Bellies to BirthCast

Bellies to BirthCast |  Week of November 10, 2008  |  Episode 1  |  Subscribe

ICAN and You Can Too: Choosing a Homebirth After Cesarean Section

Pamela Udy, President of ICAN, the International Cesarean Awareness Network (, joins the Bellies to BirthCast to discuss why more women are choosing homebirth after cesarean section (HBAC) due to widespread hospital bans on VBAC (vaginal birth after cesarean section).

A full transcript of the interview appears below:

CATHERINE:  First of all, hello and welcome Pam, it's an honour to have you with us today.

PAM:  Oh, thanks for inviting me.

CATHERINE:  Could you tell us a little bit about yourself and your organization, the International Caesarean Awareness

PAM:  Sure. I've been involved with ICAN since my third baby was born. He was a vaginal, hospital birth with a certified nurse midwife. After two caesareans; I had two caesareans with my, well I had a caesarean each with my first two babies and then my next three were all vaginal births and most of that is due to a support encouragement of ICAN. ICAN stands for the International Caesarean Awareness Network. We are a non-profit organisation, all volunteer, and we work to improve the maternal and child health by preventing unnecessary caesareans through education. We provide support for caesarean recovery and we promote vaginal birth after caesarean. Every month we have support meetings held throughout the United States, Canada, and one in the UK now. We offer forums on our website and offer support and encouragement for moms there, and we provide evidence based information using all the latest research. Moms made educated decisions about their healthcare. 

CATHERINE:  It's really a wonderful organisation and definitely something more women should be aware of especially as the caesarean rates are climbing in the US. Let's address the issue of VBAC or vaginal birth after caesarean. What are the primary reasons to consider a VBAC?

PAM:  Well, one of the biggest reasons is simply safety. A VBAC is safer for moms and babies than if we schedule in a caesarean. There are some really great long term health reasons for having a VBAC for the baby. The baby is less likely to have respiratory problems or to be born premature and he has a better breast feeding and bonding experience. And those aren't just woo, woo, nice happy things, those are real health benefits the baby; and a VBAC usually has an easier recovery for mom than a caesarean. A caesarean is major abdominal surgery. I think somewhere along the way, that's gotten lost and it just has been presented as a safe option to vaginal birth; a caesarean is surgery and it has risk inherent within that.

  Can you tell us a little bit more about the risks of a c-section? Especially some potential long term risks?

PAM:  Sure. Mom has immediate risk on the surgical table. She has risk of bleeding and risk of shock, risk of problems with anaesthesia. She has long term risk of infection and nicks to other internal organs which lead to long term problems. She has risk of depression and traumatic recovery due to the surgery. I want to be careful here and say that not all caesareans are traumatic and definitely there are some vaginal births that are traumatic as well. That some women perceive their surgeries as being traumatic, especially if there is an anaesthesia problem and they can't communicate that, or somebody just isn't listening well enough to them. Also the risk of the baby being cut by the knife and having to recover from that. He, the doctor could have underestimated the length of the pregnancy and then baby is born premature and has respiratory problems. Even if baby isn't born premature, they could still have respiratory problems due to not being squeezed through the birth canal. Therefore, all the fluid's not squeezed out of their lungs. Babies with caesareans just simply have more respiratory problems and they spend more time in the NNICU.

CATHERINE:  Now, what are some of the situations in which a VBAC would not be encouraged?

PAM:  I think that's very individual. Some moms will have a different comfort level. Some will be okay with delivering with a condition that another would not be. An example of that would be different types of uterine scars. Maybe the last caesarean was a classical incision.  Some women would be comfortable with delivering vaginally after that and some would not. So the key here is education and knowing what the options are, and having those options be accessible to them without them feeling like “well, I have to do this because that option's not even available to me.”

CATHERINE:  What percentage of women are actually having a VBAC?

