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Texas Abortion Drug Bill Could Mean More Side Effects and Higher Costs

12:51 pm in Uncategorized by RH Reality Check

Written by Mary Tuma for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

CORRECTED December 20, 2012, 12:41PM ET: This story originally said the mifepristone drug label was last revised in 2005. In fact, minor revisions were made to the label in 2009, but the FDA’s protocol for using the medication wasn’t changed.

Published in partnership with The American Independent.

A GOP lawmaker is looking to make Texas the latest state to restrict the use of abortion medications in a way that some experts warn could increase the drugs’ side effects while making them more expensive.

Anti-choice activists and legislators can’t enact an outright ban on abortion-inducing drugs like mifepristone (formerly known as RU-486). Instead, they have sought to force doctors to strictly adhere to U.S Food and Drug Administration guidelines that appear to be significantly out of step with the current scientific understanding of how the medications should be used.

Lawmakers have passed abortion drug restrictions in Arizona and Ohio, overcoming legal challenges. The Oklahoma Supreme Court recently ruled that similar legislation in that state was unconstitutional. A North Dakota bill is currently tied up in litigation.

In Texas, state Sen. Dan Patrick’s bill, which mirrors model legislation drafted by anti-choice group Americans United for Life, would require doctors who prescribe an abortion drug to follow the protocol outlined in the official drug label approved by the FDA. He introduced similar legislation in 2011 — with the AUL’s support — but it didn’t pass. Patrick also authored the state’s controversial pre-abortion sonogram law.

In most state’s, doctors aren’t required to abide by the FDA guidelines. And since the FDA only regulates the drug market and not the practice of medicine, “off-label” treatment isn’t against federal law either. In fact, the FDA itself notes that physicians may prescribe a medication off-label as long as they are well informed about the product and “base its use on firm scientific rationale and on sound medical evidence.”

AUL insists that off-label use of mifepristone “can be deadly.” While Patrick did not respond to interview requests from The American Independent, he “said the intent of [the bill] is to improve the doctor-patient relationship” in an email to the Texas Tribune. But the legislation’s strict adherence to the FDA guidelines worries reproductive health care advocates and medical experts. They say a substantial body of recent research shows that the mifepristone drug label is outdated, potentially creating unnecessary burdens, financial costs, and health risks for women.

During a medical abortion, mifepristone is given to the woman at the clinic. The second round of medicine, misoprostol, is taken a day or two later to help end the pregnancy.

The FDA guidelines say that women should take 600 milligrams of mifepristone. But 2012 World Health Organization guidelines recommend a lower dose of mifepristone. Citing several studies, the report states that “200 mg of mifepristone is the dosage of choice, since it is as effective as 600 mg, and reduces costs” when it is followed by a dose of misoprostol.

Some of the language in Patrick’s bill is ambiguous, but it appears that it would also require women to receive their second dose of abortion pills — the misoprostol — in the presence of her doctor rather than at home, where it is typically taken. A number of reproductive health advocates find that rule troubling.

According to the National Abortion Federation, the majority of women who take mifepristone will abort within four hours of using misoprostol. Because of this, most women choose to take the misoprostol dose in the comfort of their own home due to painful side effects such as cramping and excessive bleeding that can also occur within the first few hours. Nausea, vomiting, and fever are among the other side effects women may experience, according to NAF.

“Women want to plan for the expelling of this fluid and blood tissue at their own time and they want to be in a comfortable place,” said Elizabeth Nash, state issues manager with the reproductive health and policy-based Guttmacher Institute. “So you can understand why a woman would want to take the medicine at home, especially if she has a fair distance to travel, which could happen in a place like Texas.”

The FDA guidelines and, apparently, Patrick’s bill do not give women the option of taking the second drug at home.

But the medical consensus has evolved in recent years. Unlike the old FDA guidelines, the 2012 WHO guidelines say that “[h]ome use of misoprostol is a safe option for women.”

