The bill was just released from the House Policy and Steering Committee and is now in Third Reading, chaired by Rep. Vincent Pedone of Worcester.  The legislative session closes on Saturday, July 31. If it’s not voted on by then, the bill would die and have to be reintroduced in the next legislative session.

If you’re able to discuss the bill with your legislator or a staff member, please be aware that some legislators have misinformation about the midwifery bill’s content, especially regarding the items below. Here’s some background:

1. The Massachusetts Medical Society strongly objects to CNMs functioning without direct MD supervision, yet has articulated no sound basis for this objection. Nationally, ACOG already supports the elimination of direct supervision of CNMs by physicians, acknowledging that it is not required for safe practice, and 44 other states no longer have such requirements.

2. Some legislators incorrectly think that the bill would provide new prescription-writing privileges for nurse-midwives — this is not really the case. Nurse-midwives already have prescription-writing privileges but can now exercise these privileges only if an MD is technically providing supervision, which amounts merely to a review of sample prescriptions on a quarterly basis.

Because of hospital accrediting rules, this clause prevents CNMs from admitting patients in labor under the midwives’ own names; prevents CNMs from serving on hospital committees that determine maternity care policies; and bars them from control of their own practice environment. This undermines the ability of CNMs to provide the most effective care. (CNMs already have independent prescription authority in most other states, including New Mexico, New Hampshire, Washington, Arkansas and Oregon, and the District of Washington.)

3. Although the legislation has already been rewritten to accommodate concerns about the age at which a midwife could begin training (it was changed from 18 to 21), legislators are still being misled about this fact. There are, by the way, no such age requirements that we have been able to find in the Massachusetts statutes with respect to the education of nurses.

4. Another objection is that the bill does not require a midwife to carry malpractice insurance. In almost all states, malpractice insurance is not required by statute, and it would be unfair to single out one professional group in this regard. Some would argue that such a requirement would violate equal protection clauses.

Because the “risk pool” of homebirth midwives across the country is small, malpractice insurance has never been available for homebirth midwives, despite the concerted efforts of national and local organizations over several decades. Requiring CPMs to adhere to a standard that is impossible is another mechanism to restrain trade and prevent access to home birth midwives.

Childbearing women who want to be protected by malpractice insurance have the option of delivery in facilities, where such insurance coverage is required. Moreover, the Massachusetts legislature could follow a few other states in making disclosure of this absence of malpractice insurance coverage part of a required informed consent procedure. The malpractice insurance issue is not a credible objection to this bill.

Please share this news, and thanks for taking the time to take action on this important piece of legislation!

From organizations:
Lamaze International calls the new guideline “a step in the right direction, clearly stating that women with one previous cesarean should be offered VBAC,” but wonders if there is too much of the “immediately available” language still in the current version.

Choices in Childbirth applauds the new version for “encourag[ing] autonomy for women in their maternity care decisions.”

The International Cesarean Awareness Network expresses that ACOG is going to need to take “an active role in educating both women and practitioners about healthy childbirth practices; practices that not only encourage VBAC but discourage the overuse of primary cesareans” in order to “reverse the over a decade long trend of increasing cesarean rates and decreasing VBAC rates.”

From the blogs:
Birthing Beautiful Ideas expresses that the importance of the new guideline is “not because it will effect any immediate policy changes but because it gives women a tool to help them facilitate discussions with their care providers and/or their local hospitals so that they can advocate for their birthing options.”

Jill at The Unnecesarean asks How will ACOG handle the PR challenge of promoting VBAC as a safe option? and wonders how the organization and individual physicians will approach the shift in attitudes toward VBAC that the new bulletin represents. She also has links to coverage at several other blogs.

The Well-Rounded Mama is lighting virtual fireworks over the bulletin’s Good News for Vaginal Birth After Multiple Cesarean! (The new guideline says that women with two previous low transverse incisions can be considered candidates for a trial of labor)

Amie Newman at RHRC, Babble, and Broadsheet also discuss the new guideline.

Seen other online commentaries or responses worth a look? Please share them in the comments!