  Unfortunately, the 2006 numbers tell us that the VBAC rates have dropped in correlation with the rising caesarean rate. Only about 7.6% of women actually VBAC. The generally accepted numbers for those that could have a successful VBAC is between 62% and 82% of women so only about ten percent of the women who statistically could VBAC are VBACing. I just find that very shocking.

CATHERINE:  It definitely is. What are some of the reasons women are not successfully VBACing?

Well, obstetricians have done a great job of blaming moms for the rising caesarean rate. We're too old, we're too fat, we're too short, but if you listen to moms, you'll hear that it's their doctors who are pushing caesareans out of impatience, sake of convenience or fear of law suit.

CATHERINE:  Do you find that some physicians are just unaware that the risks with vaginal birth after caesarean are lower than that of a repeat caesarean section?

PAM:  Unfortunately I don't believe that doctors are using evidence based medicine when it comes to VBAC. It's all based on a fear of liability, the fear of law suit.  That is very unfortunate. They're putting their protection of their pocket book ahead of the health and safety of mother and baby.

CATHERINE:  Hospitals are also, due to this liability issue and some other reasons, banning VBAC or saying that at this hospital, it's not an option. Why is that occurring?

PAM:  Again, it's all about a perceived risk of liability. There is great irony in the fact that caesareans pose more risk to mom and baby than vaginal births do, and that these risks translate to more of moms and babies being hurt by the very surgeries that doctors are trying to protect themselves with. Hospitals and doctors are really good right now at pointing the finger back at each other. Then you have the insurance companies too.  So they're just making this little triangle of blame. “It's their fault, they're the ones that are requiring it, and they won't let me.” It's the moms and the babies that are really suffering from significant health complications and even death due to these bans.

CATHERINE:  Can you show just how the ban on VBAC is encouraging more women to opt for a home birth after caesarean section?

PAM:  Sure. If the medical community is unwilling to support VBAC in the hospital, women will choose to give birth at home rather than schedule unnecessary surgery. Doctors don't like this. If we're not supposed to give birth at home, and we're not supposed to give birth in the hospital, it seems like the only acceptable option to them is that we have our babies in the operating room, and that's not okay. Women are willing to pay out of their pockets for a home birth midwife rather than have their insurance company pay for a caesarean that they did not medically need. What does it say about our medical community when our hospitals – which are supposed to be places of comfort and healing, are instead places of coercion and fear? Doctors need to realise and work with us to make hospitals again, a safe and a respectable place to go and have our babies. We need to feel like its successful there, that it's going to be encouraged and that is actually an option and that as soon as we step in the door, we're not going to be rushed off to the operating room. And if they want us to deliver there, they're going to have to meet us and make some real changes in the way that VBACs are handled in the hospital.

CATHERINE:  Can you share some rough estimates on how many mothers are choosing home births after caesarean versus being forced to have repeat caesarean section?

PAM:  I don't have a good number for that. I don't think that those numbers have been collected anywhere. However, we do know that less than two percent of women deliver outside the hospital and I'd imagine that VBAC moms are a growing number of these births. We need to be sure that VBAC is a protected option when it comes to home births. That comes with the midwifery licensure, which is happening in many states. VBAC needs to be a viable option for that.

CATHERINE:  How does ACOG's stance on VBAC affect hospital's policy regarding the option?

PAM:  ACOG came out with a statement saying that obstetricians and anaesthetist staff needs to be available immediately; immediately available twenty-four hours a day, seven days a week, and this had a serious impact on hospital's willingness to offer VBAC to mom. Small rural hospitals without twenty-four anaesthetists; they all almost immediately placed a ban in effect. Other hospitals are following suit so that even though they're within our communities and have adequate staff, that they - For instance, our local hospitals had twenty-four anaesthetist staff. We have a very high epidural rate in my local hospitals here in Utah, and we don't have twenty-four obstetricians on staff. It's very hard to get a VBAC in these hospitals, which is very unfortunate because it is a huge leap to go from having a caesarean for whatever reason to having a home birth. Like I said, 98% of our population delivers in the hospital. For a mom to feel unsafe enough to turn away from the hospital and turn to home birth is very significant and it says some really bad things about our hospitals.