Similarly, abortion drug guidelines set forth in 2005 by the American Congress of Obstetricians and Gynecologists say that the lower 200-milligram dose of mifepristone is as effective as the higher, FDA-approved dosage and that “multiple large studies in the United States have demonstrated that a patient can safely and effectively self-administer the misoprostol … in her home.” The ACOG guidelines note that the alternate drug regimens were developed in an effort to “reduce side effects” and “make medical abortion less expensive, safer, and more rapid.”

Dr. Mitchell Creinin, who worked on the ACOG guidelines and currently chairs the Department of Obstetrics and Gynecology at the UC-Davis, says the FDA-approved regimen is “outdated” and that the “vast majority” of providers follow the updated protocol.

The FDA guidelines don’t just stipulate when and where the woman can take the abortion drugs, but how. Misoprostol is only approved by the FDA for oral use, says Creinin, whereas research has shown that ingesting a higher dose of the medicine buccally (placing the pill in between your teeth and cheek) or vaginally can, in some instances, decrease side effects and work faster and more effectively — especially as the pregnancy advances.

According to ACOG, the new protocol is effective for women who have been pregnant for up to 63 days; by contrast, the FDA guidelines limit the use of mifepristone to the first 49 days of pregnancy.

The proposed law could also place significant financial and logistical burdens on women. At roughly $100 for each 200-milligram pill, the FDA’s higher mifepristone dosage is expensive. Moreover, Texas already mandates an ultrasound at least 24 hours before an abortion, so the legislation would actually require four separate trips to the doctor (for the ultrasound, the mifepristone, the misoprostol, and a follow-up visit.)

Texas OB-GYN and abortion provider Dr. Bernard Rosenfeld says the FDA guideline requiring women to take the misoprostol in a clinic was meant to standardize a variable in the trial and that several subsequent studies have shown women can safely take it at home.

Rosenfeld, who has practiced medicine for more than three decades, says the rule goes against “good medical practice” and advises all his patients to take the pills at home.

“There is zero medical basis or benefit to take the pills in the clinic,” he said. “To make a woman come back to the doctor’s office and then find a way to get back home after taking the drug is really just mean and cruel and puts them at medical risk.”

“It’s really just meant to give women a hard time,” he added.

The bill also compels doctors to create a contract with another physician who promises to treat the woman should an emergency arise from the drug. The doctor must have “active admitting, gynecological and surgical privileges at the hospital designated to treat the emergency.” But because some women, especially those in rural areas, may have to travel far to receive an abortion, the hospital in which the admitting doctor works may not be the closest to the woman in the event of a medical emergency.

“Living in a small, rural town can be really problematic for a woman seeking an abortion under these rules,” said Nash. “This part is not well thought out. It does not think through what actual steps will be best for the patient.”

The legislation seeks to penalize doctors who do not follow the requirements. According to the bill, the Texas Medical Board may take disciplinary action, such as revoking a medical license, or assess an administrative penalty, which can mean a fine of up to $5,000 if a doctor fails to comply.

‘More dangerous and more expensive’

Anti-choice lawmakers promote the use of outdated FDA rules when it comes to abortion-inducing drugs as a way to stigmatize doctors, says Nash.

“Whenever you invoke the FDA guidelines you are essentially making it wrong to do something that doesn’t abide by them. But in reality, what we are talking about is off-label protocol that is less expensive and has fewer side effects,” she said.

Anti-choice advocates disagree. Dr. Donna Harrison, a pro-life doctor and director of research and public policy at the American Association of Pro-Life Obstetricians and Gynecologists, says the rigorous FDA process should be followed.

“The FDA guidelines are the only real safeguard for the American people,” she said.  ”So when you go off-label with the drug, you are experimenting on women.”

But doctors in many medical fields routinely prescribe off-label drugs. A 2006 study found that an estimated one-in-five drug prescriptions were off-label.

A 2007 study found that 79 percent of pediatric patients discharged from the hospital received off-label drugs. Off-label drugs are also commonly used in cancer treatments. According to a 1997 survey of 200 cancer doctors conducted by the American Cancer Society and the American Enterprise Institute, 60 percent of them prescribed off-label drugs to patients.

