Florida Agency Set to Ban VBAC in State’s Birth Centers

Anna Clark

This Wednesday, Florida’s Agency for Health Care Administration is expected to permanently ban Vaginal Birth after Cesarean (VBAC) in the state’s birth centers. Legal challenges are already in the works.

This Wednesday, Florida’s Agency for Health Care Administration is expected to permanently ban Vaginal Birth after Cesarean (VBAC) in the state’s birth centers. In response, BirthGirlz, a national nonprofit based in Florida, is mounting a legal challenge, arguing that the ban is beyond the scope of the state health agency’s role.

The ban aims to close the loop on what is already a stringent policy on VBACs in Florida. To have a non-surgical birth after a C-section, women are compelled to go to hospitals that permit it (which are not accessible throughout the state), or, if a physician signs off on the procedure, they can have one at home with the guidance of a licensed midwife. VBACs currently don’t occur in Florida birthing centers because of what is being a called a “de facto ban” due to outdated language in the state regulations. The language, which will be updated this week, will turn the ban from de facto to explicit—making VBACs illegal in all of Florida licensed birthing facilities.

Miriam Pearson-Martinez, a licensed midwife who serves on the Pushing for VBAC committee of BirthGirlz, said that the organization has hired an attorney and will file a legal challenge to the ban when the AHCA moves to amend its regulatory language.

“We believe that the role of our law, and the agency’s duty, is to provide access to birth centers, not limit access, and that this ban is outside the scope of its role,” Pearson-Martinez said.

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She noted that licensed Florida midwives are legally permitted to oversee VBACs, so long as a physician signs off on it, and that not all birth centers are owned by midwives—marking the ban as a move that conflicts with legal activities.

The AHCA contends that this week’s adjustment is merely cleaning up its language, rather than an attempt to make any new restrictions on VBACs, birthing centers, or midwives, according to Pearson-Martinez.

“I might be able to believe that, but at the same time (that they are making this ban explicit), they are (in a separate act) eliminating the ability for people who have had multiple births to go to a birth center,” Pearson-Martinez said, noting that the AHCA intends to reduce the maximum number of births a woman can have before she is allowed to use a birth center. While before a woman who had seven births can have her eighth child at a birth center, she now will not be able to do so if she’s had more than five births.

While BirthGirlz will file its challenge this Wednesday, Pearson-Martinez believes that the AHCA will pass the new regulatory language anyway. The process then moves on to the state’s Joint Administrative Procedures Committee, which is tasked with ensuring that all new state regulations meet legal requirements. At this state, Pearson-Martinez is hopeful that her organization’s lawsuit will make its case and change the trajectory of the ban. If that doesn’t succeed, the organization intends to take the case to appellate court

Mary Ann Gibson, co-owner of the Birth Center of Gainesville, said that the ban is troubling, especially given recent statistics that reveal a 12% chance of something going wrong with a VBAC in a hospital setting, compared to a 4% chance in a birth center.

“There’s not a single statistic that justifies this (ban),” Gibson said.

Gibson, who also sits on the board of the International Cesarean Awareness Network, said that she is concerned that by restricting women’s ability to give birth where she chooses, the Florida policy will lead to dangerous consequences—including women having unassisted births at home or the prosecution of licensed midwives.

“Throughout history, the traditional medical field has frowned upon midwives, and this (ban) seems to be taking another step to maintain the power of their industry,” said Gibson. “It seems like a ploy for doctors to say this is one more thing midwives can’t do, one more thing to have control over.”

Nationally, VBAC rates have declined since 1996, while the delivery rates for cesareans are increasing. According to the Center for Disease Control and Prevention, U.S. births resulting from cesarean deliveries in 2005 are at the fourth highest rate of the world’s developed nations, behind Italy, Mexico, and Korea. This rate is exacerbated by the American College of Obstetricians and Gynecologists 2004 recommendation that women not attempt a normal birth after a C-section if a hospital does not have round-the-clock obstetrics and anesthesia backup. Likewise, medical practitioners’ fear of being sued if something goes wrong with the procedure has also discouraged VBACs.

