How ICAN could dramatically increase the VBAC rate with one simple step

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ICAN, the International Cesarean Awareness Network, is the premier organization promoting vaginal birth after Cesarean (VBAC). ICAN has taken the lead in advocating for VBAC in nearly every circumstance, opposing VBAC restrictions put in place by hospitals and malpractice insurers, and arguing that principles of bodily autonomy mean that women should be able to force doctors to attend VBACs even when they believe them to be unsafe.

Presumably there is nothing that ICAN wants more than to increase the rate of VBAC in the US, which has dropped precipitously from the 1996 high of approximately 28% to the current rate of only 10%. ICAN has correctly identified the strict ACOG guidelines for VBAC as one reason for the decline, as well as fears of malpractice suits, and so called “defensive medicine.”

But ICAN could fix all that, making it possible for any woman seeking a VBAC to have one regardless of where she lives or what her doctor recommends. What could ICAN do? ICAN could indemnify the doctors and hospitals when they supervise a VBAC.

What does it mean to idemnify? According to Merriam-Webster:

to protect (someone) by promising to pay for the cost of possible future damage, loss, or injury

In this case, ICAN would be promising doctors and hospitals to pay for the cost of possible lawsuits and legal cases that arise from VBACs. Doctors would face no risk from attending VBACs because ICAN would function as a form of insurance, paying them when a woman sued in the wake of serious complications from VBAC.

From ICAN’s point of view, it would be a win-win. On the one hand, they would relieve doctors and hospitals of the fear of malpractice suits and the crushing burden of multi-million dollar verdicts for babies who sustain brain damage or die during attempted VBACs. On the other hand, the financial burden for ICAN would be minimal if VBAC is truly as safe as they insist.

ICAN and its members appear to despise doctors who practice defensive medicine. In one simple step they would relieve doctors and hospitals of the need to practice defensive medicine. They could inform grateful doctors and hospitals to worry no more. From now on, ICAN would agree to be responsible for footing the cost of any lawsuits and subsequent judgments. Imagine the relief of providers who foolishly imagine VBACs to involve indefensible dangers to babies and mothers. Imagine the relief of mothers who would never face so-called “VBAC bans” again.

The best part is that there could be no greater demonstration of ICAN’s belief in the safety of VBAC than its willingness to pay for the outcomes. If VBACs are as safe as ICAN claims, if complications are as rare as ICAN insists, and if defensive medicine is as despicable as ICAN implies, it should cost nearly nothing.

So how about it ICAN? All you need to do is indemnify doctors and hospitals for the outcomes of VBACs and the VBAC rate would soar.

If you truly believe in the safety of VBACs, you should have no trouble putting your money where your mouth is, right?

  • Karen in SC

    This journal article was just mentioned in support of a mother seeking a HBA3C. It’s from Washington U doctors in St. Louis which is an institution I respect. Anyone with stats can take a stab at this? I am skeptical that success rate is the same after 3C as 1C.

    http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2010.02498.x/abstract

    • Amy Tuteur, MD

      Interesting, but doesn’t really tell us anything because it included only 89 women.

    • Young CC Prof

      They got their results by combing medical records from 17 major medical institutions over a period of 4 years. They only found 89 women who attempted it, compared to 1082 women who attempted VBA2C and 12,535 women who attempted VBA1C.

      They provided demographic data for those women, but we don’t really know enough about their medical history. Only 89 women. Why did they attempted VBA3C? Why did their providers sign off on it? Were they just bound and determined to have a trial of labor against all odds, or was there something special about their cases that made the doctors think it might work?

      One thing they do tell us is that out of the 71 women who succeeded, 29 had previously had a successful vaginal birth, which is a different situation. We don’t have any idea whether some of those women had 3 c’s for failure to progress. Personally, I suspect they didn’t.

      • Haelmoon

        I have once delivered a lady how had a successful VBA3C. She was Mennonite and she came to the hospital to deliver.
        She started with 2 vaginal deliveries, than a C-section for breech/breech twins. Then another vaginal delivery (all the rest were actually in hospital), followed by an emergency C-section for placental abruption. Then a previa. The pregnancy I was involved in we had a long discussion about the risks and benefits, and she planned a repeat C-section and tubal ligation, because of the increasing risk of complications (not to mention soon to be eighth child). We booked her early to try to avoid labour, but she presented two days before in active labour. She was 5 cm on arrival, and quickly was eight. We quickly discussed the risks of an intrapartum C-section, but she had the urge to push during this time and quickly had a baby. This is likely somewhat representative of the 71 successful women with VBA3Cs. She went on to have an elective C-section for baby nine and got her tubal ligation.
        I am supportive of VBAMC, but only in hospital, only with an understanding that we will have a low threshold for C-section if things are not progressing or questionable heart rate, and they have to have a spontaneous onset of labour (preferably before their due date, as this has a better chance of success); if there is a medical indication to deliver it is a C-section. However, I rarely have women interested. Most times the discussion is related to if they show up in labour, how quick can I do the C-section, they often have no interest in a vaginal delivery – they want a healthy baby.
        What I don’t really understand is if you were unable to have a vaginal delivery the first three times (especially if failure to progress), why do they think they will be successful this time?

        • Young CC Prof

          Actually, that would explain why the success rate was so high: A lot of the successes were semi-accidental VBACs like that your patient with many children, which means the authors have essentially stuffed the numerator with a whole bunch of cases that really shouldn’t be there.

          In fact, that seems to fit: The mean gestational age was only 37.2 weeks, and 7.8% of the babies were born before 34 weeks.

          The retrospective success rate was 71 out of 89, but how many of the 71 actually planned to try?

  • AnonyMommy

    This is OT, but many of the commentors here seem knowledgeable. I am a pregnant second time mom who has started reading this site. I had been considering VBAC, not because of any political stuff or because of a natural birth obsession, but because my doctor thinks I’m a good candidate. Where can I get more solid information on having a VBAC? A friend pointed me to VBAC Facts, but I get the impression from this site that it isn’t a good resource. It is really hard to find legit sources of information that aren’t pushing toward some natural ideal. Assuming nothing comes up to change me into a poor candidate, is VBAC ever an okay decision? I’ve been reading some of the posts and comments on this site, and have sort of come away with the perception that choosing VBAC is tantamount to neglect of my baby because it’s so risky. I don’t want to hurt my baby! Does being open to VBAC mean my OB is a quack, and I ought to find a new one? My OBGYN practice is in the hospital I plan to deliver at, and I like them, but if suggesting VBAC is a red flag for mine or my baby’s safety, I’m still early enough in pregnancy that I could search for a new one.

    • Young CC Prof

      As ACOG says, for most women with a prior history of c-section, VBAC is a good option.

      The key word is most. There’s nothing wrong with trying as long as your doctor thinks you’re a good candidate. Also, remember that things may change in late pregnancy or during the delivery.

      The nutty folks are the ones who are absolutely committed to VBAC after 2 doctors tell them “not a good plan for you.”

    • KT

      I’ve been getting what seems to be good information (lots of links to studies, no medical advice, lots of level-headed reasonable discussion) from the Facebook group VBAC and Birth After Cesarian Facts. I also read the NIH consensus statement and ACOG’s own literature for myself. But most importantly, I talked to all 3 of my OBs and together we have nailed down a plan everyone is comfortable with. I’ve raised my questions and concerns to them. I trust these OBs a lot from prior experience and I know my hospital is fully equipped to handle a catastrophe. I’ve educated myself as to the risks as best I can, my husband is on board.

      I agree that some commenters here do make it sound as though THEY would never chose VBAC because it is horribly risky and get close to implying that no one should. But they’re just commenters.