“Off-label use is pretty much the mainstay of how we use medicine in the U.S.,” says Creinin, pointing to everything from birth control regimens to anxiety medication. “Just because a drug is approved by the FDA doesn’t mean there aren’t better ways to use it after approval. Research continues on the drug and finding new uses and assigning different dosages is normal.”

“The bill is really about trying to make providers look as though they are not following the rules when in fact, [the more recent protocol] is just as safe and effective and actually has additional benefits,” said Nash.

Creinin is skeptical of legislators’ intentions.

“The question here is: why would lawmakers, who say they are looking out for the health and welfare of their constituents, want to legislate that women must follow the label when sufficient medical literature shows the old guidelines are more dangerous and more expensive?” he said. “What they’re really trying to say is that they know more than the doctor – but they really need to be getting out of this business.”

‘No medical benefit whatsoever’

Dr. Lisa Perriera, a fellow with Physicians for Reproductive Choice and Health in Ohio, is familiar with the legislation. She says that after her state passed its own law in 2004 restricting use of mifepristone, she began to see unfortunate consequences. For example, patients have reported back that after receiving their misoprostol dose in the clinic, they begin to experience uncomfortable side effects while driving home from the clinic.

“We have patients that have to travel as far as five hours in a car while the abortion process starts – that’s just not fair,” said Perriera.

Based on her experience, Perriera says the legislation has not deterred her patients from having abortions; it has simply affected how they have them. As a result of the seven-week gestational limit, more of them have switched to surgical abortions.

“Some women want to have abortions naturally, without medical instruments, but this bill would eliminate that option for them,” she said. “Legislating the way women have to take their medicine is taking choices away from them.”

In the end, the rules have made it “more inconvenient for patients and more costly,” said the Ohio physician.

“It is also forces women to undergo more visits for no medical benefit whatsoever,” said Perriera. “So this is really not about their health and safety.”

Is It Safe? Asking the Wrong Question in the Home Birth Debate

11:47 am in Uncategorized by RH Reality Check

Written by Miriam Pérez for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

A recent heated dialogue between journalists Michelle Goldberg and Jennifer Block about the safety of home birth has been the latest in a recent media flurry about the rise in home births reported by the CDC in January. A New York Times Magazine profile of Ina May Gaskin, arguably our nation’s most famous home birth midwife, was just one of the most mainstream of the recent articles, and seems to have stirred up much scrutiny of the practice. 

I feel compelled to dip my toe into the conversation, if only to try and steer it in a different direction. The source of the back and forth between Goldberg and Block centers on this question: “Is home birth safe?” It’s not a new question; in fact it has been debated since the beginning of obstetrics and hospital birth at the turn of the 20th century. 

Unfortunately, though, it’s exactly the wrong question to which to be devoting so much air time. A scant share of all women giving birth in the United States do so at home. Despite the reported 29 percent increase in home births nationally between 2004 and 2009, fewer than one percent of births happen out of hospital. While home birth gets much scrutiny, particularly when wealthy white women are seen as forging a new trend by choosing it, the place where the majority of women give birth in the United States — the hospital — goes largely un-scrutinized. 

Hospital births do get a lot of attention in birth activist circles (where I spend significant time, as part of my work at Radical Doula). Midwives and doulas will quickly recite the problems with hospital birth, e.g., why high intervention rates (c-sections, inductions) are bad for mother and baby. But outside of that arena, where it’s arguably most needed, the conversation is stalled. 

Here is the reason this matters: we are in the midst of a maternity care crisis. I’ve said it before, but I’ll say it again: our maternity care system is broken. Why? Because our maternal and fetal mortality rates are worse than 40 other countries worldwide, despite the fact that we spend more money than anyone else on maternity care. And where is  almost all that care being delivered? In hospitals. 

More than thirty percent of all births in the United States are through c-section – a rate twice what the World Health Organization identifies as a dangerous level of c-sections. Maternal mortality is actually on the rise — more mothers are dying from childbirth-related causes now than thirty years ago. I could go on, but I’ve said this all before. 