A 2009 survey by ICAN in 2009 revealed that about 45% of hospitals in the United States formally ban VBACs either explicitly or through unsupportive policies and procedures.  

While cesarean sections can save the lives of both mother and baby, the “Evidence-based Maternity Care” report from Childbirth Connection indicates that the rate of C-sections has been increasing out of proportion to their need. In 1965, when the C-section rate of delivery was first measured, it weighed in at 4.5 percent; in 1996, the rate was 20.7 percent, and the provisional 2006 rate was 31.1 percent of all births – representing a 50 percent increase over fifty years. Meanwhile, VBACs have declined by 72 percent in less than a decade – 28 percent in 1996 to eight percent in 2005.

The World Health Organization recommends that the optimal cesarean rates of delivery should be between five and ten percent of all births, and explicitly notes that rates above 15 percent are likely to do more harm than good.

Earlier this month, the National Institutes of Health hosted its first conference to discuss how VBACs fit into the high numbers of surgical births in the United States; 500 attendees gathered for three days of data-sharing, panels, and testimony. A diverse team of experts indicated that VBACs are actually safe for most women—and more practitioners should encourage them, according the conference’s draft statement. While the deadliest risks of VBAC, including uterine rupture, are possible, the risk is limited—impacting less than one percent of patients. Seventy-four percent of VBACs are successful, according to the NIH panel, which affirmed that the procedure is a unique medical decision that should be made between doctor and patient.

“The final statement from the NIH concludes that a VBAC is a reasonable option for most women. Over 75% of women who attempt VBAC will be successful,” said Desirre Andrews, ICAN President, in a press release. “Currently less than 10% of women who have had previous cesareans deliver vaginally in subsequent pregnancies, leading to significant and preventable illness and death.”

Moreover, the NIH panel urged ACOG to reassess its guidelines on VBACs, noting that large swaths of the nation don’t have the resources for hospitals with obstetrics and anesthetics back-up teams.

Jane Peterson, a certified professional midwife in Wisconsin and a member of the Big Push for Midwives, said that while there are health risks in VBACs, as there is in any birthing experience, it has been shown that the risk increases with more labor interventions, such as induction.

“Births in birth centers under the midwifery model of care don’t have interventions, and so they have a greater opportunity for success,” Peterson said.

She added that birth centers screen very carefully for VBACs, ensuring that candidates are healthy. They also make plans to move to traditional facilities if anything occurs that is not reassuring.

Peterson said she advocates for “complete informed consent” from mothers about the risks and benefits of VBACs—a conversation that is most likely to happen outside a hectic hospital setting.

“The fix (for poor maternity care in the United States) is to increase access to midwives, not decrease them,” Peterson said. “That’s not the only fix, but its one of them.

“We should be focused on solving problems, not restricting choices,” she said.

Public protest to Florida explicitly banning VBACS from the state’s birth centers has emerged through a petition to the regulating health agency that asks it to change the policy language so that it will ensure competent care from licensed practitioners even as it “respects the right of the patient to make an informed decision. We ask the State of Florida to remain a regulatory body and not take on the role of medical surrogate.”

Women voice overwhelming support for VBAC, despite sometimes receiving pressure from their physicians to avoid them, according to the national Listening to Mothers studies commissioned by Childbirth Connection in 2002 and 2006. From the most recent report:

Among only those women who had had a cesarean in the past, 11 percent had a vaginal birth after cesarean for the most recent birth, while 89% had a repeat cesarean. We asked women with a previous cesarean about their decision-making relating to a VBAC and found that 45 percent were interested in the option of a VBAC. We also asked if mothers were given the option of a VBAC, and a clear majority (57 percent) of mothers who had a previous cesarean and were interested in a VBAC were denied that option. We then asked what reason was given for the denial of a VBAC, and the leading responses were unwillingness of their caregiver (45 percent) or the hospital (23 percent), followed by a medical reason unrelated to the prior cesarean in 20 percent of the cases.