      • momofone

        I may be one of the commenters of whom you speak. For me, VBAC would be horribly risky, and I would never even consider it, even if it were offered as an option for me (which it would not be). I also had a wonderful experience with my c-section, and would not hesitate to do it again. I admit being baffled by some people’s fascination (read: obsession) with vaginal birth; there is a lifetime of experiences after birth, as long as everyone survives, so I can’t imagine getting hung up on this part. My son is seven, and I can assure you that our days are full of lots of things, but not a single one has to do with how he was born, or how long he was breastfed, or whether he was carried in a sling. He is the biggest reason I would never take on any preventable risk–he needs me here, not dead because I martyred myself (and possibly his sibling) in pursuit of an ill-advised (again, for me) vaginal birth.

        As far as whether “no one should,” as people say where I live, I have no dog in that hunt. If you’ve talked to your doctor and s/he is comfortable, and you’re comfortable, great. If you had three doctors telling you they did not believe you would have a favorable outcome, and you insisted on doing it, that would seem pretty reckless to me, but obviously you get to choose either way.

    • The Bofa, Being of the Sofa

      No, suggesting a VBACS isn’t a “red flag.” There are benefits and risks, like anything.

      If you are able to do a VBACS in a properly equipped environment, with people who know the potential risks and are prepared for them, then it’s certainly an option.

      Listen to your OBs. They know more about your situation than even the knowledgeable commentors here. If they are telling you you are a good candidate for a VBACS, then sure, why not? Unless you have reasons to not trust your OBs, in which case, you are seeing the wrong doctor.

      You want information? Ask your OB. They’ll help you out, and are better resources than anything that you will find on the internet, because they know the situation. For example, they aren’t going to suggest that you do a VBA3CS or do a homebirth.

    • fiftyfifty1

      “Where can I get more solid information on having a VBAC?”
      From your own OB who should know your own personal situation better than anybody. This includes knowing the particulars of your previous CS, your anatomy, and your future reproductive plans (i.e. hoped for family size). There is no better resource than your own OB unless you feel you aren’t getting your questions answered, in which case seek a second opinion.

    • Guesteleh

      The only thing I want to add to the good advice here is if you don’t feel comfortable with your OB for any reason, switch to a new doc as early as possible. I switched OBs halfway through my pregnancy and I’m so glad I did. It wasn’t a skills issue but a communication issue. But that’s a hugely important aspect of good care. You have to feel confident in the person caring for you. Many good wishes to you whatever you decide! Hope you have a smooth and boring pregnancy and labor.

    • Susan

      I just want to chime in as a l and d RN that I find nothing red flag about a doctor offering a VBAC to a good candidate. I also think that a hospital that offers vbacs is likely to be a hospital with good resources. We offer vbacs where I work and even though yes, they have risks, and yes, they happen, there is no such thing as a risk free pregnancy or birth. So it’s a matter of how the risks apply to you and what is best for you. Where I work all the docs I consider the best will do vbacs. I think the general discussion here can give people the idea posters here are “against” things we actually support. I am against treating birth and breast feeding like a religion… But I am actually very natural
      Birth, Vbac and breast feeding in terms of how I care for my patients who want those things.

    • Paloma

      I agree with most of the commentors, you should talk to your doctor and ask him/her to give you more information on VBAC. If your hospital does them, they probably have information prepared to give you that will be great quality and easy to understand (much better than what you will find on the internet). Also they could tell you why they consider you to be a good candidate and what the possible complications are and how they would handle them. That will help you make a decision and also will take the uncertainty of not knowing all the possible scenarios that could arise.
      I don’t think that they offered a VBAC is a red flag at all. It is a very common practice and if they are offering, it probably means they are equipped to handle any complication. But if you feel uncomfortable it might be a good idea to get a second opinion and info from another OB, just for you to be completely sure once you make a decision. The important thing is that whatever you decide, you are comfortable with your decision and know what you are getting into. Good luck!

  • Cobalt

    My cousin is currently contemplating VBAC. Her doctor says she is a great candidate for it and is very likely to have a safe and successful TOLAC and has no hospital access issues. As perfect a setup as can exist for VBAC.

    She still is leaning towards RCS, though. Her logic is “what is the benefit of assuming the extra risk? It’s the same baby either way.”

    Calling ICAN out is excellent. But it wouldn’t mean a thing to women like her.

    • fiftyfifty1

      “Her logic is “what is the benefit of assuming the extra risk? It’s the same baby either way”
      Exactly. The exception to this is if a woman is planning to have a large family. Then the equation is “I will have this baby bear a slightly higher risk so that subsequent potential siblings can bear a lower risk”. Also the risk of accreta. Choosing a repeat CS does not increase a woman’s risk of accreta in THIS pregnancy, but it increases it in subsequent potential pregnancies.

      • Cobalt

        It certainly changes an individual equation if there are future pregnancies to account for and the current pregnancy is a good candidate for VBAC. They’re done having kids though, they have 3 already (the youngest by cesarean).

        If the first of the 4 had been by cesarean, she might feel differently. Or they may have just had fewer, it’s hard to retroactively speculate.

  • ihateslugs

    You know, I just don’t think this would help much. Why? Well, it turns out those oh-so-conventional doctors really don’t like dead babies. Or dead mommies. Or dead babies with dead mommies. Or mommies in ICUs, not holding their babies. Handing a parent a dead infant swaddled in a receiving blanket remains one of the lowest lows in my life. No amount of money or indemnification from could ever make me OK with that. (And we wonder why physicians have a higher rate of suicide!) Furthermore, having a lawsuit (even just being named and later dismissed) can haunt a physician’s professional record for their entire career, making it more difficult to get licenses, malpractice insurance, hospital privileges, and certain types of positions or appointments. Even if ICAN were to “settle” the case for the doc, it would still tarnish his or her professional record. And, oh, there’s the matter of that pesky little oath we take, a little something about harm…

    • Sue

      Indeed – a personal sense of responsibility for outcomes seems not to be shared by ICANites.

      But Dr Amy is merely calling their bluff – it’s not likely that they will be rushing to put their money where there mouths are.

      (Stray thought – should they change their name to “ICAN’T”?)

      • Who?

        IWON’T or SHANT would be more appropriate though how to work them back to a name?

  • An Actual Attorney

    It appears, according to at least some studies, that malpractice issues do not affect CS rates. Perhaps docs (and most moms) just don’t like dead or injured babies.

    http://onlinelibrary.wiley.com/doi/10.1111/jels.12046/abstract

    http://onlinelibrary.wiley.com/doi/10.1111/j.1740-1461.2012.01259.x/abstract

    Sorry for the abstract links, the journal articles aren’t available publicly, as far as I can tell.

    • Karen in SC

      AAA, I’ve been waiting for your comments on this issue.

      • An Actual Attorney

        Sorry, been actually attorneying. But I should I say, that I do agree with asking ICAN to put their money where their mouth is. While I don’t think it would change #s, it would change minds. People evaluate risk very differently when they are the ones paying for it.

  • Young CC Prof

    I’ve said before, I’d love to know how many women in the US are affected by lack of VBAC access. ICAN doesn’t appear to have this information, nor have they attempted to get it, instead they throw around the number of hospitals that allow or don’t allow VBAC.

    I’d like to know how many women would like to attempt VBAC, are reasonably good candidates medically, but wind up not doing so because no hospital that’s at all nearby will permit it and/or no local provider who accepts her insurance will allow it. I always say, you can’t make choices without good data, and I have no data at all about the scope of the problem.

    • Trixie

      Anecdotally, I see it a lot on VBAC boards.

