National Advocacy Group Responds to Cottage Hospital’s VBAC Announcement

By the International Cesarean Awareness Network, Santa Barbara Chapter

An open letter to the Santa Barbara Community:

The International Cesarean Awareness Network (ICAN) has been made aware of Santa Barbara Cottage Hospital’s (SBCH) recent announcement regarding future plans to remove a longstanding VBAC ban. ICAN believes that VBAC bans are a form of obstetrical violence, as pregnant people are considered decisionally capable and acting on another’s body without consent can be considered assault or battery. A key component of the medical ethics of informed consent is that it be voluntarily given. If a policy is coercive, how valid is the consent?

Supposedly, the policy change ending Cottage’s 20 year legacy of denying patients the right to birth vaginally after a prior cesarean locally, will be rolled out “in the fall”. However, the update seems to hinge on SBCH’s ability to recruit multiple hospitalists, more anesthesiologists, and additional on-call OB/GYNs. While having all of that sounds great and we wish them success in growing their team, patients’ rights don’t get to wait. VBAC is not a concierge “service” or “option” to provide as a bonus. Rather, it is birth mode (VB) + birth history (AC). 

• Affect a large subset of the population – around 1 in 3 who give birth

• Many families cannot travel for healthcare

• VBAC Bans leave many with no access to prenatal care

• Disproportionately affects socioeconomically disadvantaged populations

• Creates inequitable access to healthcare

• Disproportionately affects black and brown birthing populations who are more likely to feel forced into a primary cesarean, and have worse outcomes than white patients, including 3-4 times more likely to die

• Increases cases placenta accreta in future pregnancies (serious obstetrical emergency directly linked with cesareans)

The issues that plague our healthcare system at large, and the United States maternity care system are known and complex.  From reimbursement rates, rural health crises, maternity care deserts, legislative barriers, regulatory hoops, even a known shortage of prenatal care providers that is slated to get worse. Yes, we’ve got issues, but this is why multiple agencies exist to make sure that these shortcomings aren’t used as excuses to violate human-rights of healthcare consumers. 

For example, CMS, The Centers for Medicare & Medicaid Services, includes patient rights in the laws on Requirements of Participation for any hospital that wishes to be eligible for state insurance participation. Because, even in an imperfect world, we are still human beings that deserve respectful, equitable, and dignified care. This should include our own decision making after being given information about risks, benefits and alternatives. 

ICAN knows the subject of VBAC bans very well. We published a VBAC ban database in 2009 where Cottage Hospital was listed. We had representatives speak at the NIH Conference which was an instrumental event leading to the American College of Obstetricians and Gynecologists (ACOG)’s 2010 Update to VBAC Guidelines where they walked back language that had been misinterpreted as cause to ban VBACs. “The American College of Obstetricians and Gynecologists and international guidelines have recommended that resources for emergency cesarean delivery be immediately available….Restricting access was not the intention of this recommendation…” And we are here 12 years later, still fighting legally, morally, and ethically impermissible policies from even large, teaching hospitals with level 1 trauma units. 

The language Ms. Zate used in her statement and her unwillingness to answer important questions from the journalists leave us concerned about many things. That policy-makers still don’t fully understand the ethical, legal, and psychosocial implications of a policy that is as of today still standing. We call on the leadership at Cottage Health to employ CMS’s “Person and Family Engagement Strategy,” and form community partnerships with consumer organizations like ours to help guide changes in a way that centers those receiving (or seeking) care at your facility. 

Protect human Rights right now by ending your policy without a conditional roll-out plan, reach out to providers with rights at your hospital and encourage them that your hospital would never expect them to violate their ethical standards of care to keep their privileges.  Update your consumers and providers as you hit milestones in implementing your hospitalist program, so that all are able to give and receive full information before they decide your hospital is right for them. And finally, align yourself with what ACOG truly says about VBAC, consent, coercion, and VBAC Bans. 

The following are actual direct quotes from the ACOG:

• “There is nothing unique about the delivery of the fetus or placenta during VBAC”

• “The National Institutes of Health panel recognized that TOLAC was a reasonable option for many women with a prior cesarean delivery and called on organizations to facilitate access to TOLAC.”

• “Consistent with the principle of respect for patient autonomy, patients should be allowed to accept increased levels of risk; however, patients should be clearly informed of the potential increases in risk and management alternatives.”

• “Respect for patient autonomy also dictates that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.”

• “Ultimately, however, the patient should be reassured that her wishes will be respected when treatment recommendations are refused.”

• “Trial of labor after previous cesarean delivery should be attempted at facilities capable of performing emergency deliveries.”

The final quote leaves us with one urgent question for Santa Barbara Cottage Hospital. Is Cottage Hospital prepared for an obstetrical emergency right now or not?