I realize that things which are deemed “new trends” often get attention, despite the fact that we are only talking about a small minority of people. But there is another reason I think this crisis isn’t getting the air time it deserves — it disproportionately affects women of color. Black women are four times more likely to die in childbirth than white women. And remember, these are hospital births we’re talking about here. While CDC data showed an increase in home births from 2004 to 2009, non-Hispanic White women accounted for 90 percent of this increase. Women are dying from childbirth in our hospitals at alarming rates, under the care of obstetricians and nurse midwives. Something is wrong here.

I don’t hide the fact that I’m a supporter of the midwifery model of care. I do think home births can be a safe and viable option, given adequately trained providers and a relationship with emergency back up services if necessary (something that because of the history of hostility between midwifery and obstetrics is hard to come by). But I’m interested in seeing our energy and scrutiny focused on the vastly dominant portion of our maternity care system: hospitals. While some people know well what challenges arise in that environment, the stories of parents who’ve lost children or mothers in hospital aren’t often publicized in the same way as are those of that small share of home births. We know they happen — mothers and babies are dying from childbirth-related causes in our hospital system. Malpractice rates for OB-GYNs may be high, but the stories of what sometimes happens under their care doesn’t get the same level attention. Why? Because doctors practicing in hospitals have an army of institutional supporters that protect them legally, financially, and in the media.  

As I’ve said before, we desperately need innovation and new approaches to maternity care. Whether you think midwifery and home birth are viable alternatives or not, it’s hard to ignore the statistics that say what we’re currently doing isn’t working. We should be able to guarantee better (not perfect, but better) outcomes for parents and children. If I were to play the blame game, I’m going to look to where almost everyone is giving birth — the hospital. It’s likely that we’re not going to find just one solution that will reverse our rising maternal mortality rate, or our infant mortality rate (not to mention the less discussed, but also important, disability from childbirth-related causes); we will need a range of solutions.

I do think maternity care provided out of hospital by trained providers (yes, even midwives without nursing degrees) deserves our attention. I think evidence-based care should be the standard across maternity care disciplines, but right now it seems that the scrutiny spotlight is unfairly trained in only one direction. It’s the direction that affects very few people, and this imbalance undercuts efforts to do the work of improving birthing outcomes in all settings.

Midwifery, particularly Certified Professional Midwifery, the focus of Goldberg and Block’s conversation, is an under-resourced and extremely marginalized movement. It’s a movement with almost no institutional support, little lobbying power, and with a number of powerful groups (the American Medical Association, American College of Obstetrics and Gynecologists, even the American College of Nurse Midwives) working against it. It’s hard to imagine a movement so maligned being able to prove its worth in that kind of climate, even if Rikki Lake and the New York Times Magazine choose to promote it. 

Let’s focus our scrutiny on the system that is failing us, and figure out how we can make it better. A few things that would help greatly in this matter: transparency about c-section rates from hospitals, an independent body investigating deaths from pregnancy-related causes, and real pressure on the obstetrics community to follow their own advice on practicing evidence-based medicine. 

Repro-Briefs: Graphic Billboards, Defunding Services, and Other State News

9:42 am in Uncategorized by RH Reality Check

Written by Robin Marty for RHRealityCheck.org – News, commentary and community for reproductive health and justice.

When it comes to creepy, offensive anti-choice billboards, Texas has decided to one up Georgia. Midland Catholics for Life has taken Radiance’s "abortion is genocide" message even further, adding in some graphic images and even more overwrought rhetoric to its display.

Via CBS 7:

A graphic downtown billboard is turning heads and raising questions in Midland.

Some who have spoken out against the public display considers the billboard’s depiction of a dead baby inappropriate.

Located at the corner of Texas Avenue and Ft. Worth St., right across the street from Planned Parenthood’s Midland Office, the billboard shows what appears to be a dead baby in a doctor’s hand on the left side.

On the right side it shows what looks like a woman in emotional distress. Above the left side it reads “one dead” and above the right side it reads “one injured.”

On the right side near the woman it reads, “One wounded.”

The two-sided billboard also has a message on the back.

That side says, “Abortion is genocide” and is accompanied by two photos.

The left side depicts what is presumably a healthy baby and the right side shows what looks like a baby that is not alive.