      • Haelmoon

        But the boards are unfortunately a skewed population. How many women with access to VBACs, with support of their health care provides would actually be on these boards? There is be skewed, likely to those searching for access (I am not doubting it is a problem for some women) and those preaching their cause
        Don’t forget how many women are online about homebirth, when this represents maybe 1-2% of pregnant women!

        • Trixie

          Yes, I agree. But, there is a population of people out there who would stay within the hospital system and not go looking for alternatives if they had access to a TOLAC.

          • Haelmoon

            Trixie I agree. The problem with the internet is that the fringe can contact other members of the fringe and start to feel like they represent a much large segment of society. Just because you can find a board to agree with you, it does not make it a good options. There is a generalized lack of trust that some of these women exude and it is concerning that they trust strangers on the internet better than their own health care providers.

          • Cobalt

            They are few but loud.

    • Cobalt

      Where we lived when our third was born there was no VBAC option with 2 hours, and that is only under good road conditions. All bets are off in winter. The local hospital (only 1 OB in town at the time, a lot of prenatal care provided by GPs) had a 55% cesarean rate.

      If there was any indication you would be likely to need a cesarean, you either scheduled it or were told to go to the hospital 45 minutes away for L&D (no TOLACs, but generally higher risk). A lot of cesareans were repeats for lack of options.

      But that’s life in a small rural town, and something you knew from your first prenatal appointment. Nobody made a fuss about it because it made too much sense to not ask for emergencies that couldn’t be managed.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    Under the Accountable Care Act, I imagine there will be considerable pressure (misguided) to lower CS rates – they may even goes as far as encouraging VBACs. It is a growing fear among those in Canada and the UK that some women who desire RCS may be denied access to it. I do think that if governments want patients or provided to take on ‘risky’ behaviour that on a population level is seen as ‘cheaper’ it should offer no-fault compensation for victims of the harm that will result.

    • http://Www.awaitingjuno.blogspot.com/ Mrs. W

      And more on point – if ICAN offered a no fault system it could offer compensation to those babies sacrificed on the alter of their cause who would not meet the standard of being victims of malpractice.

    • Therese

      Yeah, but the Affordable Care Act is through private insurance companies…so why would they start pushing to lower C-section rates now if they weren’t before? I think it’s different than in countries where the government pays for health costs directly and therefore would have motivation to try to cut costs.

      • Bombshellrisa

        http://www.astho.org/Washington-Uses-Quality-Improvement-Measures-to-Reduce-Elective-Deliveries/
        Hospitals already have an incentive to keep their c-section rate low if they accept Medicaid. Some states like Washington have their Medicaid patients on united healthcare community plan or Molina health but to the hospitals it is still Medicaid.
        “The dollar amount for incentive payments doesn’t have to be huge, but some incentive is useful for maintaining momentum and bringing along reluctant participants.
         The focus on elective deliveries prior to 39 weeks is the first step in an effort to reduce the rate of C-sections in Washington, which have already started to come down as elective deliveries drop. The collaborative’s goal for 2014 is to focus on labor management practices that directly impact C-sections.”
        “The state legislature passed the Safety Net Assessment Act (HB 2956) during the 2009-2010 session, which offered hospitals an incentive to change their practices. In this pay-for- performance initiative, hospitals that meet five quality improvement benchmarks, one of which is reducing elective deliveries prior to 39 weeks, receive a 1 percent increase in their Medicaid reimbursement rates.”

      • Guesteleh

        Not true that the U.S. does not pay health costs directly. The federal government is the largest insurer in the U.S. through Medicare, Medicaid and the VA system. The ACA has put a lot of financial incentives in place (and penalties as well) to push hospitals and clinicians to adopt evidence-based best practices. Not just for maternity care but also for surgical practices, cancer screenings, medication management, etc.

  • Ellen Mary

    Risk doesn’t explain a 10% rate tho, IMO. Some of it has to be just bullish chauvinism. I recognize the limitations & the risks, so much so that attempting a VBAC is not a slam dunk for me, even with 2 prior vaginally births & a totally random non-repeating indication, but I do not think all RCS can be justified even by legitimate risk avoidance & maternal preference. IMO there are access issues rooted in medical backwardsness & sexism & subjectivity, same as overuse of D&C & Hysterectomy & Mastectomy for that matter. JMO.

    • Sullivan ThePoop

      I disagree with a lot of what you are saying. I live in a large suburban area with a whole lot of large highly rated hospitals. You can find almost any crazy birth you want around here in a hospital or hospital birthing center located in a hospital complex. Even here some hospitals that do not specialize in birth will not allow doctors to attend VBACs at their hospital because they do not feel equipped for it, nor does their insurance. Here that might not be a problem but in an area with less hospitals or low income areas it can be. That has nothing to do with any of the things you are talking about and is very likely to make up a good majority of cases.

      • Ellen Mary

        Right, I agree, but there IS a tendency in US OB to do other elective procedures without indication or a big risk to the alternative. So why then too many Hysterectomies, why too many ovaries removed without indication & in defiance of modern best practice, why not enough women offered expectant management or Cytotec in m/c if every RCS is either situational (rural), indicated, or maternal request?

        • Amazed

          How do you know it was without indication? How do you know that “not enough” women are offered these procedures? Maybe they were offered but explained that they are not recommended because of this or that?

          • Ellen Mary

            It is factual that many more ovaries could be left in place than currently are. It is factual that many Hysterectomies are performed without clear medical indication. I enjoy this blog sometimes but y’all really go off the deep end when you act like everything that happens in women’s health is on the up & up. SMDH!

          • attitude devant

            citation please. If you are going to say something is ‘factual’ please provide a source.

          • Sue

            ”that shift is heavily documented.”

            SO it should be easy to show us the documentation – how is it that this person has seen it an OBs haven’t?

          • Amazed

            Factual? Please share the citations. I’d like to know just how many doctors remove ovaries just for fun. Holding my breath, actually.

          • attitude devant
          • Amazed

            Hey, what does that mean? I am not this good with internet slang (which is a more dignified way to say that I suck at it).

          • attitude devant

            It means that she’s not replying to you. Usually the use of the phrase implies that she has nothing to offer in reply.

          • Amazed

            Thanks guys. I was curious. Emoticons and internet slang are so not my forte.

          • fiftyfifty1

            “Emoticons and internet slang are so not my forte”
            Me too. It seems like every day I have to look up some sort of internet slang. Usually I Google the word along with the word “meaning”.

          • The Bofa, Being of the Sofa

            When some person makes a lot of noise but then you render them speechless, and they are so quiet you can hear crickets chirping.

          • Ellen Mary

            Until recently it was the thing to remove ovaries & some older doctors remain unconvinced, that shift is heavily documented.

          • attitude devant

            “Until recently is was the thing.” Uh-huh. So they USED to but they don’t now? That’s not what you claim (repeatedly) above. You really have no idea, do you? Someone said that somewhere sometime and you just swallowed it as gospel.

          • Ellen Mary

            No I have met many women that were not even given the OPTION of keeping their ovaries & I became very sad over it, especially when these women were in their 30s. You seem to think we aren’t allowed to be sad when these things happen to our neighbors & relatives. To have them say ‘I didn’t know it was possible to keep my ovaries until after my surgery.

          • Sullivan ThePoop

            That is anecdotal. Maybe these women were not told they could keep their ovaries because they couldn’t for some other reason and didn’t understand. You don’t really know.

          • Amazed

            I have met a woman who was convinced that footling breech is the best position for the baby to be in. She was devastated when multiple providers refused to even discuss the possibility of a successful TOLAC, insisting that it was so small that they wouldn’t take the risk because… didn’t matter. She knew best.

            Her baby was born through a RCS. And no, no matter how heartbreakingly she can present her story, I don’t believe for a moment that she knows what she is talking about.