It definitely does. Can you share a little bit more information on the safety of home birth after caesarean versus a vaginal birth after caesarean in the hospital?

PAM:  VBAC is a very safe option. The major risk of a VBAC is of course, uterine rupture. Unfortunately, something that women aren't being told is that once you have a caesarean, your chance of having a uterine rupture is carried throughout your pregnancy. It's not just while you're in labour. However, your risk of uterine rupture is still very - well, it is about par to that of moms who do not have a caesarean, but who are being induced with some of these induction drugs such as Misoprostol and Cytotec. I guess that the thing that I tell women is not to be induced with any kind of drug unless there is an urgent medical reason, and to be sure that you're interviewing your care providers. Find out what kind of protocol they have, what do they suggest for induction, why do they do it? Do 80 or 90%of their moms have inductions because it's convenient, or are they only doing it when it's very medically necessary?

CATHERINE:  And what precautions should women take when planning a vaginal birth after caesarean or a home birth after caesarean?

PAM:  Both of these are going to be very similar. Whenever you're planning any birth, but especially VBAC birth, you're going to want to interview multiple care providers. Choose one that practices the midwife model of care and be open to your options. Consider going outside of your insurance network to get the care provider with the really great VBAC rate. You'll want to find out what the doctor or midwife's caesarean rate is. What do they risk women out for? Really consider what is important to you. That's going to be different for every woman. For some women, they just want to go into labour on their own, and they don't want a care provider to have a 90% induction rate. So really look at what is important to you. If a mom is going to deliver in a hospital, veto the induction, veto the epidural and any kind of medications during labour so that you can really listen to your body, and notice any sudden changes.  There are some who would suggest an ultra sound to see where the placenta had detached, to help or allow any placenta implantation problem. So if a placenta has attached near the prior uterine scar area, then the mom may be at more risk for placenta problems even after delivery. That might be an option. Some women are very comfortable with that, and some aren't. You have to decide that and find a care provider who's going to be respectful of that which is important to you, that you're comfortable with. I would guess taking out of hospital classes – child birth classes. Sometimes moms just said, “Oh well, I've already done that.” but they were the hospital “how to be a good patient” class, and perhaps something out of hospital may give you a little more education on how to handle labour and how to prepare for it, and give you a little more encouragement and strength for doing it.

CATHERINE:  Now how can women advocate for VBAC in their area? If it's not an option, what can they do, who can they
talk to, to try to raise awareness or to make this a valid choice in their particular area?

PAM:  It's a lot of work, but it can be done to encourage hospitals and doctors to be supportive of VBAC. Write letters to the hospital; you may actually call and make an appointment to meet with hospital staff. Let them know that this needs to be an option. Women want this option. Maybe go to the press. Contact your local newspapers, write an opinion, talk to reporters, and then also talk to government representatives. Talk to your congress woman, talk to health representatives, talk to these people who need to know that patient's rights are being violated with these VBAC bans. If women can't refuse surgery, then they didn't consent to it. If you're in a position where that is your only option, that is coercion and illegal.

CATHERINE:  It definitely should be; it's choice for lack of choice.


Is there a way that women can get more information on the status of VBAC at the hospitals in their area? Is there a good place to find the numbers for the rates of induction; things of that nature?

  On our website, and that's We have a page that is a state map. You can look and see what hospitals in your area are VBAC friendly, or who have a VBAC ban. I'm not sure that we have epidural and induction rates, and where you find that varies from state to state, but most hospitals are willing to talk to you if you call and just ask for the maternity ward. Talk to the nurse who answers the phone and say, “oh, I just moved to the area, and I'm looking to get some more information on the local hospitals. Can you tell me…?” Most of them are very chatty. I've called two, three hospitals to get the information. If they're not busy, they're willing to sit and chat with you and  they'll even exchange birth stories with you, and be friendly and talk to them about what's happening within their hospital and, and so that's a great way to get information. 