ACOG’s press release on the guidelines is available online; the full recommendation, which appears in the journal Obstetrics & Gynecology (August 2010 issue), is available here as a PDF.

The guidelines, noting the decreasing VBAC rate, increasing cesarean rate, and lack of access to a trial of labor at some hospitals, takes an approach that clearly emphasizes individualized decision-making (rather than blanket policies) and women’s autonomy.

First, the document recognizes that desire for VBAC is not simply a lifestyle choice or preference, but one with implications for women’s health and outcomes:

In addition to providing an option for those who want the experience of a vaginal birth, VBAC has several potential health advantages for women. Women who achieve VBAC avoid major abdominal surgery, resulting in lower rates of hemorrhage, infection, and a shorter recovery period compared with elective repeat cesarean delivery. Additionally, for those considering larger families, VBAC may avoid potential future maternal consequences of multiple cesarean deliveries such as hysterectomy, bowel or bladder injury, transfusion, infection, and abnormal placentation such as placenta previa and placenta accreta.

The authors explain further that, “VBAC is associated with fewer complications, and a failed TOLAC [trial of labor after cesarean] is associated with more complications, than elective repeat cesarean delivery. Consequently, risk for maternal morbidity is integrally related to a woman’s probability of achieving VBAC.”

It goes on to review a number of factors that may be associated with a woman’s likelihood of successfully having a VBAC after a trial of labor, emphasizing the need to examine the clinical picture for an individual woman with regards to the potential benefits and harms of elective repeat cesarean, VBAC, and failed trial of labor. Again, there is explicit consideration for individual autonomy, with the statement that “The balance of risks and benefits appropriate for one patient may seem unacceptable for another.”

With regards to who may be a good VBAC candidate, the document states that “The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC,” and reiterates that “Individual circumstances must be considered in all cases.”

This recommendation was actually present in the previous (2004) recommendation, but was offset by the so-called “immediately available” standard which led many facilities to decide that offering VBACs was not an option.

The current document states that “Restricting access was not the intention of the College’s past recommendation.” It clarifies that while facilities offering trials of labor should have “staff immediately available to provide emergency care,” when organizing transfers to better equipped facilities is not realistic, “Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk.” Patient counseling and early conversations between the woman and her provider are urged, with the ultimate decision to be “made by the patient in consultation with her health care provider.”

Patient education and access to trial of labor is emphasized throughout, and I think this is the key portion for those concerned about autonomy and forced or court-ordered cesarean:

…none of the principles, options, or processes outlined here should be used by centers, health care providers, or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC as safe as possible for those who choose this option….Respect for patient autonomy also argues that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.

Also of interest may be the conclusions that women with two previous low transverse incisions, carrying twins, or with single previous cesarean with an unknown type of incision may be candidates for a trial of labor.

Overall, I think the new practice bulletin is going to be much more agreeable to advocates and useful as a tool in encouraging hospitals and providers to reconsider their VBAC practices. We look forward to hearing your take in the comments!

Efforts against shackling, led by a coalition that includes the ACLU and The Rebecca Project, have gained significant ground recently. Colorado, West Virginia, Washington state and Pennsylvania passed laws in 2010 banning the practice.

And the American Medical Association (AMA) voted in June to develop model legislation states can use to pass their own anti-shackling laws. The AMA resolution condemned the practice, calling it “barbaric” and “medically hazardous.”

But recent stories by Colleen Mastony of The Chicago Tribune and Andrea Hsu of NPR offer vivid and personal reminders of the entrenched and widespread use of shackling — even in a state like Illinois that has supposedly banned the practice.

In fact, more than 20 lawsuits have been filed by women against the Cook County sheriff’s office since 2008, even though Illinois became the first state to ban the practice in 1999. The lawsuits were granted class-action status last month; attorneys told Hsu that there ultimately could be up to 150 women included in the case.

From the Tribune:

Latiana Walton went through most of her labor at Stroger Hospital with an arm and leg chained to her bed, she remembers.