          • attitude devant

            You cannot be serious. THIS is your explanation? Someone had their ovaries out and you thought they should keep keep them? Oh. my. g*d.

            Just stop. Right now. You haven’t a clue and you’re demonstrating that to everyone here.

          • The Computer Ate My Nym

            A high school friend of mine had her ovaries removed in her 30s. She wasn’t given the option of keeping them*. I’m not at all sad about it, because the ovaries were malignant and she’s still alive because of their removal.

            *Well, really she was. She could have walked out of the surgical consult and said forget it, I’m dying with my ovaries. Fortunately, she did not do that. But she was given no treatment option that did not involve removal of the ovaries.

          • Beth S

            My mom had a hysterectomy when she was 28 because of pelvic organ prolapse she was so ill her next of kin which was my grandparents at the time had to sign off on her surgery. To this day even fighting early menopause she says the surgery was the best decision for her and they took her ovaries.
            So yeah there’s some anecdata for you.

          • momofone

            I had bilateral mastectomies six months ago. I am in my early forties. I also chose not to pursue reconstruction. Two of my friends were “very sad” about it. I, on the other hand, could not be more relieved. Don’t confuse YOUR reactions with those of the people whose decisions they are.

          • The Bofa, Being of the Sofa

            What are they sad about? That you had the mastectomies? Or that you didn’t do the reconstruction?

          • momofone

            Both. Because they knew how awful I “must” feel, not being feminine anymore. Because of course, there’s no way to be feminine without breasts, and clearly I am just lying to myself about not wanting to do reconstruction. This “must” be the case, because they believe it, and surely their beliefs about it trump my self-deception, right?

          • FormerPhysicist

            I hope you have other, supportive friends.

          • momofone

            Thank you. I do. And I appreciate the (misguided) concerns of these two. I certainly don’t mean to say I didn’t grieve, but there are worse things.

          • pinkyrn

            Are you a medical professional Ellen Mary? A Medical Librarian? Just wondering where you are getting your information.

          • Amazed

            I see. So, there is a generation of American women who mostly walk around without their ovaries because doctors just decided to remove them just because?

            Well, the older generation is heavily represented here (no offense, ladies, I just happen to have some idea of the general age of some commenters). Let’s ask them (since you place such a great trust in commenters on boards). Ladies, do you walk around without your equipment down there? Addi? Dr A? Anyone?

          • attitude devant

            The trend toward hysterectomy alternatives actually dates way back. It was old news when I graduated med school in the 1980s. There was a time that hysterectomy was commonly used to help women limit their families, this being even further back, before the wide availability of safe effective birth control. Believe it or not, there was a time when you could get a hyst but not a tubal ligation in many areas of the country. But this was thirty years ago. As for a woman in her thirties winding up without ovaries, that would be extremely unusual, unless she had some disease involving the ovaries, such as endometriosis, certain cancers, or chronic PID.

          • Amazed

            But that was not what I asked. Ellen Mary claimed that hysterectomy was done TO women, not to HELP women. She said it like doctors were the one deciding that this or that woman – almost every woman, in fact – had to be given this form of birth control without bothering to ask.

            So, my question still stands. If a woman of the older generation feels that she had been hyst-ed for no reason but a sadistic doctor and actually without being consulted, I urge her to raise her hand.

          • Karen in SC

            I graduated from college in 1980. In my close circle of contemporaries there has been only one hysterectomy. I believe the ovaries were kept, but I’m not sure.

            My sister who had been so anemic with perimenopausal bleeding she needed a transfusion consulted with doctors and ended up with an ablation and prophylactive removal of her ovaries since her blood test result for ovarian cancer was troubling. (later pathology okay)

          • Rabbit

            My mom had a hysterectomy in 1987. I know they left the ovaries, because she developed a mass on one of them last year. Fortunately it was benign, but she was happy to have both of her ovaries removed before they could cause more problems!

          • Houston Mom

            My mom had her hysterectomy in the early 70s, kept her ovaries.

          • ericacrochets

            My grandmother had a hysterectomy decades ago. Ovaries were left in; she later died of ovarian cancer.

          • Sullivan ThePoop

            You have to admit it is an extraordinary claim and extraordinary claims require at least some proof.

          • The Bofa, Being of the Sofa

            You have to admit it is an extraordinary claim and extraordinary claims require at least some proof.

            Screw that noise. Let’s start with ANY back up at all, as opposed to blatant assertion.

          • Ellen Mary

            That there are too many Hysterectomies in the US & that not enough ovaries are left in place is an extraordinary claim? I am afraid that is THE point upon which we fundamentally disagree.

          • Sullivan ThePoop

            Okay then provide a link

          • Amazed

            When someone who has her information not from online mommy groups but actual medical practice disagrees, then yes, it is an extraordinary claim.

            VBACfacts is also a mommy group. And they have their “information”. Surely you don’t think it’s accurate just because they are a group of mothers who love to chat?

          • attitude devant

            Give me a break. REALLY? THAT is a given? Girl, I have done my best to treat you as if you had a lick of sense, but I see you are a total waste of anyone’s time here.

          • KarenJJ

            Problem with this style of disagreement is that you seem to not have anything to back up your claim and appear to be unwilling to examine the evidence you’ve based your opinion on. It’s hard to take your disagreement seriously after that.

          • Amy

            It is when you can’t back it up. How many hysterectomies are the right amount? How many are too many? What percentage of ovaries should be left in place, and why?

          • attitude devant

            You come here and say this crap to people who actually provide care to women and you’re amazed when we call you on your assumptions. If this is true, show us.

          • The Bofa, Being of the Sofa

            I enjoy this blog sometimes but y’all really go off the deep end when you act like everything that happens in women’s health is on the up & up.

            Yeah, those crazy OBs, like attitude devant, getting all offended when you suggest that they are doing things willy-nilly and accuse them of practicing bad medicine.

            Seriously Ellen Mary, you insult them and then get all offended when they call you on it?

          • Haelmoon

            But there is a significant life long risk for ovarian cancer. Although the rate is not high, the morbidity and mortality is. Once a woman is menopausal, there is little benefit to leaving the ovaries behind.

            Sure that means I will take ovaries out that would have have developed cancer. However, since we are not good a predicting that, I will continue to offer to remove them in all of my patients having postmenopausal hysterectomies (but I won’t have any more since my practice is finally all ob/perinatology – no more general gyne for me!!)

          • Ellen Mary

            All the research I have seen says that surgical castration of women lowers overall life expectancy, removing ovaries without indication is very much like removing testicles without indication.

          • Karen in SC

            but what do the ovaries do after menopause?

          • An Actual Attorney

            Make unicorn sparkles.

          • KarenJJ

            I imagine any condition chronic enough to involve surgery lowers life expectancy. Have you got more details? Causation /= correlation.

          • Haelmoon

            Actually the evidence is quite mixed. If the women is over 65, the evidence supports no increase risk to removing the ovaries. If they are over 55, there is likely a small risk a best. However, there is not evidence that firmly shows and increased mortality. Also, the risks are associated with the small amount of estrogen that is produced in the postmenopausal ovary. However, it is not clear if that is ameliorated by HRT supplementation. However, even the RANZOG (Australia and NZ “ACOG”) acknowledges the role of patient choice. If the woman is most concerned about ovarian cancer, it can still be appropriate. Also, the lack of estrogen risks in women who are obese are unclear as the adipose tissue produces estrogen too.
            In women under 45, there is an associated increased risk of all cause mortality. Therefore most gynecologist recommend ovarian conservation for this age group. The exception of course is women who are a genetic increase for ovarian cancer.
            I have not ever forced a women to remove her ovaries. However, when presented with options, most choose to have them removed. They are more afraid of ovarian cancer than osteoporosis or coronary heart disease. (Most women have multiple risk factors for either, and our evidence for the benefit of ovarian protection is not iron clad).
            However, OB/GYNs are not static, they respond to research. The evidence is mounting that it is the tubes, not the ovaries, that need to be removed to prevent ovarian cancer. Maybe in the future, we will just take the tubes unless there is another reason to take the tubes.
            However, to just accuse OBGYNs of “too many hysterectomies” and “too many ovaries removed” is not a fair statement. What about patient choice? Lots of women choose these options, who are you to decide over the internet when it was necessary or not??