The purpose of the graphic photos, which only recently went live, is to "expose the atrocities that are occurring in Planned Parenthood every week," according to the president of the group. The pictures used are originally from anti-choice group The Center for Bio-Ethical Reform (note, links go to graphic photos), and allegedly depicts an aborted 13 week fetus (11 weeks post fertilization) and 26 week fetus (24 weeks post fertilization), even though 90 percent of all abortions performed are done prior to 12 weeks, and the majority of these before 10 weeks.

The Midland anti-choice group asserts that subjecting the public, even possibly children, to bloody fetus photos, is the only way to make women understand the choice they are making. Planned Parenthood clinic staff disagree. From MyWestTexas.com:

Those who oppose abortion, [president of Midland Catholics for Life Pebbles] Kincheloe said, don’t like seeing images of bloody developing babies either. But, she added, as a group they agreed that’s what it was going to take to "open our eyes to Planned Parenthood being in our backyard."

She said those who support a woman’s right to choose an abortion often call the fetus "a blob of tissue" and that their sign is meant to show women the developing baby is a human who they believe God intended to be born.

The backside of the billboard also displays a baby and says "Abortion is genocide," which supporter Danny O’Grady said represents all the families they believe are being killed.

[Carla] Holeva and Planned Parenthood Choice say particularly for children in the area, they think the images are too graphic. They also question why the group acts as if it knows God’s will for area women.

Women who are clients at Planned Parenthood, Holeva said, are presented with all of the options and the organization assists thousands in carrying out their pregnancies to birth as well as connecting several with adoption agencies.

But, she said, they make it a point not to make the decision about what’s best for their clients and they wish others would provide them the same courtesy instead of posting signs and yelling things like "God will not forgive you" at those who come into the clinic.

Both groups do state however, that more needs to be done to prevent unwanted pregnancies in the first place. It comes as little surprise that the Midland Catholics for Life approach, however, is a "Just Say No To Sex" push, that they believe should not include any safer sex or contraception education.

In fact, contraception, safer-sex education, and general reproductive health access are fairly low on the list of priorities for the anti-choice in Texas, who are still working to see if they can convince the Attorney General to strip funding from state Planned Parenthood organizations — even those that don’t provide abortion services. And more voices are starting to join into the fray, as News8Austin reports:

Planned Parenthood clinics provide family planning services, such as screening for breast and cervical cancer, testing for sexually transmitted diseases and prescribing birth control to women. Some Planned Parenthood clinics in Texas also perform abortions.

But the Austin area clinic’s spokesperson said clinics under the state’s Women’s Health Program strictly provide family planning services.

"If Planned Parenthood isn’t able to participate in the Women’s Health Program, it basically means that there are tens of thousands of women across the state that probably aren’t going to get that health care," Sarah Wheat, with Planned Parenthood, said.

Anti-abortion advocates like Joe Pojman, with Texas Alliance for Life, say that’s not the case. Pojman backed up Sen. Deuell’s request to the attorney general to clear up any confusion about the 2005 law that states participating clinics can’t "perform or promote elective abortions" or be "affiliates of entities that perform or promote elective abortions."

"Women and families will get excellent treatment by the other, more than 400 family planning providers across the state of Texas that do not run abortion facilities or are affiliated with abortion facilities," Pojman said.

A recent Health and Human Services Commission study shows that the Women’s Health Program prevented more than 10,000 unplanned pregnancies in 2008 and saved the state about $40 million a year.

The Senator claims he’s simply trying to get the money to clinics that provide "comprehensive care," something he asserts Planned Parenthood clinics do not do. It is unclear what he thinks is more comprehensive than providing cancer screenings, birth control, gynecological exams and testing and treatments for STIs.

But of course Texas isn’t the only state in which anti-choice legislators are on a crusade to defund Planned Parenthood. A State Senator in Indiana is claiming he will reintroduce a bill next legislative session that will require the state not enter into any contracts or grants with the group. It would also cancel any current funding the group receives from the state. State Senator Greg Walker (R-Columbus) also introduced the same bill this legislative session, but it was never brought up for a vote.