As contractions surged through her body, she could not move or change position to relieve the pain. A Cook County correctional officer repeatedly refused to remove the restraints, she said, even when a doctor objected, saying that he was unable to administer an epidural.

“I actually said to the guard, ‘Where am I going?’ I’m crying. I’m in pain,” recalled Walton, 26. “‘I’m not going to get up and run out of the hospital.’”

On Aug. 27, 2008, Walton, who had been arrested after she missed a court date on a retail theft charge, became one of an estimated 50 women who give birth every year while in the custody of the Cook County Jail. [...]

In Walton’s case, she did not get an epidural and the guard agreed to remove the leg shackle only 10 minutes before she gave birth to her son, Darrion, she said. The handcuff remained on through the delivery, and the leg shackle was replaced immediately after the birth, she said.

“I couldn’t push the placenta out because I couldn’t position my legs,” Walton said. “It is not fair to treat a person like this. I did a crime … but I’m not willing to be treated like a dog. I was treated like I wasn’t human.”

Almost all of the women are low-level, non-violent offenders — their crimes include drug possession and forged checks. Yet the Cook County Sheriff’s office believes it is following the law in these cases:

A pregnant woman can be restrained, according to the policy, until a medical official confirms that she is, in fact, in labor. “When does ‘labor’ begin? Our officers aren’t trained to know, the state law doesn’t say, so we rely on medical personnel to advise us,” Steve Patterson, a spokesman for the sheriff’s office, wrote in an e-mail. “Once a medical person advises us someone is in labor, restraints of whatever sort are removed.”

But the plaintiffs’ attorney argues that restraints were, in his clients’ cases, removed too late or not at all. He contends that sheriff’s officials interpret “labor” as the moments immediately before birth, and that guards sometimes deny requests by doctors and nurses to remove the handcuffs and shackles. “When you talk to these women, they say, ‘Yeah, when I’m delivering and I’m pushing, that’s what they consider labor,’” said plaintiffs’ attorney Thomas G. Morrissey. “They remain in shackles and handcuffs until the baby is about to be delivered.”

The ignorance and stupidity on the part of the sheriff’s department is mind-boggling. Besides the harm and humiliation of the shackles, some women also had to put up with a stranger’s presence at one of the most intense and intimate moments:

Melissa Hall, 32, held on a drug possession charge, said that not only did she give birth in shackles in 2007 but, all through her labor, the guard sat next to her bed watching the NBA Finals, cheering and yelling at the television despite her repeated pleas that he leave.

“My legs were open, and my baby’s head was crowning,” she recalled. “And that’s when he walks out of the room.”

State law requires that a correctional officer be posted outside the delivery room. The policy of the sheriff’s office, according to Patterson, states that “an officer (preferably female) must provide security for the subject and be posted discreetly near the head of subject’s bed.” He contends that this policy does not violate the law because the law “does not say anywhere that an officer cannot be in the room.”

While the focus is on Illinois because of the class action lawsuit, it is equally disturbing that the policies of other states, including the 40 that do not ban shackling, are not widely known.

NPR interviewed Ginette Ferszt, associate professor and psychiatric clinical nurse specialist at the University of Rhode Island College of Nursing, who sent questionnaires to wardens in all 50 states about how they treat pregnant inmates. She received 19 replies.

Ferszt says she was quite surprised to find that two facilities continue to use leg irons, belly chains and handcuffs during transport to prenatal visits.

She also learned that among the 19 prisons that responded, six of them cuff either a woman’s hands or her ankle when labor begins. During the delivery of the baby, one prison says that handcuffs stay on, and four reported back that an ankle shackle remains on.

While disturbed by the findings, Ferszt did find hope in conversations with two wardens, when she realized their shackling policies weren’t something they’d thought much about.

“For many rules and policies whether for women or men, they’ve existed for them a long time,” Ferszt says. “It hadn’t really occurred to these two wardens that this could potentially be a health problem, a health issue.”

She says the two wardens have since said they’ll sit down and make changes.