          • Roadstergal

            Tangentially – is there a ‘Skeptical GYN’ site along the lines of this one? This is all very interesting information, and I’d love to have the opportunity to read more about the non-reproductive aspects of the whole kit and caboodle…

          • theadequatemother

            Our center takes the tubes with every Hyst now for that reason. A late proportion of cancers begin there. Ovaries are left in young women and in peri menopausal or menopausal women it is variable.

          • fiftyfifty1

            “All the research I have seen”
            And that’s the problem. All the evidence YOU have seen was cherrypicked and fed to you by NCB, but you believe yourself to be educated on the issue.

          • Daleth

            Removing the ovaries is actually very different than removing the testes, for two simple reasons:

            (1) Testicular cancer is very rare (about 1/250 men), easily detectable at early stages, very susceptible to chemo and radiation, and thus highly survivable (95%+ survival rate). In contrast, ovarian cancer is more than three times as common (1/72 women), very hard to detect at an early stage, harder to treat and less survivable (even if you catch it at stage II, which is early, you’re looking at about a 66% survival rate). Long story short, the risk of leaving ovaries in place is much greater than the risk of leaving testicles in place.

            And testicular cancer usually strikes men between ages 18 and 40. It’s much, much rarer in older men. Do you see the difference between removing the testicles of men in their teens, 20s or 30s who haven’t had children yet or haven’t finished having them, vs. removing the ovaries of women in their 50s who have finished? And there’s no point in removing the testicles of men in their 50s or up, because their risk of testicular cancer is minuscule.

            (2) Men’s testicles keep working for their entire lives. I know a man who had a daughter when he was 70 years old. Testosterone levels go down as men age, but not dramatically. In contrast, women’s ovaries don’t keep working their entire lives; estrogen levels plummet after menopause. Thus, removing the ovaries in a post-menopausal woman doesn’t have a huge effect on her, whereas removing a man’s testicles does.

          • An Actual Attorney

            When my mom had a hysto (I was in HS), I remember her telling me that she wanted the ovaries gone too, because all they were going to do at that point was possibly turn cancerous. Makes sense to me.

          • Bombshellrisa

            Without clear medical indication until the pathology report comes back.

          • Sue

            Ellen Mary – what makes you pontificate about things you know so little about, in the presence of people who do? Have you ever had to make a decision about treatment recommendation for anyone with post-menopausal bleeding? Have you audited an OB surgical list?

          • fiftyfifty1

            In my experience, most women at or near menopause want their ovaries removed during a TAH. Most women far from menopause do not and don’t have them removed unless there is a strong indication.

          • Jenny_from_da_Bloc

            SMDH is right? How do you know that there is any medical indication for someone’s ovaries to be left in during a hyst? You are making no sense whatsoever because you are not a doctor and Google doesn’t count

        • attitude devant

          Ellen Mary, with all due respect, why do you insist that there are ‘too many’ hysterectomies? What is your source? For me to get a hysterectomy approved I have to meet a long list of clinical requirements. Some of my patients who are BEGGING for hysterectomy can’t get them approved. (Sad but true: if your hyst is for bleeding, even if you’ve failed every conservative therapy there is, some plans won’t pay unless you bleed so much you are anemic. Imagine what it’s like to have bleeding almost every day but be denied a hyst because you are not at death’s door.)

          • fiftyfifty1

            “Some of my patients who are BEGGING for hysterectomy can’t get them approved”
            This is my observation too. Patients frequently complain to me that they already know that they just want to have a hysterectomy and be done with it, but that when I sent them for a OB/GYN consult the OB had them listen to all sorts of less invasive options that didn’t sound guaranteed to fix their issue and that they tried the endometrial ablation or whatever, and just like they predicted it didn’t work and NOW maybe they can have their hysterectomy that they wanted from the start.

          • Roadstergal

            I had a consult with my OBGYN on Monday about endrometrial ablation, and she talked me out of it for just that reason – not guaranteed to work, and she said she’s seen it ‘reverse’ and the tissue regenerate in a nontrivial number of her patients at the ~5 year mark. She also talked me out of a tubal ligation – both of which are procedures she’d preform. So much for excessive interventions and docs being all about the mo-nay.

            Incidentally, I drive almost exactly the distance to see her that other gal didn’t want to go for a VBAC. Because she’s a good doc and can do a Pap smear that doesn’t make me feel like I’m auditioning to be a muppet.

          • The Computer Ate My Nym

            Some of my patients who are BEGGING for hysterectomy can’t get them approved.

            A friend of mine had uterine bleeding that made her anemic. She had also had a history of DCIS and was on tamoxifen. In addition, her mother had had uterine cancer. Guess what happened when she asked her doctor to do a hysterectomy? Yep. Insurance denied because she hadn’t tried OCPs to stop the bleeding. You know, the OCPs which are contraindicated in breast cancer. Yeah, those.

        • Sullivan ThePoop

          Not knowing anything about that aspect of things I didn’t have anything to say on it and it was the reason I said “a lot of what you are saying.” You cannot disagree about something you are ignorant of.

        • The Computer Ate My Nym

          why then too many Hysterectomies

          Which hysterectomies should not be done? How do you know when a hysterectomy is not necessary? Which “modern practices” are you talking about that would negate the need for hysterectomy?

        • Daleth

          An elective c-section, hysterectomy, etc. is *scheduled*, and will only be scheduled for a time when the necessary staff (anesthesiologist etc.) is on site.

          A VBAC by definition cannot be scheduled, because labor happens when it happens and lasts however long it lasts, and most if not all induction drugs are contraindicated in women with a history of c-section.

          Hence the problem: because the VBAC can’t be scheduled and uterine rupture happens (when it happens) very suddenly, there is no possible way to ensure that the necessary staff will be on site when it happens… unless you have the necessary staff at the hospital 24/7.

          Do you understand that basic point?

    • The Computer Ate My Nym

      So, how would you want to increase the VBAC rate? How is sexism leading to a lower VBAC rate?

      • Ellen Mary

        Give every woman a fair, balanced, unsubjective analysis of her risk, including the option to transport to a larger VBAC equipped hospital for just delivery, and then even if it isn’t a higher rate, it will be the right rate. Too often now women are denied options they could choose if they had better access.

        • attitude devant

          Numbers and citations please. You say this, but don’t back it up. You say ‘it has to be just bullish chauvinism.’ And yet, most OBs are female these days.

          • Ellen Mary

            Not in many areas. Female OBs definitely tend to certain areas of the country. Also most established OBs in the US are not women. And I am chatting on a blog with three kids & a baby. If I wanted to spend all day digging for citations, I would be in grad school, not in the *comments* section of a blog. I can find some citations, as what I am saying is reasonable but it is hard to do while caring for small children & on my phone, which is why I mostly chat.

          • attitude devant

            So you have nothing. You come here and tell me this crap and you have nothing to back it up. OK, at least we have that clear.

          • MLE

            Why do you get so defensive when you’re challenged? You should know that this crowd isn’t going to swallow ANY sweeping statement, and adding “JMO” does not make you immune to a critical reception, especially when you’re making serious accusations such as that sexism is preventing women from VBACing. What response were you looking for exactly?