CATHERINE:  Are there any specific strategies that one can use to find supportive providers or midwives in their area?

PAM: ICAN, as an organization, does not give out recommendations for care providers; that's so individual. Some women will have a wonderful experience with an obstetrician, and that same obstetrician will be another woman's nightmare. So it really just depends; you're going to have to interview and go in. Some women are very reluctant to do that, but really, just go in and talk to them and say, “this is what I want. What would you do in this situation? How many of your moms do this?” Talk to them about their vacation schedule. “Well, I'm due in four months, are you going out of town?” Really, that is the best way to get a sense for them and how they practice. Watch for those red flags. It is a lot of work, that you can go in and just say “I'm here to interview, I'm looking for a new doctor.” You don't have to take off any clothes and most often, you are not paying a copay, you're simply trying to find a new doctor and most will sit down and talk to you about it. If they won't, then that is a point that a lot of women miss. 

CATHERINE:  Interviewing a provider is something you should do regardless of your history for any type of medical care – especially with having a baby. As you talked about earlier, it is such an individual experience. It's not just practice and procedure, but it's also that personal connection that you want to have with that person. So, you definitely don't have to take the first one that you talk to.

PAM:  Right, or the one that your sister-in-law loved, or the one that's on your insurance plan because there are a lot out
there and you may have to search through a haystack to find that one shiny needle. But it's so worth it. 

CATHERINE:  Now recently, insurance companies have started denying coverage to women who've had previous caesarean sections. Do you think that that will have an impact on the number of women who have access to VBAC?

PAM:  You know this is such a frustrating trend. Caesareans impose risk as medical complications, short term and long term, which carry a huge price tag. Insurance companies have done the math and they recognise that caesarean moms are high cost beneficiaries. They are working to weed them out as the school of people that they cover. And that's frustrating because, it is discriminatory. Law makers need to clue into this, and we need a way to protect moms. However, these restrictions speak very loudly to the true risk of caesareans. They do carry significant risk of complications and should be used only when medically necessary. And yet we have the medical community, just as a casual convenience way to schedule their day, and they're working hard to convince us as women that it's no big deal.  Then you have these insurance companies that are saying that it is a big deal and our life long health and insurance coverage is at risk due to this. We need to clue into this and be aware that this is a possibility, we need to be very careful about why we're scheduling these caesareans and being sure that they are very necessary.

CATHERINE:  Can you share a little bit more on how many women are currently having caesareans with their first babies
and what some of the recommended percentages would be?

PAM:  The world health organization has recommended that the caesarean rate be between10 and 15%. ICAN was started 26 years ago, by several women who were outraged that the caesarean rate was 16%,16%. I'm not sure what I would do to have a 16%caesarean rate at my local hospital. Our caesarean rate is now 30%and climbing. We see states who are – who's caesarean rate is 30%, and caesareans for breach and twins and premature babies are not even being counted in that percentage rate. And so you have to wonder what their real caesarean rate is, and why they have a 30%, when they're not counting all these that may actually have been necessary. The first time caesarean rate is one in three, and moms who have had prior caesareans, the caesarean rate is much higher than that; you're more likely to have a repeat caesarean. Unfortunately, that's something that doctors are telling women. “Well, let's do this now because it's a little more convenient, I'm not really sure about what's going on and you can have a vaginal birth with your next baby.” but that's not always true. The women may not be in an area where that is encouraged and supported, and then she has this huge fight on her hands it's not a very comfortable place to be.

CATHERINE:  And that is a very, very disturbing statistic that she's at. Nearly half of the caesareans performed today are most likely unnecessary and preventable.