In Colorado, the battle over "personhood" continues, this time with the American Congress of Obstetricians and Gynecologists weighing in. In a publicly released statement, ACOG stated unequivocally that the language being used to define "person" is both scientifically inaccurate and would greatly jeopardize a doctor’s ability to provide health care to a patient. From the press release:

1. The phrase “the beginning of biologic development” is not a scientific or medical reference point in the process of human reproduction. Developmental Biology is a scientific field that studies the mechanisms of development, differentiation, and growth in animals and plants at the molecular, cellular, and genetic levels. Developmental biology includes the study of embryology and the complex factors involved in human reproduction which leads to the birth of a human being. “The beginning of biologic development” has no specific meaning in the context of human embryology and could even refer to the growth of specific human cell lines, for example, in the study of human transplant possibilities and the cure for diseases such as diabetes and spinal cord injuries.

2. Human reproduction (briefly described as the development of egg and sperm, their union into a fertilized egg (or zygote), then division of the embryo and differentiation into a blastocyst, implantation into the uterine wall, and then growth into a fetus, and then viable newborn) is an intricate and inefficient process. The overwhelming majority of potential egg-sperm unions do not result in human beings.

3. Current medical and scientific practice/procedures that involve the term “person” as defined by Amendment 62:

Treatment of Miscarriage: Miscarriages are commonly treated with medical and surgical therapies as well as supportive means; the goal is the removal of the pregnancy tissue from the uterus, which cannot, by any therapy available, produce a live born infant. There were an estimated 102,517 pregnancies in Colorado in 2006, resulting in 70,737 live births (CDPHE, Health Statistic Section) and an estimated 15,377 spontaneous miscarriages in this year alone.

Treatment of Ectopic Pregnancy: In the U.S., ectopic pregnancy is the leading cause of pregnancy related death in the first trimester. Once detected, an ectopic pregnancy is treated with the removal and destruction of the pregnancy either by medical or surgical means, as it cannot result in a live born infant, and yet the growing pregnancy tissue is a threat to the health and life of the mother.

Infertility treatments: Infertility affects at least 10 percent of couples who desire pregnancy; for many of them, assisted reproductive technologies are necessary. Currently 1 out of every 100 babies born in the United States are born through in vitro fertilization (CDC, 2009). This amendment would hold a patient and her physicians liable for embryos which fail to develop or do not result in a pregnancy due to completely natural biologic processes despite rendering the best possible medical care. This amendment can be seen as blocking the rights of infertile couples within the state of Colorado from having a family and will set back the standard of infertility care in this state to the level of medical care practiced in the United States before 1980. What could more antithetical to “family values” and the “right to life”?

· Treatment of Molar Pregnancy: Approximately 20 percent of patients will develop malignant sequelae requiring administration of chemotherapy after initial treatment. All molar pregnancies need to be ended as they cannot produce a live newborn and substantially threaten the mother’s health and life.

· Stem cells research: Stem cells are a unique population of unspecialized cells characterized by their ability to continuously renew themselves for long periods of time through cell division. Researchers are using stem cells to study conditions such a spinal cord injury, diabetes, Parkinson’s, and Alzheimer’s disease. Human embryonic cells are commonly derived from unused fertilized eggs (donated with the consent of the infertile couple).

· Safe and legal abortion: Although not mentioned in the Amendment itself, the intent of Amendment 62 (from www.personhoodcolorado.com) is to provide a legal framework to make all abortions illegal. The American Congress of Obstetrician and Gynecologists opposes unnecessary regulations that delay or limit women’s access to needed medical care and that subject physicians to criminal charges for practicing according to accepted medical standards. [v]

Finally, Louisiana is taking a page out of Oklahoma’s book when it comes to the new mandatory ultrasound law, with six clinics challenging the language of the new regulations. From Courthouse News Service:

Six medical clinics have challenged Louisiana laws on abortion, including the "Ultrasound Statute," which could force doctors to make women take home ultrasound pictures of their fetuses, even if the women resist, according to the federal complaint.
The Hope Medical Group for Women and five other clinics say the two state laws are vague, "will deter qualified, reasonable health care providers from entering the field of abortion provision," will "make it more difficult for women in Louisiana to obtain abortion services," and are "not rationally related to any legitimate state interest."
The two statutes in question are the Exclusion Statute, which, the plaintiffs say, would exclude abortion services from medical malpractice coverage, and the Ultrasound Statute.
"The plain language of the Exclusion Statute applies only to health care providers when they are performing certain illegal abortions," the complaint states. "Plaintiffs believe, however, that defendants intend to apply the Exclusion Statute to health care providers performing lawful abortions. Such application would be unconstitutionally vague. It would also deny abortion providers equal protection of the law by excluding them from access to benefits that are available to all other health care providers."
A doctor’s failure to comply with either statute could subject them to criminal and civil liability and professional discipline.

A major disagreement that the clinics are having with the ultrasound law is the mandate that they must provide a copy of the ultrasound in a sealed envelope to every woman, with no clarification as to whether the woman must accept and leave with the image. Each ultrasound picture reveals, among other things, private patient information such as name of patient and age of fetus. One major concern the clinics have is that such information, once discarded, could be used to target the women who may have had abortions.

"At Hope Medical, for example, every print reveals the woman’s name, the fact that she is pregnant, the gestational age of the fetus, and that fact that the woman obtained her ultrasound at Hope Medical, a facility publicly known to provide abortions."
The plaintiffs say that if "a woman is required to take a copy of her ultrasound print, there is a risk that it will be discovered by the woman’s partner, relatives, co-workers, or other persons to whom the woman may not wish to disclose her pregnancy or her consideration of an abortion."
The clinics say this could be dangerous, because for "women in abusive relationships, disclosure of a pregnancy or an abortion to an abusive partner is likely to spark violence."
The plaintiffs add that the "ultrasound print may also be discovered by anti-abortion extremists. For example, an ultrasound print thrown into a garbage can near a clinic might be discovered by extremists surveilling the clinic, particularly since the print will be contained in an envelope clearly stating its contents."

The lawsuit was filed in Baton Rouge, Louisiana on Friday, August 6th.

ACOG Says Yes to VBACs

7:18 am in Uncategorized by RH Reality Check

Written by Amie Newman for RHRealityCheck.org – News, commentary and community for reproductive health and justice.

Good news from the American College of Obstetricians and Gynecologists (ACOG), on VBACs (Vaginal Birth After Cesearean). New guidelines were released by the organization yesterday marking a significant change in their recommendations regarding VBACs:

"Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans," note the guidelines released today by the American College of Obstetricians and Gynecologists.

VBACs have been treated controversially over the years by hospitals and organizations like ACOG, with guidelines and hospital policies designed to bar women from choosing a "trial of labor" for a birth, even after they’ve had one or more prior c-sections. The thought process behind these bans seemed to be most often connected to the fear, by hospital administrators and doctors, of uterine rupture and other complications. Unfortunately, the fear is more perception and suggestion than rooted in fact. The risk of uterine rupture, according to ACOG themselves, is extremely low, occurring in one-half of one percent of all cases (though serious, requiring emergency surgery). It is unquestionably a serious risk to take into consideration when planning for the type of birth one wants to have – but it has been "over-emphasized" by ACOG, according to Lamaze, International, making it more difficult for women to authentically assess the risks vs. complications of a VBAC. Cesarean sections are major surgery though and come with risk and potential complications as well. In addition, the c-section rate in the United States has climbed to dangerous levels, according to the World Health Organization, with one out of every three women birthing via cesarean section.

Just last year Joy Szabo of Page, Arizona was told she’d essentially be forced into have a c-section because her local hospital refused to allow VBACs. She decided, instead, to drive the 350 miles into Phoenix to a hospital that "allowed" her to birth vaginally.

In fact, the hospital in Page, AZ adopted their guidelines banning VBACs because of the way administrators interpreted the original ACOG guidelines suggesting hospitals have a surgeon and anesthesiologist on call during a VBAC. The Page hospital understood these guidelines to mean they needed coverage of both a surgeon and anesthesiologist at the hospital "24/7" as well as two physicians present at any VBAC. Unfortunately, other hospitals followed suit after ACOG released their original guidelines (which did recommend the "immediate availability" of surgical and anesthesia personnel before allowing a trial of labor for a woman who has had a previous c-section) and VBACs became less and less available over the years.