Despite the arrogant rationalizations and depressing ignorance of the responses from the powers-that-be, one inspiring story comes from some of the first inmates who spoke out about the abuse. Their age-old strategy: female solidarity. Again from the Trib:

In Illinois, the first movement against shackling came in 1999, after a former inmate named Warnice Robinson testified before a group of female legislators, explaining how, while pregnant and imprisoned for shoplifting, she had been shackled to a hospital bed through seven hours of labor. “The women legislators kind of expressed disbelief because it was so horrifying,” recalled Gail Smith, director of Chicago Legal Advocacy for Incarcerated Mothers, who had helped organize the day’s testimony. “There was a minor disruption, because the women who had been formerly incarcerated started shouting, ‘Believe her!’”

Upon reading the Wax paper, my first response was “Great, I’m going to have to read every one of the original studies to make heads or tails of this.” This is because, as Amy Romano points out when she notes the absence of forest plots (which would provide more detail on the findings of each included study, and are common among this type of paper), the meta-analysis itself is not terribly detailed* with regards to the characteristics and findings of each included study.

Likewise, it was difficult (for me anyway, perhaps someone else can chime in) to make some of the numbers add up, such as the size of the planned home birth population analyzed for neonatal deaths, and here again I feel the need to revisit each of the original studies in order to better understand the possible meaning for home birth safety.

First, the authors emphasize the conclusion that less frequent intervention is “associated with” increased neonatal death. The term “associated with” implies a statistical relationship between the two factors, but as we read further we find that other variables (such as attendant type) may play a role.

As far as I can tell, the authors did not attempt to do any calculations that would specifically tie the neonatal death rate to the decreased rate of interventions (more on this in a minute), they just find that both occurred. It may be the case that some of the neonatal deaths could have been prevented in the presence of additional interventions, but this is difficult to determine based on the paper at hand.

I also would have liked to have seen more thorough explanation of what the contrast between the perinatal deaths and the neonatal deaths might mean. Perinatal death (for which the authors report no significant difference between planned home and hospital births) is defined by the authors as stillbirth of at least 20 weeks gestation or 500g through death of a live born infant up to 28 days after birth. Neonatal death (which the author reports as elevated in the planned home birth group) is defined as death up to 28 days after delivery.

So, the elevated risk of death is among live born infants up to 28 days after delivery, but it’s hard to tell how many deaths occurred during labor/delivery or in the first few days after birth (for which we might assume a more important role for intrapartum care, such as a failure to note distress or a failure to resuscitate) versus how many occurred later, or their causes or possible prevention strategies.

Without seeing more data from the original studies on the causes and time frames of the deaths, it’s difficult to fully understand any possible implications of this finding.

The authors do say in the “Comment” section (not where you’d normally expect to find results) that “planned home births were characterized by a greater proportion of deaths attributed to respiratory distress and failed resuscitation” and refer to some of the included studies for support, but I would love to see some data extracted and presented more clearly in the meta-analysis. There were very small numbers of neonatal deaths in the referenced studies, and it’s not clear from spot-checking a couple of the original papers whether those researchers actually attributed the deaths to a lack of intervention without other confounding factors.

I’m also not entirely sure how useful it is to do a meta-analysis on home vs. hospital birth using data from lots of (Western) countries when the mostly non-U.S. countries have a range of current practices/trends in home birth and midwifery (such as different standards for midwifery education and stronger traditions of home birth, etc.), and rather different healthcare systems.

I recognize that this is going to be an issue for other meta-analyses on birth topics, and I’d be interested in being pointed to any good discussions of this particular issue or in hearing others’ take in the comments.

The authors raise one other issue related to the neonatal death rate that is different from the “less intervention” conclusion — they note that when the analysis excluded studies in which the providers were not “certified or certified nurse midwives,” the odds ratios for all neonatal death and “nonanomalous” (without congenital issues) neonatal death became non-significant.

In other words, when the planned home births had some type of certified midwife present, the neonatal death rate was no different than that in the planned hospital birth group. Readers, however, must have access to the full text of the article in order to view this conclusion, which is not emphasized in the abstract or media coverage of the paper.