PAM:  You know, preventable is a huge word. We talk about unnecessary caesareans, and I'm not sure people can wrap their brains around that. But when you talk about the fact that you have choices that you make as you go along, and your doctor makes, you go into the hospital; well, when do you go into the hospital? Well, do you go into the hospital the minute that you, have a contraction, or do you wait until you're in active labour? That is something that can determine whether you have a caesarean or not. And you don't see birth anymore, we don't see labour anymore, so when labour hits, we go into the hospital because that's what we're told to do. The minute that you walk in those doors, you're put on a time clock. Your labour may slow at that point. I had two of my babies after my caesarean at the hospital and one at home, and my home birth basically was a much shorter labour than either of my two hospital births. I really feel think that's because I had the transition, that change. It was getting used to the environment and having things happen to me there. It took labour longer at that time. So, that is something that women need to be aware of. Go into the hospital when you're in active labour and make sure that your provider is somebody who is supportive and encouraging. Opt for natural pain relief measures instead of the epidural. All of these things can help you to have a vaginal birth instead of a caesarean.  That's kind of what we're talking about when we talk about preventable. If you do this, this, and this, and this, you're going to have a caesarean. If you maybe make some different choices, you can prevent that caesarean and help yourself stack the odds in your favour of having a vaginal birth.

CATHERINE:  Are there any primary things that women should try to avoid that typically do lead to a caesarean? You've talked a little bit about going to the hospital too soon, using pain medications; are there any other things for women to really be aware of that are maybe not the best choices in most situations and have been shown to lead to caesarean?

PAM:  Sure, I can think of two right off the top of my head. The first would be inductions. Inductions are being touted as being convenient  and fun; you're tired of being pregnant anyway, so just let me schedule it for this day. What the doctors aren't telling you is that's the day he has all his moms come in for an induction, and he's going to be done by 5'o clock whether your body is or not. Unless there's a real medical reason for you to have that induction, then just stay home and let baby pick its own birthday. The other thing is constant fetal monitoring. The monitor has not been shown to improve fetal outcomes. It hasn't been shown to help baby at all. The only thing it has been shown to do is increase the caesarean rate. Think about it; you go into the hospital, your clothes are taken, you're denied food and water, you're strapped to a bed with a monitor wired, and the minute that any of those monitors beep, you're off down the hall in the operating room. So really talk to your doctor about having intermittent monitoring, and make that a real possibility for you. The nursing staff may freak out about it, but just say “oh well, I talked to my doctor about it and he said that was okay.” Then they go along with it - doctor usually trumps hospitals. Just because its protocol doesn't mean that it's something that you have to do. Maybe the only other one that I can think of is just to stay home – have your baby at home. Hospital protocol is designed around liability, not necessarily what's best for mom and babies, or even what the research says is safest. Definitely, research is very clear on continuous electronic fetal monitoring; that it isn't superior to intermittent monitoring and that it doesn't improve outcome. The high rate of false positives typically leads to unnecessary interventions that can lead to a caesarean, but also it misses some of the most critical complications that can occur such as a uterine rupture. It's not going to tell you if that has happened.


PAM:  Being with a mom, watching her one on one, looking at skin tone, those types of things will give you more of a warning if something of that nature has occurred, but there is that tendency to rely on that monitor, that strip. “Oh well, it's not beeping, so everything's fine.” Then on the reverse side the “oh, it's beeping, we're in trouble.” Definitely those are some, some good points.

CATHERINE:  Do you have one piece of take away advice for women who are desiring a VBAC or considering a home birth after a caesarean section?

PAM:  I would say to educate yourself; really look at what the options are, look at the research, and look at what's important to you, and know what's important to you. Roll that all up with the big ribbon that says, “VBAC is safe,” and then go with what your own intuition is telling you.

CATHERINE:  Well excellent, thank you so much for being with us today. Does ICAN have any news, any recent happenings, anything for us to be looking forward to in the coming months?