          • Sue

            In relation to ”JMO”, what’s the basis of your opinion? Have you run a hospital or a medical insurance company? Practiced OB? Or just read stuff?

            In general, when your casual opinion differs from that of an entire profession or industry, you might want to consider that they have good reasons that you are not aware of. Just my suggestion.

          • momofone

            So just to be clear, you want to say whatever you want to say, unsubstantiated, and then say that you don’t have time to worry with pesky facts because you’re too busy when someone WITH facts challenges you?

            Got it.

          • Jenny_from_da_Bloc

            She always states something, claims it as fact, then follows it up with IMO. Followed by something even more erroneous. It is not an access problem, it is a time and travel issue

          • Ellen Mary

            I don’t know if you noticed but I ended my opening post with ‘JMO’. In Internet slang that means ‘Just My Opinion’. I have formed that opinion based on reading over the years, however as I am chatting in comments on a phone, I am not equipped to do lots of citing at the moment, especially when any link I post will be promptly discounted. I stated my opinion & then said JMO. If you think none if your colleagues is ever now or has ever been in the past too quick to surgery a woman, well that is your opinion & I just disagree.

          • attitude devant

            Not equipped, period. Phone or no phone. Because you really have no idea, and are just making shit up.

            Got that.

          • The Bofa, Being of the Sofa

            Well, it’s everyone else’s opinion that your opinion is bullshit.

            Since we are all allowed to express our opinion, why are you complaining? Or are you the only one who gets to express your opinion?

          • attitude devant

            Yenta: ‘Well my grandmother came to me in a dream and told me Tevye’s grandmother is a great big liar!”

          • Daleth

            Links will only be discounted if they’re not reputable. I don’t ever recall seeing anyone here discount a reputable link based on who posted it.

        • Sullivan ThePoop

          But some women are going want it anyway and feel like that particular hospital should be forced into doing it. This has become a serious problem.

        • Amazed

          Access to what? No one is forced to deliver in any particular hospital, you know.

          It looks to me that you think that if offered “a fair, balanced, unsubjective analysis of her risk”, most women would choose VBAC. And that simply might not be the case. Frankly, many women don’t care about being pregnant, their aim is the child but they don’t rejoice in being sick every morning for months in a row, they would like to be able to see their feet and so on. It’s the baby that makes them tolerate all inconveniencies of pregnancy. And any risk might look too great to them if it is AVOIDABLE risk.

          • Ellen Mary

            No, but you seem to think that every good candidate for VBAC has no access problem what so ever & is given every opportunity to exercise free choice. That is frankly ludicrous.

          • Amazed

            What access problem do they have? They are prohibited from getting a second medical opinion? They are physically restrained from entering their car and going to a bigger faculty that can accommodate them? What?

          • Ellen Mary

            Many women feel stuck with their local provider & women with children at home actually can’t always afford to travel birth. Some women also erroneously believe that Medicaid will only cover them at certain providers & not all providers accept Medicaid. I can’t believe I have to define the idea that there are legit access problems for women.

          • Amazed

            They are not legit access problems. They are just problems of any individual woman and her own individual circumstances.

            Nice moving of the goalposts, by the way. In the post I was replying to you were blaming the providers for… what? Not being able to magick anestesia out of thin air when the good VBAC candidate ruptures? Being this heartless not to offer the women to pay out of their own (provider’s) pocket for their babysitter whiile they travel?

            It’s up to the individual women to check with Medicaid. Medical providers are not lawyers.

            And if my grandmother – at the time, a mother of a six-year-old – could hop onto the donkey cart to go from her village to the hospital in the town to give birth, I daresay women who drive their own cars have no excuse in the realm of “it was too far away!”

          • Sullivan ThePoop

            It used to be true that medicaid was only accepted by certain providers. Then they switched to buying insurance and it works like any other insurance as far as providers go. I believe it is united health care right now. It is accepted by anyone who accepts united health care.

          • Ellen Mary

            Medicaid is not United Health Care nationwide. Maybe where you live.

          • Sullivan ThePoop

            You could be right if they buy it locally.

          • Rabbit

            Medicaid is run by the states, with federal matching funds. Not every state has gone to the insurance model, and there are providers who choose not to take Medicaid or Medicare patients.

          • The Computer Ate My Nym

            For what it’s worth PA has an insurance program for Medicaid, but the carriers it uses are so bad that many physicians and hospitals refuse to take them. The hospital where I work has an on again off again relationship with all of them. It makes it very difficult to know how to advise patients re their insurance and sometimes disrupts care. I want single payer: single payer can have ridiculous rules, but at least it has one set of ridiculous rules.

          • Busbus

            But if a hospital isn’t equipped to handle it, they aren’t equipped. It’s like wanting heart transplant in a hospital that isn’t a transplant center. It’s like my daughter saying, “but I want blueberries!!!” after I pointed out that we don’t have any. Sometimes reality is a b*itch, but that doesn’t mean we don’t have to deal with it.

            Short of pouring inordinate resources into a national program that will pay a whole c-section team for standing by so every woman can have a vbac at the hospital off her choice – which would be a horrible misuse of funds in a country where a large percentage of the population has no health insurance AT ALL – there is nothing that could change this reality.

          • Daleth

            Exactly, Busbus. If you live in a rural area and the nearest hospital with 24/7 on-site anesthesiologists is 4 hours away, and you can’t afford to go stay in a hotel near that hospital for a week or more prior to your due date (or logistically can’t do it due to childcare issues or whatever), then you have an access problem–but you would also have an access problem if you needed cutting-edge cancer treatment, a heart transplant, etc.

            So you then have to choose: do you care enough about this (VBAC, cancer treatment, transplant etc.) to deal with the extra expense and hassle? If so, go for it. If not, mourn the fact that you don’t get what you want, and move on.

            But what you do NOT get to do is complain about how the dinky community hospital near your house is a dinky community hospital that can’t provide the medical treatment you want/need. **You chose to live in a remote area with a dinky hospital,** and anyone with common sense understands that not every hospital can provide every medical service–and that small local hospitals cannot provide cutting-edge or high-resource care. That’s why they life-flight you somewhere else if you really need it.

            And they can’t provide high-resource care partly for financial reasons (the cost of providing 24/7 on-site anesthesiologists and surgical teams is exorbitant and impossible to justify if you only have, say, 20 women a year wanting to VBAC), and partly for logistical reasons (there are not enough anesthesiologists, ob/gyns etc. to staff every hospital in America 24/7).

          • momofone

            I am one of those people who would not be willing to take on any avoidable risk. Had we had another baby, I would have insisted on a repeat c-section. I do not grasp the emphasis on vaginal delivery over lower-risk delivery, but I absolutely do not share the VBAC fetish.

          • Amazed

            Keep talking sista. Speak for the women who dont’ want a VBAC and won’t be devastated when they don’t get one. Sometimes, I think that on the internet, such women are nonexistant.

            Are you sure you exist?

          • Beth S

            I hated every moment of all three of my pregnancies, loved the babies, did everything I could to make sure they were born healthy and raised in a happy loving and stable home but hated being pregnant so much I’d usually ball for three days through the puking and wonder why I was being punished. You don’t wanna know what I said about that stupid apple they talk about in Genesis.
            However for me the risks of giving birth naturally, both to me and my youngest daughter were just too high so when the time came I had my C-section. I’m done giving birth now, however if I were to somehow get pregnant through the tubal after I sued either the doctors or my DH for making me go through the hell again (just kidding, kind of) I would have a RCS, the risks outweigh the rewards way too much.