The authors do not provide much further definition or discussion of the attendant issue, leaving us without (again, without rereading each paper) a clear understanding of whether the neonatal deaths might have occurred in unattended/unplanned home births and/or births with some other form of attendant, or how the rate of interventions varied by type of attendant.

The Pang study, for example, contributed a large chunk of the population analyzed for neonatal deaths, but has been widely debated and criticized for including unplanned home births in its analysis of neonatal death at home birth, so further review of the methods of each study may be warranted.

The authors chose to clearly associate low rates of intervention with neonatal death, but I wonder if they would also be willing to support a statement that “lower rates of medical intervention during planned home birth is not associated with increased neonatal mortality when attended by a certified or certified nurse midwife.”

There is possibly a discussion to be had about whether different types of non-certified attendants (especially those cases with unattended or unplanned home births) had all of the sometimes necessary interventions and techniques at their disposal, but the Wax analysis does not attempt to delve into this issue.

There is some discussion of the inclusion of unplanned home births in a letter from Janssen and Klein and a reply letter from Wax, for those who have access to the journal. In the reply, Wax stands by the conclusions based on their exclusion of premature births (which they expect will reduce the number of included unplanned home births), but also notes that “In addition, the purpose of our article, as clearly stated, was to evaluate morbidity, not mortality.” Mortality, however, seems to be the prime area of interest in and focus on the article, and is a clear point of emphasis in the authors’ abstract.

Ultimately, I don’t think this meta-analysis would have warranted much attention at all if it were not for the authors’ bold statement of association between decreased rates of intervention at home birth and tripled odds of neonatal death. Without that bit of provocation through the authors’ framing (and relative lack of emphasis on the difference having a midwife attendant made, or the low absolute risk of neonatal death), I don’t think most readers would have thought much of this paper or considered it to make much of an impact on knowledge in the field.

Given the small number of included studies, readers interested in better understanding safety data on home birth are probably better off getting copies of the papers Wax refers to in the analysis, and looking at each one for its relevance.

Meanwhile, Medscape is offering CME (continuing education credits required for physicians) on the topic, under the headline, “Less Medical Intervention for Home Birth Linked to Increased Neonatal Mortality Rate.” The actual text of the CME activity is more balanced in pointing out some factors we would consider positive about home birth (such as-wait for it-some of the decreased intervention rates), but it ultimately emphasizes the point that “Currently, the American College of Obstetricians and Gynecologists does not support home birth because of safety concerns and lack of scientific study.”

We, on the other hand, would emphasize the need for clearly reported, well-conducted studies, support for women’s autonomy and informed decision-making in choosing a place of birth, and systems of care that provide the best possible outcomes for women who do choose to give birth at home.

*For more information on the kind of information you should expect to see in a meta-analysis, see PRISMA statement, a set of guidelines for reporting meta-analyses and systematic reviews.

The researchers are looking for women who are at least 18 years of age,  gave birth to their first child in the past year, and are willing to respond to questions about their attitudes and behaviors related to sexuality and information about their sexual health.

For more information about the study, its confidentiality policies, a gift card drawing for participants, and to decide if you’d like to participate, visit the home page for the study survey. You can email debby@indiana.edu with any questions.

In 1999 (and again in 2004), ACOG released guidelines [pdf] stating that “VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available.” This standard has been widely blamed for the lack of VBAC availability in many parts of the United States, as many hospitals discouraged or stopped doing VBACs, and in some cases malpractice insurance companies refused to cover claims resulting from the procedure.

As Rita Rubin explained in a 2005 USA Today story on the issue, “Many hospitals have interpreted that [the 'immediately available' standard] to mean they must have an anesthesiologist and operating room standing by whenever a patient attempts a VBAC, a luxury they say they can’t afford. If they can’t meet the guidelines, they argue, they’re opening themselves up to lawsuits should mother or baby be injured during a VBAC attempt.”

