Lehigh Valley Hospital Makes a Statement
Lehigh Valley Hospital has responded to the letter to the editor that was published in The Morning Call last week. You can read it here.
I’d like to respond to a couple of the statements made in the letter.
Currently, five midwives are on active staff and each practices in her own preferred model of care. In addition to full service midwifery and birthing services in collaboration with an obstetrician, some midwives choose to practice in outpatient offices….3 new midwives have joined our health network staff in the past 2 years.
It has been only with great difficulty the identity of these 5 midwives has been verified. As of Friday, May 29, a call to 402-CARE provided a response of “The Midwives and Associates“–which is Laurice’s practice that will no longer be doing births after June 30. When the caller pressed for more names she was referred to Gaye Haas and Aimee Kessler.
Gaye quit doing births several years ago–you could call 610-437-7000 to verify how long ago. Even when she was doing births, I do not think she did any at LVH–I specifically talked to her at one point about her views on the practice (Women’s Medical Specialties) getting priviledges at LVH. (NOTE: Color me surprised! As I was writing this post I went to the WMS website to see if it had any notes on whether Gaye is doing births…and found that they have a new midwife on staff–Jamie Rackoff. This is a change from the last time I looked on their website less than a month ago. However, I just spoke with a woman due in late July who told me she had contacted this practice because of not being able to stay with Laurice, and was told that “the midwife does not do births.”)
Aimee does not appear to do many births. You could call 610-820-0300 to inquire about how many she did last year compared to Dr. Osterwald. And again, this would be a case of them having priviledges at LVH, but not actually doing many (any?) births there.
A caller this morning to 402-CARE was again referred to The Midwives, and also to Cynthia Dinsmore at Casa Guadalupe and Laura Zitzer at the Center for Womens Medicine. However, the customer service rep at 402-CARE said that neither of these midwives do births.
So yes…splitting hairs, there are 5–(or possibly 6?)–midwives in the LVH network–Tina, Gaye, Aimee, Cynthia and Laura (and Jamie). However 3 (4?) of them are not doing births at all, neither of the others provide a “sure to have a midwife at your birth” option like Laurice did.
As for working under their preferred model of care, I know that was not true of Laurice. Even before this incident she was not providing services that she was skilled in and supported, simply so that she could maintain priviledges at LVH. That is why I did not use her for my most recent birth, instead using a care provider who was not covered by my insurance.
Our Health Network also fully supports the option of VBAC. Our guidelines are consistent with those published by the American College of Obstetricians and Gynecologists…
It is hard to say that they “fully support” VBAC when there are women who report being told by Drs in Hutchinson’s own practice (College Heights) that they were being denied a chance to VBAC not on medical safety grounds, but on liability concern grounds (1). Again…this is about CHOICE. If a woman has the risks explained to her (of BOTH options–the risks of repeat cesarean are rarely discussed), she should have the option to refuse surgery. Certainly an ethical Dr. should strongly discourage a medically ill-advised VBAC attempt, but even ACOG guidelines include a woman’s right to “informed refusal,” a right that is denied a woman when she attempts to advise her care provider prenatally and is told that she will be denied further care from that care provider–something that was threatened to one of my clients when she was 40+ weeks pregnant–hardly giving her enough time to find a new care provider. As a point of fact, many women across the country are unable to find a care provider who will support their right to informed refusal (of a repeat cesarean) even if they start looking for that care provider *prior* to pregnancy.
Unless we get a copy of the guidelines LVH is using, we can’t know how much it really supports womens choices or even the research regarding birth (for example, the research indicates that attempting a vaginal birth after multiple cesareans does not pose a clinically higher risk than after just one cesarean(2), but many care providers across the country refuse to “allow” women to attempt a vaginal birth in this situation based on “increased risk.” Research also supports the safety of vaginal breech birth(3), but this option is generally denied to women.)
Also, regarding using ACOG guidelines…ACOG is not the be all and end all in expert opinions on safe birth. ACOG guidelines often directly contradict the research (4) because ACOG’s primary interest is not the safety of women, but the safety of its members. That may seem to be a harsh statement…and to be sure…I do believe they want women to be safe. But as I mentioned above…women are often denied choices out of LIABILITY fears, not SAFETY fears–and this is exactly the kind of thinking that ACOG promotes.
It would seem that midwives should be able to work under the guidelines of the American College of Nurse Midwives, but they are not. Further, even among obstetricians, differing opinions hold, as other professional OB organizations around the world–often in countries with better maternal/fetal outcomes than in the US–often have guidelines that directly contradict ACOG guidelines.[5]
The most recent data … reported the national rate of vaginal birth after previous Cesarean section as 8.5%. In 2008, the VBAC rate at Lehigh Valley Health Network was 15.5%. Here, as across the nation, many women decline VBAC and many have medical conditions that prohibit VBAC. Our health network has the resources and systems of care to safely support VBAC and encourages appropriate candidates for VBAC. Our policy allows a midwife to be present during the labor and delivery of a patient undergoing VBAC, and since a midwife cannot perform a Cesarean section, an obstetrician is required to manage the labor and delivery in the event of an emergency requiring immediate surgery.