Carole McGranahan is a mother in Boulder who had a VBAC. After having her first child by an unplanned C-section, she said she realized that she didn’t know much about birth or her body. She said she went into the birthing experience fearfully, simply hoping it wouldn’t hurt and to have a healthy child at the end of it, rather than being open to “the amazing process of birth.

Her C-section came after she experienced contractions throughout her first 24 hours in the hospital, without the baby moving doing the birth canal. While there was no danger to her or her child, the hospital decided it was time for an unplanned and, McGranahan said, unnecessary C-section.

“Once you check in to the hospital, the clock starts. There’s something called ‘failure to progress,’ which basically means checking into a hospital too soon, which again women usually do out of fear when labor begins,” McGranahan said.

For her second pregnancy three years later, she heard both the “once a C-section, always a C-section,” message and the notion that if she had an unplanned cesarean, she was an excellent candidate for a VBAC. She chose to have a natural VBAC birth, assisted by OB/GYNs and a doula in a hospital—revealing that there is room for overlap and collaboration among birth practitioners and facilities.

McGranahan contends that the medicalization of birth – and of life – is pervasive.

“A C-section is something that can be scheduled and managed. Natural birth isn’t, it’s much less predictable,” she said. “When you put it in context of the health industry, its not as easily controlled.”

News Contraception

New Hawaii Law Requires Insurers to Cover a Year’s Supply of Birth Control

Nicole Knight Shine

Insurance companies typically cover only a 30-to-90-day supply of birth control, posing a logistical hurdle for individuals who may live miles away from the nearest pharmacy, and potentially causing some using oral contraceptives to skip pills.

Private and public health insurance must cover up to a year’s supply of birth control under a new Hawaii law that advocates called the nation’s “strongest.”

The measuresigned by state Gov. David Ige (D) on Tuesday, applies to all FDA-approved contraceptive medications and devices.

Hawaii joins Washington, D.C., which also requires public and private insurers to cover up to 12 months of birth control at a time.

Oregon passed a similar measure in 2015, but that law requires patients to obtain an initial three-month supply of contraception before individuals can receive the full 12-month supply—which the Hawaii policy does not.

“At a time when politicians nationwide are chipping away at reproductive health care access, Hawaii is bucking the trend and setting a confident example of what states can do to actually improve access,” Laurie Field, Hawaii legislative director for Planned Parenthood Votes Northwest and Hawaii, said in a statement.

Insurance companies typically cover only a 30-to-90-day supply of birth control, posing a logistical hurdle for individuals who may live miles away from the nearest pharmacy, and potentially causing some using oral contraceptives to skip pills. Both the American Congress of Obstetricians and Gynecologists (ACOG) and the U.S. Centers for Disease Control and Prevention recommend supplying up to one year of oral contraceptives at a time, as the Hawaii Senate Committee on Commerce, Consumer Protection, and Health noted in a 2016 conference report.

Fifty-sex percent of pregnancies in Hawaii are unintended, compared to the national average of 45 percent, according to figures from the Guttmacher Institute.

Women who received a year’s supply of birth control were about a third less likely to experience an unplanned pregnancy and were 46 percent less likely to have an abortion, compared to those receiving a one- or three-month supply, according to a 2011 study of 84,401 California women published in Obstetrics and Gynecology.

Reproductive rights advocates had championed the legislation, which was also backed by ACOG–Hawaii Section, the Hawaii Medical Association, and the Hawaii Public Health Association, among other medical groups.

“Everyone deserves affordable and accessible birth control that works for us, regardless of income or type of insurance,” Planned Parenthood’s Field said in her statement.

Analysis Maternity and Birthing

Pregnant Women Are Being Shackled in Massachusetts—Even Though It’s Been Illegal for Years

Victoria Law

According to a new report, not a single jail or prison facility in the state has written policies that are fully compliant with the law against restraining pregnant women behind bars.

Korianne Gamble was six months pregnant in November 2014 when she arrived at the Bristol County Sheriff’s Office Women’s Center, a jail in North Dartmouth, Massachusetts. Six months prior, the state had passed “An Act to Prevent Shackling and Promote Safe Pregnancies for Female Inmates.”

