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How will ACOG handle the PR challenge of promoting VBAC as a safe option?

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By Jill—Unnecesarean

I have a few questions. I’ll preface them with a hypothetical situation.

A woman has a baby in 2005 by cesarean. She hopes to avoid another surgery while pregnant in 2007, but her doctor tells her horror stories of how VBAC kills babies and she should reconsider her plans. She schedules a repeat cesarean.

Now it’s 2010 and the same woman is expecting her third child. She walks into an obstetrician’s office and is told that VBAC is a safe and appropriate choice. The woman asks if there was new research conducted that would have led to this 180 degree change in practice and is informed that, no, the evidence predated her repeat cesarean.

How will this impact the trust that patients like this woman (and those affected by the astronomical primary cesarean rates around the country) have in their doctors or in the U.S. health care system in general? I assume that there are a lot of people banking on the chance that people will be dancing in the streets about the less-restrictive guidelines and crossing their fingers that few will question how VBAC just—POOF!—became “a safe and appropriate choice” again.

I am very curious about how this will play out. Some doctors are forthright with their patients if they cannot offer them anything but a repeat cesarean for reasons that have nothing to do with the actual patient—hospital policy, ACOG’s “immediately available” guideline, not wanting to be dropped by their malpractice insurer, experienced a bad outcome and are not willing to live through that again with another family, experience with having been sued in the past, staff shortage, etc. Are many or most doctors this honest with their patients?

We’ve all heard from nurses and patients about the VBAC bait-and-switch which involves an initial openness to a trial of labor. As the pregnancy progresses, the doctor starts expressing concern for the baby’s wellbeing through the use of disingenuous scare tactics and offering reasons why the prospect of a trial of labor is becoming more and more dangerous for this particular patient with the hope that the patient will finally just consent to a planned (and “elective”) cesarean. Just ask an OB friend about it and you’ll probably get the low-down on a few colleagues who promote their practice as VBAC-friendly but are really not.

I want to know how in the world this will be dealt with from a public relations standpoint. ACOG took the first step and issued a press release. At the press level, it would be easy to say the same things that have already been said about defensive medicine and the fear of being sued ultimately hurting patients. However, it won’t backfill the decade or more of doctor-patient conversations that pitched the repeat cesarean as the only safe and reasonable option and framed VBAC as highly irresponsible and dangerous. We can all talk generally about the fear of VBAC lawsuits until we’re blue in the face, but until we acknowledge the manner in which this fear actually trickles down to the actual prenatal visit or labor and delivery, we’re merely scratching the surface.

Like many people, I’ll be observing this as it unravels. Will it change anything for those for whom the mistrust of scarred uteri is so entrenched that they ponder why there are any VBACs at all (see comment #7)? Or for those who would like to see VBAC go the way of the dodo like breech birth did in the United States?

How will this cultural shift occur? How does ACOG, as the primary mouthpiece of OB-GYNs in the United States, plan to address the years that have gone by and the thousands and thousands of women that were told that VBAC is too dangerous in spite of ample evidence that it is not? Can they save face or will this provoke too much critical thinking on the part of patients? If so many of the people that we trust with our bodies and our births have been willing to tell women to their faces that VBAC is not a safe option for them in spite of evidence, is anyone concerned that the public might be wondering what other practice bulletins need an overhaul?

I need to get back to dancing in the street, so please let me know how you think this all might pan out.




From my feedreader in reverse chronological order:

New VBAC Guidelines (Birth Activist)

Sunday News Round-Up: *Why* Is It Sunday Already? Edition (Women’s Health News)

New Guidelines OK Vaginal Birth After Cesarean (VBAC) (Medical News Today)

About Damn Time: Good News for Vaginal Birth After Multiple Cesarean! (Well-Rounded Mama)

ACOG’s VBAC Change of Heart - The What and Why (Keyboard Revolutionary)

VBAC in rural hospitals (VBAC Facts)

ACOG Releases Updated VBAC Practice Bulletin, Emphasizes Individualized Approach and Maternal Autonomy (Our Bodies, Our Blog)