Citing the national rate only highlights that this issue is not just one in the Lehigh Valley, it exists across the country. A VBAC rate in the single digits is pathetic. Dr. Hutchinson indicates that the VBAC rate is low because women “decline” VBAC or have medical conditions that prohibit it…however the International Cesarean Awareness Network (ICAN) has found that 50% of hospitals in the US have bans–either “official” or “de facto” on VBAC, which seriously limits women’s access to this option. In areas where VBAC is “allowed,” it is often under very stringent conditions that eliminates most candidates, or women are given misleading information by their OB to encourage them to decline.
Lets parse out the LVH data for a few moments though…
Using data available from the PA Dept of Health and from Dr. Hutchinson’s letter, I am able to determine this for Lehigh Valley Hospital:
Year Number Cesarean # of Repeat Number of VBAC
of births Rate Cesareans VBACs Rate
2005 3196 31.4% 329 40 10.8%
2006 3360 29.5% 308 77 20%
2007 3716 26.8% 291 103 26.1%
2008 (data not yet available from Dept of Health) 15.5%
Now…I can tell you as a childbirth educator/doula who keeps track of these things…prior to 2005 LVH had a steadily climbing cesarean rate, and a dropping VBAC rate. I can send you the data that I’ve pulled off the Department of Health website in an Excel spreadsheet if you want it. So what happened in 2006 to change things? Why the sudden reversal?
Wasn’t it about 2006 when Laurice abruptly quit doing births at Sacred Heart, and switched over to LVH? Did her presense there make that much of a difference? I guess we will not know until a couple more years of data come out.
And speaking of reversals…wow…put into perspective, that 15.5% VBAC rate in 2008 doesn’t seem all that great when it was 26% in 2007. What happened there? It is worth noting that Laurice only did about 5.4% of the births at LVH in 2007 (she did 200 by herself, she brought on Tina in 2008), and of those, 6 were VBACs that year. But even though the VBAC rate for the hospital dropped in 2008, Laurice attended MORE VBAC’s in 2008 at 10 (and was on track to attend 10-12 in 2009). Assuming that approximately the same number of women had previous cesareans in 2008 as in previous years (369 in 2005, 385 in 2006, 394 in 2007), that means that about 60 women had VBACs, so Laurice attended 17% of the VBACs.
I will reitterate though…that the issue here is MUCH bigger than just midwives, or VBAC, or even Lehigh Valley Hospital. The “straw that broke the camel’s back” was an issue of cesarean vs. vaginal birth with a midwife at LVH. The bigger issue is women’s ability to make their own choices in their maternity care. Choices ranging from whether water will be broken, to positioning for labor and birth, to eating during an extended labor, to care provider, to whether birth will be vaginal or an elective cesarean.
Ultimately, maternity care is the only area of medicine where adults are unable to refuse treatement. The argument will be made that choices in birth are about more than just the mother’s own health because of course the health of the baby is at issue. However, there is no other situation where one person is compelled to submit to treatments to save another person–even a parent to save a child. If a child was dying of kidney failure, the mother could not be compelled to give her own kidney even if she was a perfect match, though the vast majority of mothers WOULD give their own kidney–even their own life–to save their child. I do not know a single person involved in the current local group who would not walk through fire–or birth via cesarean–if the health of her child depended on it. But all of us would prefer, if possible, to avoid those things.
(1) Discussion on Facebook “Wall” post on May 31, 2009
(2) https://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0806_AOM.cfm talks about how the ACOG guidelines are VBAC were made based on a single study with a low number of VBA2C examples, ignoring other, more sound data that supports the safety of VBA2C. Also , http://vbacfacts.com/2008/06/18/rupture-rate-10-for-vba2c-with-prior-vaginal-birth-within-one-year-of-last-cesarean/ makes good reading, as it gives an example of how obstetricians will use misinformation to manipulate women’s choices
(3) http://www.ncbi.nlm.nih.gov/pubmed/…
(4) http://vbacfacts.com/2009/04/05/vbac-class-bibliography/
(5) For example, “SOGC”–The Society of Obstetrician and Gynecologists of Canada–has recently come out with a positon on breech birth that contradicts the ACOG position http://www.sogc.org/media/pdf/advisories/CpgBreechJune09_e.pdf
Tags: ACNM, ACOG, birth choices, breech, Facebook, Lehigh Valley, Lehigh Valley Hospital, midwife, VBA2C, VBAC