 Congressional offices on behalf of midwives and mothers. It was clear in these visits that our policy gained significant support in 2009 in key offices and that this support can be leveraged as we move forward in 2010.

You will be hearing from us over the next weeks and months, asking for your input, your engagement and your support as MAMA continues to do our part to improve maternity care in the U.S. and to increase women’s access to Certified Professional Midwives.

Thank Your Legislators!
If your Senators and Congress Members voted for health care reform, including the provisions for women and families, please write to them to thank them. If your legislators voted against health care reform, please write to ask them to ensure in Federal legislation that women have access to Certified Professional Midwives, a high-quality, low-cost option. As always, your legislators need to hear from you on behalf of midwives and mothers!

Support Your MAMA
In celebration of the passage of our “partial victory” and in support of our on-going work to increase women’s access to Certified Professional Midwives, please consider donating to the MAMA Campaign today!

If you have any questions, concerns or comments please contact the campaign at info@mamacampaign.org.

Women's (Birth) History Month

Birth Activist is having a blog carnival in honor of Women's History Month this month. The theme is about women in history who have changed pregnancy and birth. I immediately knew that Ina May Gaskin's name would probably appear in every post writing about this theme (go Ina May!). So, that led me to think about the other "classic" authors who have had a profound influence on my own ideas about birth. This thought, coupled with the fact that for some time I've wanted to write a post about "older birth books" that are still excellent reads today, has brought me to this moment: a list of my favorite "old" birth books and the lovely women who wrote them. When I first started out in birthwork, I wanted to read "new" stuff--stuff that was "up to date" and "current." After I read almost all of the "new" books, I started to cast my eye around for more and guess what I discovered? No surprise to many of you, but many of those "out of date" books with the retro-looking covers are still just as good and just as relevant as they were 20-30 years ago. Since medical information and science/evidence changes fairly rapidly and a pregnancy and childbirth 101 type book from 30 years IS more often than not completely inappropriate today, I had made the mistake of thinking ALL "old" birth books would be similarly irrelevant. Instead, many have a power and passion that is not easy to come by in any decade and that rouses the activism spirit or stirs the heart or challenges the psyche just as effectively today. Here are some of my recommendations (and of course, Spiritual Midwifery is a good choice too, I just want to add some less usual recommendations!):

• Transformation through Birth by Claudia Panuthos (also known for writing another great resource: Ended Beginnings: Healing Childbearing Losses). Written in 1984, this book "goes beyond" the scope of traditional birth books and really gets into some deep topics and insightful ideas.
• Special Delivery by Rahima Baldwin (another good, less well-known one from her is Pregnant Feelings). Revised in 1986, this book is one of my favorite homebirth resource books. Though some segments are in fact, "outdated," I find this to be one of the very best ("old" or new!) resource books for women planning to give birth at home.
• Open Season by Nancy Wainer (Cohen) in 1991 (how can 1991 be called "old"? Well, it was nearly 20 years ago and considering that many women giving birth today were born only a couple years prior to that, it IS old!). Nancy has a lot of FIRE and I love it. Some people have been known to call her "angry" or "bitter." I call her...amazing. Her writing lights you up and calls you to action. She has incredible passion, fire, brightness, drive, and enthusiasm. Recently one of her newer articles in Midwifery Today has been making the Facebook rounds: VBAC and Choice.
• Birth Book by Raven Lang (available in a limited edition from Citizens for Midwifery). This is the original counterculture birth book written in 1972 at the launch of what would become the modern movement to return birth to the hands of women.
• Childbirth with Insight written in 1983 by Elizabeth Noble, is another one of the birth books that I say "goes beyond." As a childbirth education, I especially benefitted from her exploration of some of the failings of traditional approaches to childbirth education.
• Lots of older books from Sheila Kitzinger are very good also. I particularly enjoy The Experience of Childbirth and Giving Birth: How it Really Feels.
• My last recommendation for today is Mothering the New Mother by Sally Placksin (revised in 2000, which again sounds fairly recent, but in reality is ten years ago--how is that possible?). It is classic must-read for doulas as well as any other birth companions. It is wonderful and I wish I would have read it before my own first child was born.
  

There are many more excellent books out there, both modern and "historical," but I'll leave you with these treasures for now. I'm grateful for each of these birth activists whose words and spirits helped deepen and refine my own passion for birth.

--
Molly
CfM Blogger

Grassroots Network: Be Part of CfM’s Exciting Change!