ACOG’s New VBAC Guidelines: Making (and Seeing) the Difference (Birthing Beautiful Ideas)

ACOG Says Yes to VBACs (RH Reality Check)

ACOG Scraps “Restrictive” Guidelines on Vaginal Birth After Cesarean (Pushed Birth)

Did ACOG (finally!) Take Their Meds? (Navelgazing Midwife)

ACOG issues less restrictive VBAC guidelines (Stand and Deliver)

ICAN Responds to New ACOG Guidelines on VBAC (ICAN)

Progress not perfection, right? Thanks, ACOG. (Cross-posted on VBAC). (Unnecesarean Fan Page)

ACOG issues less restrictive VBAC guidelines (VBAC Facts)

Ob-Gyns Issue Less Restrictive VBAC Guidelines (ACOG News Releases)


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Reader Comments (14)

I have a client right now, a VBA2C wanting TOLAC. When she went to her large HMO asking for a VBA2C, the first words were: ACOG says... blah blah blah. So, now, all of a sudden, "ACOG says" something entirely different. So, she's going to carry the entire Practice Bulletin to her next appt. and ask, "So, how about now?" and see what reaction she gets.

She is planning a homebirth now, knowing that even if she was "allowed" a TOLAC in the hospital, they would be hovering over her like vultures eyeing carrion. But, emotionally, the new statement has buoyed her tremendously! And while I am not wont to follow ACOG "rules" and recommendations, for me as a midwife, it is like the green flag has fallen at the Daytona 500 racetrack.

July 26, 2010 | Unregistered CommenterNavelgazingMidwife

Typically, do ACOG statements have a big impact on actual OB practice / hospital policy? My assumption was that, sure, the statement was out there, but that it will take eons to trickle into reality, if ever. There are too many powerful ve$ted interests in the status quo, no?

July 26, 2010 | Unregistered CommenterAnother Rachel

I think you're giving ACOG far too much power over what actually goes on in doctor-patient "decision making." Here's my take on things: physicians will hold up the "ACOG says" card when it lines up with their preferences and belief systems, but are free to ignore or downplay what ACOG recommends if it doesn't jive with what they want to see happening. For example, if ACOG were to adopt the same position on breech birth that SOGC recently did, I highly doubt the breech climate would change at all.

What I'm really curious to see is if malpractice insurance carriers and hospital administrators pay attention to this new practice bulletin and actually reverse VBAC-hostile policies.

July 26, 2010 | Unregistered CommenterRixa

Rixa, point taken. The hypothetical scenario really should have ended with the woman picking up a newspaper in 2010 and reading that ACOG issued a new PB on VBAC (and realizing that perhaps her doctor had been unrealistic in his description of the risk associated with VBAC), not a magical scenario in which every OB practice and hospital suddenly dropped what they were doing after reading the new PB and started attending VBACs. I wasn’t going for farcical but it ended up that way.

I got a little carried away with the questions and they swallowed up my primary question about how an organization like ACOG which advocates, handles PR, lobbies and provides education for its members will be traversing the gap between what is discussed at the level of the media and what actually happens between its members and their patients. In the case of VBAC, I see a dilemma. If they announce that the reason it took so long to revise VBAC recommendations was due to legal fears, malpractice, insurance companies and other factors not related to the actual patient, how will they deal with the reaction of individual patients who weren’t told the truth and were instead told that the reason they couldn’t VBAC was because there was something wrong with them or because VBAC itself is simply too dangerous for them or their baby?

Personally, I would react much differently to hearing, “I can’t do anything here but a repeat cesarean because of hospital policy” and “VBAC is simply too dangerous and you should really think about how much you want your baby to live.” One is honest and one is manipulative and dishonest.

I can’t see how they wouldn’t be aware of this discrepancy and I wonder how they will address it, if at all.

