In it, Sakala discusses maternity care in the context of healthcare reform, noting the lack of focus on maternity care quality, outcomes, and value despite its “major role in the nation’s healthcare system.” She also addresses overused and underused interventions in maternity care; the need to have evidence-based practice guidelines based upon good quality studies rather than expert opinion; VBAC; provider and birth place choices; and barriers to transforming care.

Asked about her vision for the future of maternity healthcare, Sakala responded:

I’d like to answer this question by paraphrasing the final paragraph from the Transforming Maternity Care Vision paper, and I encourage Medscape readers to read that paper and the blueprint as well, and consider becoming involved in blueprint implementation.

In describing the vision, the Vision Team says that:
The 2020 Vision for a High-Quality, High-Value Maternity Care System will be actualized through concerted multi-stakeholder efforts ensuring that all women and babies are served by a maternity care system that delivers safe, effective, timely, efficient, equitable, woman- and family-centered maternity care. The US will rank at the top among industrialized nations in key maternal and infant health indicators, and will achieve global recognition for its transformative leadership.

The whole interview is well worth a read for a good discussion of U.S. maternity care issues. Medscape requires a free registration in order to view the article. Readers may also be interested in Amnesty International’s recent report, “Deadly Delivery: The Maternal Health Care Crisis in the USA.” [PDF]

Materials from the conference are available at http://consensus.nih.gov/2010/vbac.htm, including the draft panel statement, archived webcasts from each day of the conference, the previously completed evidence report on VBAC, and call-in access to the archive of a telebriefing that followed the event wrap-up (a transcript will be available soon).

One important topic included perceptions of the risk of trial of labor; a speaker who reviewed factors associated with uterine rupture and other adverse outcomes stated that “there is a major misperception that trial of labor is extremely risky,” calling the risks to women comparable to other common medical procedures. Amy Romano provides additional commentary on uterine rupture risk at Science & Sensibility, noting that “we heard a rather consistent message that uterine rupture itself is not the issue.”

There was an excellent audience question following the presentation about whether, if successful VBAC carries the lowest morbidity, it is ethical for providers to refuse to allow a trial a labor. One panelist’s response was, “I think that’s the point of the conference.” Audience discussion sections for day one start at about 1:41, 3:01, 4:03, 5:55, and 7:19 [hour:minute].

Day one also featured another presenter, Dr. George Macones, who challenged ACOG’s “immediately available” physician and anesthesiologist standard for offering VBAC. This requirement has effectively led to the restriction of VBAC around the U.S.; Dr. Macones called it “overkill,” and argued that “the risk of rupture is comparable to other bad things that happen in labor that lead to an emergency cesarean section.”

As examples, he noted that prenatal diagnosis for Down Syndrome via chorionic villus sampling is routinely offered to all pregnant women and carries a 1% pregnancy loss rate, and external cephalic version requires immediate c-section about 1-3% of the time, making the risks from VBAC not that different from other things that are done “all the time” in obstetrics.

Day three generated perhaps the most heated discussion, in which a panelist stated that it is not a settled matter that women have a right to refuse a cesarean, reminding us of the need to continue to advocate for choices and rights for childbearing women. The relevant audience question comes up at 1:47:20 and comes from Shannon Mitchell of BirthAction. She raises the concern that there is nothing in the draft document that says that women have the right of refusal of a cesarean, an issue of concern given reports of court-ordered cesareans. The moderator refers the question to a medical ethicist, who responds:

That’s a very large topic in obstetric ethics there’s not a settled answer to it. There’s actually — contrary to what you heard yesterday — some serious disagreement in the obstetric ethics literature, but in any case I think it’s beyond the charge of this panel to take that question up.

Courtroom Mama provides further discussion of this issue at The Unnecesarean, including additional commentary from the telebriefing.

Despite this comment on women’s right to refuse a repeat cesarean, I hope that the conference will lead providers and institutions with codified or de facto VBAC bans to reconsider their policies and attitudes. I’m encouraged by this statement from the conclusions of the draft panel statement:

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL [trial of labor]. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.

Democratic leaders say a bill will pass this week.  House Minority Leader John A. Boehner (R-Ohio) pledges obstruction, saying Republicans will do “everything we can to make it difficult for them, if not impossible, to pass the bill.”

Jen Nedeau covers the multiple threats to women’s health and reproductive rights that must be addressed, including the House anti-abortion language. You know it as the Stupak/Pitts admendment. But Richard Doerflinger, the U.S. Conference of Catholic Bishops’ point man on abortion, should have had his name in there, too. Meanwhile, Jessica Arons tries to see the world through the lens of Rep. Bart Stupak (D-Mich.).