Dear Friends,

Be Part of CfM’s Exciting Change!

Citizens for Midwifery is looking for feedback from our members and supporters. As part of our exciting transition, with new leadership and an expanded board ahead of us, we at Citizens for Midwifery are thinking about how we can better focus our work to serve our members and friends: you! So:

· CfM is conducting a survey. Please participate here.The survey will only be available till April 2nd, so please take the survey today!

· CfM is holding our annual meeting as a webinar on March 23^rdat 8 PM Eastern Time. Please register here to join us--everyone is welcome. During our webinar meeting on March 23^rd, we will also gather feedback from participants and share information about CfM. Visit the URL above to register.

We want to hear your opinions. Your participation is crucial to our growth, so please join in. The survey results and the feedback during the webinar will help inform CfM's mission, goals, and services as we move forward in 2010.

Thanks so much for your time! We really look forward to hearing from you!

Sincerely,
Susan Hodges, “gatekeeper”

Book Review: Get Me Out

Book Review: Get Me Out: A History of Childbirth From the Garden of Eden to the Sperm Bank
By Randi Hutter Epstein, MD
W.W. Norton & Company, 2010
ISBN 978-0-393-06458-2
302 pages, hardback, $24.95
http://www.randihutterepstein.com/

Reviewed by Molly Remer, MSW, ICCE
http://talkbirth.wordpress.com

Since it shares a subtitle about the history of childbirth, I expected the new book Get Me Out to be very similar in content to the recent book Birth Day by Mark Sloan or to the book Birth by Tina Cassidy. I wondered how much more could possibly be reported about the history of childbirth. It turns out there is plenty more and I was delighted to discover that Get Me Out stands alone as a unique and interesting contribution to books of this genre.

Written by a physician and mother of four, Get Me Out focuses on some very recent elements of birth history including assisted reproductive technologies (ART), ultrasound, and freebirth, subjects not addressed in the books referenced above. Aside from familiar content about things like the Chamberlen brothers and the Twilight Sleep movement, the remainder of the text was fresh and engaging. Part one included an interesting and disturbing chapter about Marion Sims and his research and experiments with fistula repair on enslaved women. A later chapter explores Sims’ research with artificial insemination (this time with middle class white women). In fact, the latter half of the book contains an extensive historical look at artificial insemination, moving into present day history including an exploration of sperm banking and cryo-preservation of eggs.

Unique among birth history books is Epstein’s chapter on freebirth (more commonly known as “unassisted childbirth”) followed with a chapter about ultrasound including content about 4D and “novelty” ultrasounds. There is also a chapter exploring DES and its effects on reproduction.

Also different than Birth Day and Birth, is the total absence of memoir or personal reflective content. Epstein is a medical journalist and Get Me Out is written in that voice. There is a light, personal tone to the text, but nothing personal aside from occasional descriptions, observations, or quotes from interviews with sperm bank mangers (for example). I found myself feeling a little curious about her personal history of childbirth, an element freely interspersed throughout the texts of other recent birth history books.

As the author says, “…the way we give birth is a story about our deepest desires and our fundamental concerns about life, death, and sex.” Get Me Out is a fascinating tale focusing on our collective, cultural story about birth in the late nineteenth and twentieth centuries, as well as dip into the story that continues being written today.

--
Disclosure: I received a complimentary copy of this book for review purposes.

NIH VBAC Conference

The NIH Conference on VBAC is currently in progress. Citizens for Midwifery's new president, Willa, is attending the conference and has been able to pose questions about VBAC bans and also to make a statement about the lack of feasibility of conducting double-blind trials in VBAC study as well as to encourage the inclusion of a homebirth cohort as a control group in studies.

If you haven’t been able to watch the conference, here some some other resources:

Abstracts PDF

Live Twitter coverage on Feminist Breeder

Those will at least give you a flavor for how things are going!

--

Molly

CfM Blogger

International Women's Day

Today is International Women's Day! Yesterday, I watched Eve Ensler speak about "the girl cell" on YouTube. It contains some very disturbing content about rape and abuse and war violence against women in other countries. I also happened to read the following quote in The Birth Project book I am currently reading: "...if Beth or I recounted the facts of birth conditions in this or that country, we would be silenced by someone recounting her 'wonderful' home birth experience, as if her personal good fortune somehow overshadowed the larger political, social, and medical implications of what we had learned about the rest of the world." These two experiences made me think about the larger world of women and the many forms of violence they may experience in their lives (I've mentioned here several times that my pre-childbearing past was spent working in domestic violence shelters). It also made me think, however, that we cannot discount or ignore the violence women may experience in the birthplace in the U.S. Though it may not be as horrific and degrading and violating as some other experiences or as the experiences of women living in war-torn countries, it still is an important issue worthy of concern. It is also an issue that I see nothing about on the International Women's Day website, which I find interesting. There is a lot of excellent information on the site--but nothing that I can find about international birth issues.