According to the new law, the jail should have been prohibited from using any type of restraint on Gamble during labor, and using of leg and waist restraints on her during and immediately after her pregnancy. It also guaranteed her minimum standards of pregnancy care and required—as with everyone incarcerated while in their second or third trimesters—that she be transported in the jail’s vehicles with seat belts whenever she was taken to court, medical appointments, or anywhere outside the jail.

But that wasn’t the case for Gamble. Instead, she says, when it came time for her to give birth, she was left to labor in a cell for eight hours before finally being handcuffed, placed in the back of a police cruiser without a seatbelt, and driven to a hospital, where she was shackled to the bed with a leg iron after delivering.

According to a new report, Gamble isn’t alone. Advocates have been monitoring pregnancy-related care since the law’s passage. After obtaining and analyzing the policies of the state’s prison and jail system, they found that no facility has policies that are fully compliant with the 2014 law. They issued their findings in a new report, Breaking Promises: Violations of the Massachusetts Pregnancy Standards and Anti-Shackling Lawco-authored by Marianne Bullock of the Prison Birth Project, Lauren Petit of Prisoners’ Legal Services of Massachusetts, and Rachel Roth, a reproductive-justice expert.

In addition to analyzing policies, they spoke with women who were pregnant while in custody and learned that women continue to be handcuffed during labor, restrained to the bed postpartum, and placed in full restraints—including leg irons and waist chains—after giving birth.

“The promise to respect the human rights of pregnant women in prison and jail has been broken,” the report’s authors concluded.

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Medical experts, including the American Congress of Obstetricians and Gynecologists, the American Medical Association and the American College of Nurse-Midwives, have all agreed that shackling during pregnancy is unnecessary, inhumane, and dangerous. Shackling increases the risk of falling and injury to both mother and fetus while also preventing medical staff from assessing and assisting during labor and delivery. In 2014, both the Massachusetts legislature and then-Gov. Deval Patrick (D) agreed, passing the law against it.

“The Massachusetts law is part of a national trend and is one of the most comprehensive in protecting pregnant and postpartum women from the risks of restraints,” said Roth in an interview with Rewire. “However, like most other states, the Massachusetts law doesn’t have any oversight built in. This report clearly shows the need for staff training and enforcement so that women who are incarcerated will be treated the way the legislature intended.”

Gamble learned all of this firsthand. In the month before her arrest, Gamble had undergone a cervical cerclage, in which a doctor temporarily stitches up the cervix to prevent premature labor. She had weekly visits to a gynecologist to monitor the development of her fetus. The cerclage was scheduled to be removed at 37 weeks. But then she was arrested and sent to jail.

Gamble told jail medical staff that hers was a high-risk pregnancy, that she had had a cerclage, and that her first child had been born six weeks prematurely. Still, she says she waited two months before seeing an obstetrician.

As her due date drew closer, the doctor, concerned about the lack of amniotic fluid, scheduled Gamble for an induction on Feb. 19, 2015. But, she says, jail staff cancelled her induction without telling her why.

That same evening, around 5 p.m., Gamble went into labor. Jail staff took her to the medical unit. There, according to Gamble, the jail’s nurses took her blood pressure and did a quick exam, but did not send her to the hospital. “They [the nurses] thought I was ‘acting up’ because my induction was canceled,” she told Rewire.

She was placed in a see-through cell where, as the hours progressed, her labor pains grew worse. “I kept calling to get the [correctional officers] to get the nurse,” Gamble recalled. By the time a nurse came, Gamble was bleeding. “The nurse made me pull down my pants to show her the blood—in front of a male [correctional officer]!” Gamble stated. Still, she says, no one called for an ambulance or made arrangements to drive her to the hospital.

At 1:45 in the morning, over eight hours after she first went into labor, the jail’s captain learned that Gamble was in labor. “[He] must have heard all the commotion, and he called to find out what was going on,” she said. He ordered his staff to call an ambulance and bring her to the hospital.