In an Obstetrics and Gynecology editorial titled “Solving the Vaginal Birth After Cesarean Dilemma” (only available with login or payment, unfortunately), journal editor James R. Scott, M.D., references the “immediate availability” standard on VBACs:

Although all guidelines have been well intentioned, each new set resulted in unintended consequences. Today, the VBAC issue remains contentious and unresolved. Many hospitals no longer allow VBAC because they are unable to provide the level of response recommended, and some insurance carriers prohibit physicians from performing VBAC. Consequently, trial of labor after cesarean is now denied to many women who strongly desire this option and to physicians who want to provide it.

Scott’s conclusion sounds very much like something OBOS could agree with (emphasis added):

What level of risk is acceptable, and who decides? Currently, hospitals, insurance companies, and plaintiff attorneys decide or strongly influence whether VBAC is an option. Instead, the patient should be allowed to make that choice after she has been informed of the facts and has been counseled by her physician thoroughly.

“Despite the reality of disparate resources, we should ‘find a way’ for those who want the option of VBAC,” Scott continues. “Reducing the number of primary cesareans deals with the problem where it originates.”

The second piece of interest is a synopsis of the address that ACOG’s president, Richard Waldman, MD, delivered at ACOG’s 2010 annual meeting. In his remarks, Waldman calls for better data about birth and raises concerns about maternal mortality and high cesarean rates. On this last point, he states:

In 2008 the cesarean delivery rate reached another record high—32.8% of all births. There is a community not far from my home in which 45% of the newborns are delivered via an abdominal incision. [...] Liability dampens our spirits but unfortunately, it is also starting to define our specialty. [...] Let us recommit to do everything in our power to perform surgery only when necessary. Let us recommit to induce only when indicated and let us vow to never electively induce or perform an elective cesarean prior to 39 weeks. Any time we are tempted to take the safe path but not the righteous path, we should all say, “not on my shift.”

Each of these statements seems to reflect concerns about limited VBAC options that birth advocates and others have been expressing for some time. Who wants to take bets on whether they’re also laying the groundwork for an updated — and perhaps more permissive — VBAC recommendation?

The conference is streaming live at http://www.womendeliver.org/conferences/-2010-conference/webcast/. You can follow tweets using the hashtag #WD2010, which are also streaming on the webcast page. I’ve set up archives at Twapper Keeper and What the Hashtag? to save tweets with this hashtag for later review.

• After declining from 1.13% in 1990 to 0.87% in 2004, the percentage of out-of-hospital births increased slightly to 0.90% in 2005 and 2006;
• Home births alone were 0.67% of births in 1990, declining to 0.56% by 2004, and 0.59% in 2005 and 2006;
• Of all out-of-hospital births (in 2006), 64.7% occurred at home, 28.0% were in a freestanding birthing center, 1.1% in a clinic or doctor’s office, and 6.2% were “elsewhere;”
• 61% of home births were attended by midwives, including 16% by certified nurse midwives (CNMs), and 45% by other midwives; 7.6% were attended by physicians;
• 83% of 2006 home births were planned home births; almost all home births attended by midwives were planned; 31% of those attended by MDs and 79% of those attended by DOs (osteopathic physicians) were planned home births;
• Geographic differences were found, with 11 states having significant increases in home birth and 5 states having significant decreases from 2003-2004 to 2005-2006 (anybody want to compare these to relevant law changes in the states?).

The report also provides data on home births by race/ethnicity, but does not compare it to the percentages of the U.S. population for each group.

Eugene Declercq, professor of maternal and child health at the Boston University School of Public Health and a signatory to the Choices in Childbirth statement, is one of two authors on the report.

In the provided letter, the organization asks for such an Office to work on the following priorities:

• gathering comprehensive data on deaths, complications and performance measures along with an effective nationwide review process;
• ensuring access to timely prenatal care;
• issuing evidence-based protocols for health care providers to prevent, recognize and respond to the leading complications that cause pregnancy-related deaths;
• encouraging home visits in the days following childbirth; and
• vigorous enforcement of federal nondiscrimination laws;
• recommending the necessary regulatory and legislative changes to ensure that all women receive the quality maternal care necessary to reduce maternal deaths in the United States.

Organizations can also sign onto a letter to be delivered to Secretary Sebelius tomorrow by contacting demanddignity@aiusa.org.