Last year, I wrote an article about Birth Violence for their website, but it appears to have never been published. So, I decided to post it here in honor of this year's International Women's Day.

Birth Violence
by Molly Remer

"'Old wives' tales,' says the Oxford dictionary, are 'trivial stories, such as are told by garrulous old women.' It is significant that no one ever talks about 'old husbands' tales' or 'old doctors' tales.' Women are blamed instead. It is implied that there is poison in their speech and that the only safe thing to do is remain silent. The experiences that women share with other women are thus rejected and trivialized...In reality, it is not other women who instill and fuel anxiety in most pregnant women, but the medical system itself." This quote from the 1980’s book, Giving Birth, by Sheila Kitzinger, remains strikingly relevant today. When women in the United States today enter the hospital to give birth, many experience some form of institutional violence. They may not explicitly define it as violence, but listening to their stories provides a disheartening picture of maternity care today.

What kinds of violence occur in the birth place? Here are a few possible examples of “normative abuse” women may experience when giving birth in U.S. hospital setting

• Restriction of movement
• Restriction of nourishment
• Domination by those in positions of authority—must obey even when it is against her own best interests.
• Routine, forced interventions such as IVs
• Repeated, possibly painful, vaginal examinations by many different people
• Denial of option for VBAC (vaginal birth after cesarean)
• At the most extreme example of overriding patient rights, a forced cesarean section
• Vaginal cutting (episiotomy)
• Abusive language
• Separation from family/restriction of companionship
• Lack of respectful treatment
• Voice and wishes disregarded/unheard
• Emotional manipulation using baby as a “card” to force compliance (“you want a healthy baby don’t you?” No mother doesn’t. It is degrading and dehumanizing to suggest that she doesn’t.)
• Forced separation of mother and baby
• Administration of medications without consent
• Cord traction and interference with third stage (placenta) that may lead to hemorrhage.

The emotional treatment of women in labor is the most significant factor contributing to their satisfaction with their birth experiences (emotional factors of highest importance include having good support from caregivers and being treated with respect). According to Kitzinger, "We are only now discovering the long-term destructive effect on human beings and families of treating women as if they were merely containers, to be opened and relieved of their contents; and of concentrating attention on a bag of muscle and a birth canal, rather than relating to, and caring for, the person to whom they belong. The violence which is a common element in childbirth today leaves many women feeling that birth has been a kind of rape. This sort of experience is not easily forgotten. It can shatter a woman's self-confidence, make her doubt her ability to mother her baby, destroy joy in the expression of her sexuality, and attack her very sense of self--the roots of her identity. It is psychologically mutilating."

And, as Mary Rucklos Hampton says, "The effort to separate the physical experience of childbirth from the mental, emotional, and spiritual aspects of this event has served to disempower and violate women."

--
Molly Remer, MSW, ICCE is a certified childbirth educator and activist who blogs about birth at http://talkbirth.wordpress.com and midwifery at http://cfmidwifery.blogspot.com.

Book Review: L’Mazeltov: Your Personal Guide to Jewish Childbirth Education

L’Mazeltov: Your Personal Guide to Jewish Childbirth Education
By Pamela Nadav
L’Mazeltov, Inc. 2008
Softcover, 248 pages, $18.00
ISBN: 978-097786610-6
www.lmazeltov.org

Reviewed by Molly Remer, MSW, ICCE
http://talkbirth.wordpress.com

The title of the new Jewish childbirth education book L’Mazeltov combines “two important Jewish symbolic expressions—L’Chaim (To Life) and Mazel Tov (Good Fortune).” The first half of the book consists of basic childbirth education and preparation. The second half is about "Jewish Life Cycle Education." The strength of this book is the fusion of the two.

The childbirth education section was very conventional and conservative. I was surprised by some of the advice offered such as, “Always follow your doctor’s advice in all matters related to your pregnancy, labor and delivery” and in the section about anesthesia, “All of these modern technologies are designed to assist you in having the best possible birthing experience, and are considered to be relatively safe.” Personally, I feel like an important piece of childbirth education is encouraging pregnant couples to be informed birth consumers. There was no element of this perspective within L’Mazeltov.