But instead of calling an ambulance, Gamble says jail staff handcuffed her, placed her in the back of a police cruiser without a seatbelt—in violation of the law—and drove her to Charlton Memorial Hospital. “My body was already starting to push the baby out,” she said. She recalled that the officers driving the car worried that they would have to pull over and she would give birth by the side of the road.

Gamble made it to the hospital, but just barely. Nine minutes after arriving, she gave birth: “I didn’t even make it to Labor and Delivery,” she remembered.

But her ordeal wasn’t over. Gamble’s mother, who had contacted Prisoners’ Legal Services and Prison Birth Project weeks earlier, knew that the law prohibited postpartum restraints. So did Gamble, who had received a packet in jail outlining the law and her rights from Prisoners’ Legal Services. When an officer approached her bed with a leg iron and chain, she told him that, by law, she should not be restrained and asked him to call the jail to confirm. He called, then told her that she was indeed supposed to be shackled. Gamble says she spent the night with her left leg shackled to the bed.

When the female officer working the morning shift arrived, she was outraged. “Why is she shackled to the bed?” Gamble recalled the officer demanding. “Every day in roll call they go over the fact that a pregnant woman is not to be shackled to anything after having a baby.” The officer removed the restraint, allowing Gamble to move around.

According to advocates, it’s not unusual for staff at the same jail to have different understandings of the law. For Gamble, that meant that when the shift changed, so did her ability to move. When the morning shift was over, she says, the next officer once again shackled Gamble’s leg to the bed. “I was so tired, I just went along with it,” Gamble recounted.

Two days after she had given birth, it was time for Gamble to return to the jail. Despite Massachusetts’ prohibition on leg and waist restraints for women postpartum, Gamble says she was fully shackled. That meant handcuffs around her wrists, leg irons around her ankles, a chain around her waist,g and a black box that pulled her handcuffs tightly to the waist chain. That was how she endured the 20-minute drive back to the jail.

Gamble’s jail records do not discuss restraints. According to Petit, who reviewed the records, that’s not unusual. “Because correctional officers don’t see it as out of the ordinary to [shackle], they do not record it,” she explained. “It’s not so much a misapplication of the extraordinary circumstances requirement as failure to apply it at all, whether because they don’t know or they intentionally ignore it.”

While Bristol County Sheriff’s Office Women’s Center’s policies ban shackling during labor, they currently do not prohibit restraints during postpartum recovery in the hospital or on the drive back to the jail. They also do not ban leg and waist restraints during pregnancy. Jonathan Darling, the public information officer for the Bristol County Sheriff’s Office, told Rewire that the jail is currently reviewing and updating policies to reflect the 2014 law. Meanwhile, administrators provide updates and new information about policy and law changes at its daily roll call. For staff not present during roll call, the jail makes these updates, including hospital details, available on its east post. (Roll call announcements are not available to the public.)

“Part of the problem is the difference in interpretation between us and the jurisdictions, particularly in postpartum coverage,” explained Petit to Rewire. Massachusetts has 14 county jails, but only four (and the state prison at Framingham) hold women awaiting trial. As Breaking Promises noted: “Whether or not counties incarcerate women in their jails, every county sheriff is, at minimum, responsible for driving women who were arrested in their county to court and medical appointments. Because of this responsibility, they are all required to have a written policy that spells out how employees should comply with the 2014 law’s restrictions on the use of restraints.”

Four jurisdictions, including the state Department of Correction, have policies that expressly prohibit leg and waist restraints during the postpartum period, but limit that postpartum period to the time before a woman is taken from the hospital back to the jail or prison, rather than the medical standard of six weeks following birth. Jails in 11 other counties, however, have written policies that violate the prohibition on leg and waist shackles during pregnancy, and the postpartum prohibition on restraints when being driven back to the jail or prison.

Even institutions with policies that correctly reflected the law in this regard sometimes failed to follow them: Advocates found that in some counties, women reported being restrained to the bed after giving birth in conflict with the jail’s own policies.

“When the nurse left, the officer stood up and said that since I was not confirmed to be in ‘active labor,’ she would need to restrain me and that she was sorry, but those were the rules,” one woman reported, even though the law prohibits restraining women in any stage of labor.