In an editorial in Monday’s paper, The New York Times urges anti-abortion Democrats to accept the Senate’s restrictive provisions, the lesser of two evils.

Too Many Tests, Too Much Treatment: “A spate of recent reports suggests that many Americans are being overtreated. Maybe even President Barack Obama, champion of an overhaul and cost-cutting of the health care system,” reports Lindsey Tanner of the Associated Press.

“More care is not necessarily better care,” wrote cardiologist Dr. Rita Redberg, editor of Archives of Internal Medicine, commenting on Obama’srecent physical, which included prostate cancer screening and a virtual colonoscopy. The PSA isn’t recommended at any age and a colonoscopyisn’t recommended under age 50.

Over-testing may be due to a combination of what is known as “defensive medicine” — doctors ordering tests and procedures because they’re trying  protect themselves against lawsuits (or because they’ll be compensated by a fee-for-service system) — and patients insisting on tests and treatments that they’ve heard about or know is commonly prescribed. But the thinking around more care = better care may be shifting.

“This week alone,” writes Tanner, “a New England Journal of Medicine study suggested that too many patients are getting angiograms – invasive imaging tests for heart disease — who don’t really need them; and specialists convened by the National Institutes of Health said doctors are too often demanding repeat cesarean deliveries for pregnant women after a first C-section.”

Stopping the Campus Rape Crisis: Jaclyn Friedman, executive editor of Women, Action and the Media and co-editor of “Yes Means Yes,” wrote a must-read op-ed in the Washington Post on ending the silence around sexual assault on college campuses.

First, colleges can eliminate the “miscommunication” excuse that many rapists use by creating an on-campus standard that requires any party to a sexual interaction to make sure their partner is actively enthusiastic about what’s happening — not just not objecting. They can create judicial boards equipped to seriously investigate rape accusations, instead of throwing their hands up at the first sign that the accused’s testimony contradicts the accuser’s. They can defend the safety of the entire campus by permanently expelling those found guilty of sexual assault. And they can be transparent about every step of the process.

Plus: The Center for Public Integrity recently released “Sexual Assault on Campus: A Frustrating Search for Justice,” an in-depth report filled with useful data, articles and resources.

Recognition for Midwives: Granny midwife Margaret Charles Smith was inducted into the Alabama Women’s Hall of Fame at Judson College this month. Smith attended nearly 3,000 births between 1949, when she received her midwife permit, and 1981, when she attended her last birth. Her life story is told in a book Smith co-wrote with Linda Janet Holmes, “Listen to Me Good: The Life Story of an Alabama Midwife.”

Plus: Rachel previously noted that the National Library of Medicine is featuring an exhibition on African American midwives. ”Nothing To Work With But Cleanliness: African American ‘Grannies,’ Midwives & Health Reform” tells the story of “granny” midwives and the state and local training programs that educated them and succeeding generations of midwives. View a wonderful set of photos from the exhibition on Flickr.

Utah’s Controversial Law Charges Women and Girls With Murder for Miscarriages: Writing at AlterNet, Rose Aguilar breaks down the problems with Utah’s new law that makes it a criminal offense for having miscarriages caused by “intentional or knowing” acts.

“What happens to women who are in abusive relationships?” asks Planned Parenthood’s Melissa Bird. “What happens if a woman threatens to leave the abuser, falls down the stairs and loses the baby? What if the abuser beats the woman and causes a miscarriage? Could he turn her in? Who would the prosecutor believe? What happens if a drug addict who’s trying to get clean loses her baby? Will she be brought up on murder charges?”

Some critics point out the legislators erred in not considering the lack of access that young people have to comprehensive sex education, and the overall lack of contraception and health services, especially in remote parts of the state.

The Girls Who Kicked in Rock’s Door: Not exactly health related (unless you’re like me and consider loud music essential for well-being), but I am completely intrigued by the “The Runaways,” the new film about the 1970s all-girl rock band, starring Dakota Fanning and Kristen Stewart. Sia Michel writes about the story behind the film and its director, Floria Sigismondi.

Presenting with Lenhart was Kicesie Drew, who provides sex ed information via YouTube; Sally Swanson from the Adolescent Pregnancy Prevention Campaign of North Carolina, a group that usess texting to answer questions about sexual health; and Cornelis Rietmeijer, director of the Sexually Transmitted Disease Control Program/Denver Public Health.

More health professionals are turning to innovative techniques and technologies to reach young and at-risk populations. I recently took part in a symposium, sponsored by Chicago Department of Public Health and the National LGBT Tobacco Control Network, on how public health workers can use social media to reach the LGBT community. We looked at some of the promises and obstacles that new communciation tools present. One of the most important lessons: Know how your audience uses technology, and go where they go.