July 26, 2010 | Registered CommenterJill

Rixa's right. ACOG changed their guidelines to support drinking clear fluids during labor almost a year ago, but there are still hospitals clinging to the (completely not evidence-based and generally inhumane) "ice chips only" policy.

I highly doubt that providers who "didn't offer VBACs" before are going to suddenly start advertising "VBACs for Everyone! Come and Get 'em!!" I also don't think the new recommendations will guarantee that every woman will be offered a truly informed choice from their providers about VBAC/RCS. However, I think this will be a good weapon in the arsenal of women who choose to inform themselves and are fighting for a VBAC.

July 26, 2010 | Unregistered CommenterBirth Unplugged

Culture change doesn't happen because of one press release. It takes individual and organizational BELIEFS changing to ulitmately change the culture of something. In this case, there's a well-entrenched belief among doctors and at ACOG that birth itself is a dangerous proposition, nevermind VBAC. That belief then creates this culture of medicalized births we have today. Beliefs will only change when doctors start to experience VBAC and birth in general as a normal process, which will ultimately change the culture and pave the way for far fewer c-sections. I don't see it happening. I don't know why ACOG decided to put this out now, but I still don't trust that organization. But maybe I'm just a cynic (a cynic who had a recent HBAC because I was way too scared to go anywhere near a hospital, knowing the culture there all too well)!

I can think of one thing that would cause the beliefs to change enough to change the culture. If enough women who had been subjected to unnecesareans sued doctors for malpractice now, that might create enough of a burning platform to get them to stop doing all these elective, repeat c-sections. Their beliefs would then be, "Gee, I might get sued for doing this c-section...I guess I should give this VBAC a try!" and then, when the VBAC is a success, the doc's own beliefs about VBAC safety change too. And, voila, now we have a culture of VBACs instead of a culture of rampant c-sections.

July 26, 2010 | Unregistered CommenterRebecca

I am angry for/with the women who were denied an opportunity to have a VBAC because of the far-reaching influence that the 1999 and 2004 ACOG Practice Bulletins on VBAC had on the birthing climate. And I doubt that ACOG will even issue (let alone consider issuing) any sort of apology unless they hear these women's voices loud and clear. So maybe "we" can do some PR of our own to get these voices heard and to demand such an apology.

(So says the idealist.)

The pesky idealist in me also thinks that while these guidelines won't affect a sea change of their own, they will affect some sort of change. (Just THINK--the NIH Statement influenced ACOG to CHANGE THEIR VBAC GUIDELINES!!! That's AMAZING!) There's nothing like having a document in hand to point out someone else's contradictions to get them thinking about why they do what they do--and maybe changing why they do what they do.

(So says the philosopher, who has a penchant for things like logic.)

July 26, 2010 | Unregistered CommenterKristen

I don't see the tide changing much in response to these new "guidelines." OBs do not budge far from their comfort zone, and that is not going to change anytime soon. They will still find reasons at term to deny women VBACs, so I doubt we'll see heaps of women question the 'poof now VBACs are safe' pronouncement. It saddens me deeply that we have a whole country of women believing they need permission to birth the way they want. The birth advocacy world is breathing vigor and discourse into the issue though, and that where we need to be, that is how birth change begins.

July 26, 2010 | Unregistered Commentererinmidwife

I just don't see the tide changing much with these new "guidelines." OBs do not budge far from their comfort zone, and that is not going to change anytime soon. They will still find reasons at term to deny women VBACs, so I doubt we'll see heaps of women question the 'poof now VBACs are safe' pronouncement. It saddens me deeply that we have a whole country of women believing they need permission to birth the way they want. The birth advocacy world is breathing vigor and discourse into the issue though, and that where we need to be, that is how birth change begins.

July 26, 2010 | Unregistered Commentererinmidwife

I think that indeed it will take moms forcing the issue for OBs who have banned VBACs to come around to a new way of thinking. They won't be offering it up to moms. However, it will be interesting to see how things change. I have a mom trying so hard to find a care provider to support her in her VBA2C. We are hoping this will help.

July 26, 2010 | Unregistered CommenterSheridan
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