Birth activists and birth-bloggers who advocates for increased access to VBACs shared their thoughts on the updated guidelines calling them a "breath of fresh air" but also "long overdue."

ICAN, the International Cesarean Awareness Network, issued its own press release yesterday stating:

“VBAC bans place women in the untenable situation of being forced to undergo unnecessary major surgery if they are unable to find a VBAC supportive alternative. This is a first step in
returning to women an appropriate respect for patient autonomy.”

ACOG acknowledged that these guidelines imposed an undue onus on hospitals:

"Given the onerous medical liability climate for ob-gyns, interpretation of The College’s earlier guidelines led many hospitals to refuse allowing VBACs altogether," said Dr. Waldman. "Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC."

ACOG likely took into consideration the recent NIH Consensus Development Conference on VBACs in March of this year, from which a statement was developed by a panel of medical experts on the safety of VBACs. The statement included an agreement that VBACs are a "reasonable option" and "safe alternative" for women who have had a prior c-section.

In fact, the chair of the panel of NIH Consensus Conference experts, Dr. F. Gary Cunningham, chair of obstetrics and gynecology at the University of Texas Southwestern Medical Center, noted in reference to the panels’ findings on the safety of VBACs:

"The VBAC rate has gone from 30% to 10% over the last fifteen years… [which] would seem to indicate that planned repeat cesarean delivery is preferable to a trial of labor. But the currently available evidence suggests a very different picture: a trial of labor is worth considering and may be preferable for many women…The use or employment of VBAC is certainly a safe alternative for the majority of women who have had one prior c-section."

ACOG clearly took note and focused squarely on the rising cesarean section rate in the United States as a key element of their decision to update their guidelines:

"The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns," said Richard N. Waldman, MD, president of The College. "These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

But The Feminist Breeder, a birth activist and blogger, gave credit where she feels credit is due:

And I don’t think they get the credit here.  I think we do. That’s right – you and me.  So thank you to the the women like Joy Szabo, and Jill from Unnecesarean.  To the women like Desirre Andrews, and Jennifer Block.  To Nicette Jukelevics and Jen from VBACFacts.com.  To the women of ICAN, and the midwives who risk prosecution to attend a home birth after cesarean where the state doesn’t support it.  To all the women who Tweeted, and Facebooked, and Blogged this issue until government health experts couldn’t help but take notice.

We did this.  We made this change happen because we spoke up and insisted on being treated better. But the work is not done yet. Now, we must take this statement to our providers and hospitals and challenge those VBAC “Bans.”  Send the statement to your sisters, coworkers, and friends who may be considering a VBAC.  Write about it, talk about it, and keep spreading the message until VBAC is no longer a four letter word.

These updated guidelines encourage physicians to discuss VBAC "early in the prenatal period" to develop a plan. The group also strongly recommends that hospitals put in place policies that ensure any and all personnel needed for an emergency c-section can be gathered quickly. Unfortunately, it’s this language that still "troubles" Lamaze, International. While the organization was pleased to see updated guidelines, they did take issue with some of the language and what they perceive to be an over-emphasis on the extremely low risk of uterine rupture:

The revised guidelines acknowledge that requiring “immediately available” resources for an emergency cesarean have resulted in hospitals, insurers and the obstetric community issuing formal or informal bans of VBAC, effectively denying women access to care and choice in birth.  While this was not the intention, the “immediately available” language remains in the new guidelines, which may continue to unfairly limit women’s access to VBAC.

Additionally, the guidelines continue to emphasize risks of uterine rupture, a rare, but potentially dangerous complication, for women who choose a VBAC.  Unfortunately, this does not help women contextualize the benefits and risks of VBAC versus elective repeat cesarean delivery (ERCD). 

Women still experience high rates of particular medical interventions which not are always necessary, when birthing at hospitals in this country – from electronic fetal monitoring to labor-inducing drugs – and therefore, even with a trial of labor allowed, it’s important that pregnant women understand how best to reduce their chances for an unnecessary c-section.