I was honored to be on a panel with Lovette Ajayi, a superstar at Community Media Workshop and co-founder of the Red Pump Project, which raises awareness about the impact of HIV/AIDS on women and girls. And that brings me to the second point of this post: March 10 was National Women and Girls HIV/AIDS Awareness Day.

The Red Pump Project presents statistics about HIV/AIDS  and women — and the great disparities. Though black and Latina women represent 24 percent of all U.S. women combined, they account for 82 percent of the estimated total of AIDS diagnoses for women in 2005.  Consider that HIV is the:

* Leading cause of death for black women (including African American women) aged 25–34 years.
* 3rd leading cause of death for black women aged 35–44 years.
* 4th leading cause of death for black women aged 45–54 years.
* 4th leading cause of death for Latina women aged 35–44 years.
* The only diseases causing more deaths of women are cancer and heart disease.
* The rate of AIDS diagnosis for black women was approximately 23 times the rate for white women and 4 times the rate for Latina women.

These numbers illustrate the need for massive improvements in education, prevention and treatment — all topics the National STD Prevention Conference aims to address. High-priority issues are identified for each biennial conference, and this year’s top three issues couldn’t be more  relevant or directly worded.

The last point is a great reminder of how change is both incredibly simple and complex: “It is essential to find ways to move beyond our longstanding societal reticence to openly discuss sexual health issues and to normalize conversations around STD prevention.”

Plus: In related news, Washington, D.C. will make 500,000 female condoms available — for free. The condoms will be available in beauty salons, convenience stores and high schools in parts of the city with high HIV rates, reports the Washington Post. The project is funded through a $500,000 grant from the MAC AIDS Fund, a subsidiary of MAC Cosmetics.

In contrast to a lot of the hype and stereotypes about “hooking up,” Corinna is looking for what’s real, both in sexual attitudes and experiences among a diverse array of ages, genders and sexual identities, races and sexual ideologies/constructions. The only requirements for participating in this study are being over the age of 16, and having had some kind of sexual partnership before, even if none has been casual. The study takes around twenty minutes.

Corinna would like the study to show as diverse an array of people as possible, especially since so often media representations or cultural conversations about casual sex are usually only about heterosexual white women or about gay men. She particularly wants to be sure LGBT people, people of color, those over 45 and social conservatives are adequately represented, so please share this link with your networks after you take the survey yourself, especially if your networks include people in any or all of those groups.

To take the survey, visit http://www.surveymonkey.com/s/S97WR6H.

A free live webcast (with captioning) of the conference is being made available for those who can’t attend the Bethesda, MD event. (You may need to download an appropriate media player to watch it.)

Various experts are discussing the medical evidence on VBAC (audience discussion has been lively already!), including the following key questions:

• What are the rates and patterns of utilization of trial of labor after prior cesarean, vaginal birth after cesarean, and repeat cesarean delivery in the United States?
• Among women who attempt a trial of labor after prior cesarean, what is the vaginal delivery rate and the factors that influence it?
• What are the short- and long-term benefits and harms to the mother of attempting trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
• What are the short- and long-term benefits and harms to the baby of maternal attempt at trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
• What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean?
• What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?

They are also expected to discuss a systematic literature review on the topic prepared under contract with the Agency for Healthcare Research and Quality (AHRQ) which will be completed and released this year and will address these same key questions. The previous AHRQ review on the topic was completed in 2003, and identified significant gaps in the literature and the problems those gaps pose for informed decision-making. A full agenda with listed presenters and sponsors is available online.

Following the conference, a panel will prepare a consensus statement addressing the key questions; you can sign up to be notified when the draft and final statements are available online and/or to receive a mailed copy of the final statement.

The Feminist Breeder is planning to have coverage of the conference on her blog and radio show, and the International Cesarean Awareness Network is planning a blog carnival on the topic of why VBAC is a viable option [hat tip to Jill at The Unnecesarean]. The hashtag #nihvbac is being used for discussion on Twitter.

The full conference will be archived at the NIH website, so if you can’t watch this week, you can view the proceedings later.

Visit www.blogtalkradio.com/joykeys to listen to the show online, and call (646) 929-0368 to ask questions. You can also go to the site now to sign up to receive a reminder via email or text message.

We mentioned the bill in a post last week, after it passed the House and was referred to the state Senate’s Public Health and Welfare committee. Committee chair Hob Bryan has now indicated that he will not bring the bill up for a vote, saying that “This is something there’s a good bit of concern about. Several people in the committee said they had gotten calls to oppose it.”