          • FormerPhysicist

            I didn’t want a VBAC. I was willing to try it if I went into labor before my scheduled RCS, but I had no desire for it. Not for me and not for the baby. And I’m totally sick of people who claim nonsense risks to the baby – latest I’ve been hit with is that c/s-born children are more likely to suffer from depression as adults. Extraordinary claims require extraordinary proof.

          • EllenL

            It would be to me. There’s no way I could be talked into attempting a VBAC, if I had a choice.

            The problem is two fold: some women who want to attempt a VBAC are stymied by a lack of access. Other women who don’t want a VBAC may be bullied into one (to cut down on C-section rates).

            I sympathize with both groups and would like to see reasonable efforts made on their behalf.

        • The Computer Ate My Nym

          So why shouldn’t an OB at a hospital that can’t support VBAC say, “We can’t offer VBAC here. If you’d like to be assessed as a VBAC candidate go to hospital X and they can help you.”? Why wait until delivery when they can refer immediately and allow the patient to be followed by the person who will be there for the delivery?

          • attitude devant

            I’ve often thought that ICAN could get much farther by acting more like a consumer group than a political group. Hospitals LOVE to cater to OB patients, because marketing research shows that if maternity patients are happy they send their whole family to that same place. So go to the hospital and say, “We’d llike to do this at your hospital. We can promote your services in our national organization. We can partner you by supporting tort reform or increased reimbursements for VBAC”….or whatever.

          • Ellen Mary

            Because if the hospital is 2 hours away, that is impossible for a woman unless she has lots of leisure time & resources to travel to appointments. Very rural areas like Alaska already have a model of traveling for delivery & doing prenatal care locally.

          • Anna T

            And this is the model in Israel, too, although we don’t have a lot of very rural areas.

          • The Computer Ate My Nym

            I don’t know how OBs conduct their business, but that’s not a model I’d feel comfortable with. If the patient can’t reasonably come for regular checkups at the planned delivering physician’s office, she should at least come for an initial visit and her primary OB and the consultant who will deliver her should be in touch regularly about the progress of the pregnancy. That’s how it would happen in hematology/oncology anyway.
            I can’t imagine that any OB would feel comfortable saying that they’d take on the delivery of a patient they’d never seen before. They’ll do it if need be, of course, but I can’t imagine that they’d want to plan it that way. Some prenatal consultation would be necessary.

          • Karen in SC

            What if a family member needs care for a rare disorder or cancer and the best treatment is 2 hours away? Does it become possible then? I’m sure you can get some treatments locally so would you just settle for a less than optimum plan?

            In St. Louis there is a renown children’s hospital that draws patients from multiple states, as does the Shriner’s Hospital. How can those families make it work and VBAC desiring mothers can’t?

        • Bombshellrisa

          So how would that work for continuity of care? A woman gets all her prenatal care from a doctor close to her and then meets with a doctor once to go over her chart (a doctor who had privileges at the hospital willing to let the woman do a TOLAC) and then the woman shows up in labor and delivers with who ever is on call for that practice or delivers with a hospitalist?

          • Anna T

            This is actually the system in Israel. You get your prenatal care from an OB near your home, and then you go to any hospital and are delivered by someone who sees you for the first (and likely last) time in their lives. Not even a meeting in the hospital beforehand. Can’t say I like it much but this is what happens here for all women.

    • staceyjw

      Ellen Mary- MASTER DERAILER, and poster of unwarranted assumptions. This post is about indemnity, and ICAN. Reading comprehension much?

      Just once I want to see her post on topic, without a bunch of nonsense crap.

    • CanDoc

      Chauvinism? In a specialty now overwhelmingly populated by female physicians?

      • Bombshellrisa

        No kidding-out of the two practices next door to each other and the MFM in the same hallway at my hospital there are three male doctors. 6-8 docs in each practice

  • guest

    Niiiiiiiiiiiiice!!!

  • MLE

    BUT WE CAN’T AFFORD THAT! I mean, uh, we will take it under consideration.

  • The Computer Ate My Nym

    I like this plan but have doubts about its…practicality.

  • lilin

    This is brilliant. They can’t even say that it imposes a financial burden, because of course, by their logic, it won’t actually cost them a dime. Except they know that the stuff they preach isn’t safe.

  • Amy

    Of course, all the “educated” VBAC-at-all-costs mothers could also just agree not to sue.

    • Karen in SC

      You can’t agree not to sue though.

      • Amy

        No, I know. It was more of a put-your-money-where-your-mouth-is comment on my part.

    • TsuDhoNimh

      The mom could agree not to sue, but it’s not binding on the child … the child could sue when they are no longer a minor.

      So this program would have to be long-lasting.

      • Sullivan ThePoop

        I thought we talked about this before. You cannot sign away your right to sue. Maybe that was Dorit Reiss on another board.

  • Guest

    Oh what a great idea! Even I would have VBAC’d! Wait, no, I wouldn’t have, I wanted my baby to live. BUT STILL!

  • Dr. W

    A perfect put up or shut up. So many patients want the MD to do exactly as they say AND want to hold the MD responsible for the outcome. Basic logic: You want to make all the decisions? You have to be willing to take ownership of the outcome. If the legal system will not allow you to assume full responsibility (You can still sue), then you have to realize your MD may be unwilling to relinquish all decisions.

    • attitude devant

      Are you related to Mrs. W?

      • Dr. W

        Nope

    • MWguest

      “You have to be willing to take ownership of the outcome”

      A philosophy borrowed directly from the CPM handbook, here.

      • Dr. W

        This site is full of examples where the CPM let a situation evolve to a dangerous point, and then dropped the lady on a hospital and blamed them for the outcome.

    • Dr Jay

      Like I always say, “With autonomy comes responsibility.” Works for a lot of things… :)

  • attitude devant

    ICAN’s tactics and rhetoric are a product of the unreflective defiance inherent in the NCB movement. If they REALLY wanted to increase the VBAC rate, they’d examine exactly why it is that physicians and hospitals are so cautious. They’d push for better funding for rural hospitals and for high-risk maternity care. They’d advocate for tort reform. As it is, their ‘stick it to the evil OBs’ approach is sure to be counter-productive.

    • The Bofa, Being of the Sofa

      If they REALLY wanted to increase the VBAC rate, they’d examine exactly why it is that physicians and hospitals are so cautious.

      Because c-sections are quick and easy, so the doctor can get back to his golf game.

      • attitude devant

        Bofa, you are so male. And I mean that will all love and respect.

        • Amazed

          As a proud female, I suggest the following: let’s commission a study that would show the fact that most RCS are performed because c-sections are quick and easy, so the doctors can get back to their gold game. In other words – show the terrible care that surgeons provide.

      • The Computer Ate My Nym

        After my c-section I spent 3 days in the hospital, interrupting my doctors’ golf games, Minecraft time, and whatever else they might want to do instead of basically uncompensated follow up care of me. If doctors are doing c-sections because it’s easier then medical schools really need to do a better job teaching long term planning.

      • Beth S

        My poor doctor got his golf game, his Nap time and his office time interrupted because of an allergic reaction to the epidural, a spike in blood pressure even after I’d had the kiddo which could’ve meant a seizure and helping me remember that the CHD my daughter has isn’t all my fault it comes from my sperm donors side of the family.

  • Junebug

    Yeah, maybe on a cold day in hell. The last thing any of these people want is accountability for their agenda.

  • MWguest

    Or – if women want to VBAC in these small, community hospitals where they get more ‘personalized care’ – have the women pay out-of-pocket for the OR staff to hang out. (Anyone want to take a stab at how much per hour the hospital pays to have OR and anesthesia staff in-house?) I see the conundrum with some hospitals – they have to have the OR staff in-house when there’s a TOLAC. Yet if the VBAC goes fine, they can’t bill for surgical services they didn’t provide. Gotta pay for them to be there, but can’t bill for them if they’re not needed.