But shackling pregnant women during and after labor is only one part of the law that falls short. The law requires that pregnant women be provided with regular prenatal and postpartum medical care, including periodic monitoring and evaluation; a diet with the nutrients necessary to maintain a healthy pregnancy; written information about prenatal nutrition; appropriate clothing; and a postpartum screening for depression. Long waits before transporting women in labor to the hospital are another recurring complaint. So are routinely being given meals without fruits and vegetables, not receiving a postpartum obstetrician visit, and waiting long stretches for postpartum care.

That was also the case with Gamble. It was the middle of the night one week after her son’s birth when Gamble felt as if a rock was coming through her brain. That was all she remembered. One hour later, she woke to find herself back at the hospital, this time in the Critical Care Unit, where staff told her she had suffered a seizure. She later learned that her cellmate, a certified nursing assistant, immediately got help when Gamble’s seizure began. (The cell doors at the jail are not locked.)

Hospital staff told her that she had preeclampsia, a pregnancy complication characterized by high blood pressure. Postpartum preeclampsia is rare, but can occur when a woman has high blood pressure and excess protein in her urine soon after childbirth. She was prescribed medications for preeclampsia; she never had another seizure, but continued to suffer multiple headaches each day.

Dr. Carolyn Sufrin is an assistant professor of gynecology and obstetrics at Johns Hopkins Medicine. She has also provided pregnancy-related care for women at the San Francisco County Jail. “Preeclampsia is a leading cause of maternal mortality,” she told Rewire. Delayed preeclampsia, or postpartum preeclampsia, which develops within one to two weeks after labor and delivery, is a very rare condition. The patient suffering seizures as a result of the postpartum preeclampsia is even more rare.

Postpartum preeclampsia not only needs to be treated immediately, Sufrin said, but follow-up care within a week at most is urgent. If no follow-up is provided, the patient risks having uncontrolled high blood pressure, stroke, and heart failure. Another risk, though much rarer, is the development of abnormal kidney functions.

While Sufrin has never had to treat postpartum preeclampsia in a jail setting, she stated that “the protocol if someone needs obstetrical follow-up, is to give them that follow-up. Follow through. Have continuity with the hospital. Follow their instructions.”

But that didn’t happen for Gamble, who was scheduled for a two-week follow-up visit. She says she was not brought to that appointment. It was only two months later that she finally saw a doctor, shortly before she was paroled.

As they gathered stories like Gamble’s and information for their report, advocates with the Prison Birth Project and Prisoners’ Legal Services of Massachusetts met with Rep. Kay Khan (D-Newton), to bring her attention to the lack of compliance by both county jails and the state prison system. In June 2015, Khan introduced An Act to Ensure Compliance With the Anti-Shackling Law for Pregnant Incarcerated Women (Bill H 3679) to address the concerns raised by both organizations.

The act defines the postpartum period in which a woman cannot be restrained as six weeks. It also requires annual staff trainings about the law and that, if restraints are used, that the jail or prison administration report it to the Secretary of Public Safety and Security within 48 hours. To monitor compliance, the act also includes the requirement that an annual report about all use of restraints be made to the legislature; the report will be public record. Like other statutes and bills across the country, the act does not have specific penalties for noncompliance.

In December 2015, Gamble’s son was 9 months old and Gamble had been out of jail for several months. Nonetheless, both Gamble and her mother drove to Boston to testify at a Public Safety Committee hearing, urging them to pass the bill. “I am angered, appalled, and saddened that they shackled her,” Gamble’s mother told legislators. “What my daughter faced is cruel and unusual punishment. It endangered my daughter’s life, as well as her baby.”

Since then, both the Public Safety Committee and Health Care Financing Committee approved the bill. It is now before the House Committee for Bills in the Third Reading, which means it is now at the stage where it can be taken up by the House for a vote.

Though she has left the jail behind, Gamble wants to ensure that the law is followed. “Because of the pain I went through, I don’t ever want anyone to go through what I did,” she explained to Rewire. “Even though you’re in jail and you’re being punished, you still have rights. You’re a human being.”