The Big Push for Midwives, mentioned in the story, led the campaign to mobilize against this bill and issued action alerts last week encouraging midwifery supporters  to contact their State Senators regarding the bill. Campaign manager Katherine Prown explained that their opposition was not opposition to regulation of midwifery, but to the limitation of midwifery practice solely to CNMs (who typically do not provide home birth support).

“At least 26 states have laws authorizing CPMs and there’s an effort under way to get more states to license them so the practice of out-of-hospital midwifery is regulated nationwide,” Prown said. Without those laws “you end up with this buyer beware kind of climate and anyone can claim to be a midwife,” said Prown.

The Big Push campaign works to expand access to Certified Professional Midwives and out-of-hospital maternity care, including work to regulate and license CPMs in all 50 states.

The bill would make it illegal for Certified Professional Midwives — midwives who who are specially trained to deliver babies in out-of-hospital settings– to practice.

Right now, the Midwives Alliance of North America (MANA) categorizes the current situation in Mississippi for non-nurse midwives as “Legal by Judicial Interpretation or Statutory Inference” – in other words, interpreted to be legal but not explicitly provided for in the current law.

The organization provides some documentation from the previous MS Attorney General who concluded in 1991 that, “By its express terms, the practice of medicine as defined in Miss. Code Ann. Section 73-25-33 specifically excludes the practice of midwifery. Thus, it is the opinion of this office that those persons otherwise not licensed as nurses may engage in the practice of midwifery without licensure as a physician and for compensation.”

The current bill, which would add language to explicitly make non-CNM midwives illegal, passed the state House on February 9th and has been referred to Public Health and Welfare committee in the state Senate, whose members bill opponents are contacting. That committee consists of: Hob Bryan, Chairman; Alan Nunnelee, Vice-Chairman; Terry C. Burton; Eugene S. Clarke;Bob M. Dearing; Joey Fillingane; Hillman Terome Frazier; Billy Hewes; W. Briggs Hopson III; John Horhn; Cindy Hyde-Smith; Gary Jackson; Kenneth Wayne Jones; Tom King; Chris McDaniel; Nolan Mettetal; Willie Simmons; Bennie L. Turner; Lee Yancey. Contact information for each Senator is linked from this Senate roster.

MANA is encouraging supporters of Certified Professional Midwives who live in Mississippi to contact their state Senators. Tell them that you do NOT support making Certified Professional Midwives illegal, and ask them to vote NO on HB 695.

In other birth-related legislative news, the American Association of Birth Centers is asking supporters to contact their Senators and Representatives to support the Medicaid Birth Center Reimbursement Act (H.R. 2358 / S. 1423). For further information, see our previous post and information provided by AABC.

Thursday’s bipartisan meeting at the White House (which you can follow live) promises to kick-start what may be the final descent toward healthcare reform. An overview:

Does healthcare reform have a chance? Is bipartisanship a real possibility? David Leonhardt of The New York Times provides some provisional answers.

Igor Volsky over at the Wonk Room brings us up to speed by providing a nice, clear comparison of the House bill, the Senate bill and President Obama’s new proposal.

As far as questions women should be asking about their stake and status in the debate, Lisa Codispoti and Brigette Courtot at the National Women’s Law Center remind us of the “8 Questions” they have been asking all along — and how Obama’s proposal addresses (or fails to address) the issues.

Writing at Raising Women’s Voices, Amy Allina identifies ways in which Obama’s proposal builds on the Senate bill but also notes that it  “does not include the changes that Raising Women’s Voices has been urging Congress to make to the restrictive abortion provisions in [the Senate] bill” — namely by eliminating the requirement that policyholders make two separate monthly payments if they want a policy that includes abortion coverage.

It’s also worth taking a look at The National Partnership for Women and Families’ “The Top Ten Best Kept Secrets About Health Insurance Reform and Why Congress Should Pass It Without Delay” [pdf].

Finally, this is politics, and political agendas and expediency can often trump what’s right. Brian Beutler and Christina Bellantoni at Talking Points Memo dissect each party’s strategies, and Ezra Klein at the Washington Post provides a viewer’s guide.

All of this may come down to an arcane Senate procedure known as reconciliation. David M. Herszenhorn at The New York Times offers a primer.

When you feel yourself getting tired of all the red tape, get a pep talk from Ellen Schaffer and Joe Brenner at EQUAL/Center for Policy Analysis, whose PowerPoint — “The Truth About Health Reform: It’s Up to Us” — helps to put priorities in order.