    Feasibly – these small hospitals could be losing money with each successful VBAC.

    • Captain Obvious

      CPT billing code 99360: physician stand by, each additional 30 minutes.

      • Captain Obvious

        CMS (The Center for Medicare/Medicaid Services) DOES NOT REIMBURSE for physician standby services – billed with code 99360. These services are considered by CMS to be included in the payment to a facility as part of providing quality care and are not separately reimbursable. However, you can check with your private insurance/3rd party payors if they reimburse for these services. When I contacted some 3rd party payors in my area, they were reimbursing these services at an RVU value between 1.10 and 1.75.

      • Trixie

        This makes me wonder how my VBAC was billed. I know the anesthesiologist (whom I never needed) went home after I delivered.

      • MWguest

        OK – what about the OR nursing staff, the scrub techs, anesthetists… is there a CPT code for their “standby services?” It takes more than a doctor to perform a c-section. At least it does in our hospital.

        My point, that the VBAC advocates seem to miss – is that it takes more than one person – more than ‘their very special AMAZING doctor who supports VBAC’ – to perform an emergency c-section. It appears the small community hospitals have to eat those costs – if they don’t have 24/7 in-house OR staff – each time a woman has a successful VBAC.

        • fiftyfifty1

          Actually they have to eat a huge cost even if a woman eventually ends up with the CS. The reimbursement for the CS can’t possibly cover the cost of the whole team being in hospital if the woman for instance labors 12 or even 6 hours before having her CS.

    • Smoochagator

      But to NCB advocates, that shouldn’t matter! These money-hungry doctors already have their Mercedes and Porsches and their vacation homes in the Hamptons! They should put their financial interests aside for the mother who wants a good “birth experience.”

  • Amy M

    Hahaha! That’s awesome! Do the individual chapters ever have fundraisers, and if so, what for? Time to hike membership fees….ICAN can guarantee your VBAC attempt with this plan, if you are willing to pay the price to be a member of their exclusive club! Can’t afford the fees? Time for a bake sale! Start making those yoni cupcakes.

    • Sara

      I will have nothing to do with a yoni cupcake.

      • Dr Kitty

        Yoni cupcakes represent the intersection of cannibalism, lesbianism and competitive baking…one of which is fine*, but the other two have no place in civilised society.

        * Lesbianism, d’uh.
        Competitive baking is evil, cannibalism not being a social good is a given.

        • The Computer Ate My Nym

          cannibalism not being a social good is a given.

          With the caveat that breast feeding, while not the panacea that the NCB claims or something that should be demanded of every woman, is probably an overall social good in the right context, even though it’s technically cannibalism.

          • Sue

            What about placentophagia?

          • Amy M

            Is it? I thought just eating flesh counted.

        • araikwao

          Competitive baking is evil? How could sweet treats be born out something evil? Never mind, I’m sure there’s something in YouTube about it, I shall go forth and “educate myself” about competitive baking

          • The Bofa, Being of the Sofa

            Competitive baking isn’t evil, just cupcakes.

            People are starting to figure that out now, and the cupcake industry is tanking.

            You want cake, get a cake. Cupcakes that are piled high with frosting are no substitute for an actual cake.

          • Roadstergal

            But sometimes you want cake, but don’t want the whole damn thing (and don’t have enough nearby friends to call a party and justify it). Therefore, cupcakes – or cake pops, which I am reluctantly warming to. The little cake testicles to complement yoni cupcakes.

        • Smoochagator

          Competitive baking is definitely not evil! Anything that inspires continuous improvement to the quality of baked goods (and inspires bakers to BAKE MOAR) is intrinsically good.

          • Dr Kitty

            Depends if it’s being judged on taste or appearance.
            Too often competitive baking involves style before substance- or pretty things that taste stale and horrid.

            Just bake to feed people and make them happy. Don’t try and make the most realistic vulva cupcakes ever with a packet cupcake mix…

      • Trixie

        How about a yoni steaming?

        • Sara

          Well, there is a Certified Yoni Steam Practitioner based locally, so I may actually try this knowing that I will be in the care of an experienced professional.

          As long as no menstruating cupcakes are involved.

  • theadequatemother

    Just curious, how much do you think it would go up? I don’t think the VBAC rate would increase all that much. OBs would still want to avoid bad outcomes for their patients, even if there were no extrinsic motivators (like lawsuits). Patients would still receive risk-benefit counselling and many would probably still chose an RCS.

    So…anyone know what the proportion of TOLAC would be in a system that is “defensive” vs one with universal indemnity? The TOLAC rate in the US was something like 8% in 2005. In BC, Canada it’s around 24-25%. (http://www.powertopush.ca/wp-content/uploads/2011/05/1100-Steele-Recommending-and-Supporting-VBAC-FINAL.pdf).

    • Rabbit

      I don’t think it would change much, actually. The lawsuit would still exist as a huge negative even if the doctor wasn’t responsible for the payment in the event of a judgment. I work as an attorney for a federal agency, and am responsible for tort claims made against the agency’s doctors. Federal employees are not personally liable for judgments when the tort occurred during the course of employment. The lawsuit process is still a huge source of stress for them. Having to talk to your lawyer – even the one working on your behalf! – takes you away from your real job. Working with attorneys to answer discovery requests sucks. Depositions really suck. And trials suck more than anything else.

      • Smoochagator

        And I imagine that being the defendant in a lawsuit (or at least having to defend your actions in a lawsuit, even if you are not personal liable) is extremely stressful. Your integrity and professional ability are called into question and scrutinized. That’s gotta hurt.

    • Dr Kitty

      The UK has a high rate of VBAC, but spends about £500 per birth on indemnity (the average pregnancy and birth costing the NHS £2800), with costs rising…

    • the wingless one

      Yeah, I have zero interest in a VBAC myself and it has nothing to do with lack of access (I live in a large urban area with multiple hospitals equipped for VBAC). It’s just…what would be the point? We don’t plan to have a large family and my recovery from the first one wasn’t that bad. I’m sure it was a lot easier than recovering from labor + an emergency c/s would be. I would definitely opt for RCS and I’m sure my docs will be happy to hear it.

  • Young CC Prof

    Insurers are remarkably agenda-neutral and numbers-driven on many many issues. If an insurer tells you to do something, there’s usually a good reason. If you can’t get homeowners insurance for that house you’re trying to buy, consider another house. And if you can’t get medical malpractice insurance for a particular procedure…

    • Mel

      Flashback to a CarTalk Episode: (as I remember it)

      Caller: What should I do if my car catches on fire again?
      Tom/Ray: Get out and run away to a safe distance.
      Caller: Isn’t there a way I can put out the fire before it burns up the car?
      Tom/Ray: Have you seen those ads on TV where an insurance company explains how to safely cook a turkey or put in a fire alarm?
      Caller: Yes.
      Tom/Ray: Have you ever seen a car insurance commercial showing how you can put out a fire in a car?
      Caller: No.
      Tom/Ray: That’s because YOU CAN’T safely and the insurers know that.

      • Amy M

        OT:
        My husband’s car spontaneously caught fire while he was driving it last summer. He pulled over, got out, and moved away to a safe distance. About 10 minutes later, it was a towering inferno. Total loss. As it was a raging hot day (about 97 degrees, week-long heat wave), the insurance company and fire dept totally agreed that he wasn’t attempting to bbq hot dogs on the engine, and gave us a nice payout.
        /csb
        /you don’t mess around with car fires
        /vbacs are also pretty risky for a certain percentage of the population