The book includes some population-specific pregnancy information such as a short section on Jewish genetic diseases and testing.

There is a nice recipe section at the end of L’Mazeltov. I was inspired to make some delicious Challah bread for my family! There is no index, resource list, or glossary of terms (as a non-Jewish reader, many words were unfamiliar to me—the author does a good job defining many within the body of the text, however).

Despite my wish for a more creative and evidence-based approach to the birth education portion, this book is a one-of-a-kind contribution to birth literature, covering both the “oys and joys” of preparing for parenthood. What a resource for Jewish couples expecting their first baby! “There is such a special sweetness in being able to participate in creation.”

--
Disclosure: I was provided with a complimentary copy of this book for review purposes.

Review first published in The CAPPA Quarterly, January 2010.

Grassroots Network: Numbers of Out-of-Hospital Births Have Increased

Dear friends,

Exciting news about out-of-hospital birth! A just-released report from the Centers for Disease Control (the CDC) showed that the number of out-of-hospital births increased by 5% from 2004 to 2005 and stayed up in 2006 (the numbers had been gradually decreasing over the previous 14 years). In fact, in nine states, out-of-hospital births rose by 15% or more!

This report confirms what has been sensed in the out-of-hospital birthing community for awhile: the amount of demand, interest and births in out-of-hospital settings and the midwives who assist in them are on the rise, and the increase has to do with families wanting births that feel safe, private, affordable and in keeping with their cultural and religious practices. The report goes on to show that out-of-hospital births have better outcomes: fewer pre-term and low-birth weight babies. One theory about these outcomes is that they can be attributed in part to the high-quality, personalized, preventative prenatal care offered by out-of-hospital midwives (including CPMs, Certified Professional Midwives).

On a side note, this report also shows that women have been increasingly seeking out-of-hospital births several years before the release of Abby Epstein and Ricki Lake's popular film The Business of Being Born (2008), proving that this film and other media interest in out-of-hospital birth reflect, not lead, the desires and actions of American families.

To download the full CDC report, go to http://www.cdc. gov/nchs/ data/nvsr/ nvsr58/nvsr58_ 11.pdf.

Sincerely,
Arielle Greenberg Bywater
"sidekick"

Grassroots Network: Opportunity for VBAC Feedback at Upcoming NIH Conference

Dear Friends,

I am the new president of Citizens for Midwifery, and I will be attending the Vaginal Birth After Cesarean (VBAC) Consensus Development conference sponsored by the National Institute of Health (NIH) in Washington DC on March 8-10, 2010. This conference will examine the research around VBAC and may impact birth, especially VBAC, for the next decade.

We know from our experience with the NIH's so-called patient choice cesarean conference that our presence, pressure and input can make a difference. On the issue of VBAC, we want to make it clear that hospital bans on VBAC violate our right to informed consent/informed refusal. Curiously, there is no speaker specifically addressing this Patients Rights point. We need to hammer it home at every opportunity...with evidence of the overuse of C/S in the first place...with evidence of the safety of VBAC and the risks associated with repeat C/S...and armed with our Constitutional right to bodily integrity: with or without evidence.

Even if you can't get to DC, you can watch the conference and participate online. You can also sign up to receive the resulting statement and watch the video archive afterward. Indeed, I'm asking everyone to sign up to receive the statement that will be the result of this conference: go here and find the Pre-order Statement button at the top of the page. Signing up to receive the statement - all by itself - communicates to the NIH that there is tremendous interest and public involvement on this issue.

At the same website, you will see an outline of the speakers list and agenda and sign up for the live webcast or there are several ways in, via calendar, for example: here or here. If you are at all able to view all or part of the live webcast I urge you to do so.

There is generally an opportunity for the audience to ask questions or redirect attention after each presentation. If you can watch, and want to ask a question, email me at willa@cfmidwifery.org, post on the wall of our Facebook Fan page, or text me at 585.729.5161, and I'll do my best to make your points live and in person. If I can't, there is an opportunity to submit written feedback on-site. It may also be possible for webcast viewers to leave feedback in real time, and you can post comments on the draft document on Wednesday morning.

Please plan to watch and weigh in.

Willa Powell, President

Citizens for Midwifery

willa@cfmidwifery.org

Note from Molly: I'm not sure if all the links are working correctly--the calendar link doesn't work for me, but I think maybe I am missing something.