PAM:  ICAN has recently put forums on our website – which we are excited about. They're busy and they're great places to find information and to find connections, to get that encouragement. We are doing a lot of collaboration with other organizations, such as midwifery organizations, in order to protect VBAC when it comes to home birth and to preserve that option for our VBAC moms. We are excitedly planning our conference in Atlanta which will be held April 24th through the 26th in 2009, so we invite you to come to that. Our conferences are so amazing. They are places, a real connection to other women, they are an avenue for healing and there's no other conference like our ICAN conferences.

CATHERINE:  Can you tell us a little bit more about what these conference is look like? What women can expect if they are able to attend?

PAM:  Sure. We have some great speakers lined up – and we do every year, but this year, especially excited about our conference.  We're going to have five main speakers and then we have lots of break out sessions. We'll have time to just connect with other women. On Saturday night we have a time to sing and to look at each other in the eyes, and hug and just really connect. We have great exhibitors and the hotel that we're staying at is great. We've talked to the hotel about keeping the hot tubs open late for our conference attendee's, so that women can go and hang out there; that's one of our favourite ICAN things to do is to go hang out in the hot tub. This year we're going to have the movie “Pregnant in America”. That's a movie that speaks to dads – it is an amazing movie. And Steve; he has put together this movie of his wife's pregnancy. It's a first time pregnancy that they chose to deliver at home with a midwife. The movie can be a real guy movie, but it also speaks to women, and the path that you have to choose what you feel is the best for you, even though she was being told “are you crazy?” And “well, at least have your first one in the hospital and then have your next one at home, If you really insist.” and the movie's really great. So we're going to have that Friday night, Sarah Buckley is coming, Eugene Pacleric is coming, Pam England, and Jonie Nichols; those are our key note speakers. It's going to be a fabulous conference. We're going to have time for all those who have books there to do a book signing, and have time for us to network with the speakers. We are having a president's panel, with other organizations coming to our conference and giving us a little report of what they're doing and how we're networking together. It's going to be a great time to really just see what's happening, and yet do a little bit of healing on a very personal way as well. I just can't tell you how often these conferences are, and how ICAN women are amazing and strong. Yet we're all moms and women, and our conference theme this year is “Real Women, Real Life”. It's about how we're not toothpicks. We're women, and this is our life, and our births have impacted our lives in a very real way. It's an acknowledgement of that and it's a time to grow and to wrap everything up. It's an amazing, amazing weekend.

CATHERINE:  Well it definitely sounds like it. Are there other ways that women in different communities around the US can get involved?

PAM:  Yes, come see us on our website and we have a clickable map where you can see if there's a local chapter near you. If there is, please come and join in with us. We'd love to have you at our next meeting. If there's not, we invite you to look into whether that's something that you could do, start a chapter in your area. If that's not an option, there are the forums. We have women from around the country – even other countries, who are talking and sharing. The forums are a great way to be involved. We have lots of volunteer opportunities. Like ICAN is an all volunteer organization, and there are things that we need. We try to make all the jobs mommy size; like we talked earlier about calling hospitals and finding out whether there's a VBAC ban in place, or how supportive they are about different options, and that's something that we still need for different areas. So if you click on our VBAC ban map and you don't see your area, we invite you to call your local hospitals and let us know what the information is, and we can put that in so that other women know that. And there's a number of other things that you can do to be involved with ICAN; and I'd love to help explore those with you if you want to look into that.

CATHERINE:  Excellent. Well thank you so much Pam for being with us today. Do you have any other comments before we close?

PAM:  Well, I just want to thank you Catherine for having me today and know that it's important sometimes to do these things, so that women know the different options that are out there, and that there are other women who have had a prior VBAC, or are searching and doing the same self education that your listeners are. We're all women and we're all here for you.

CATHERINE:  Thank you very much.

PAM:  Well, thank you.

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