Your body, my choice: The medical model of maternal health care in Iowa

Rachel Bruns is a volunteer advocate for quality maternal health care in Iowa.

As the phrase “your body, my choice” has infiltrated social media in the days following the 2024 presidential election, Linda Crownover-Inch, the International Cesarean Awareness Network (ICAN) of Quad Cities chapter leader and a doula, posted the following on Facebook:

There is one place where this phrase has been accepted and normalized for decades and will not disappear until people rise up and face it head on. That place is in the medicalized maternity care setting.

In my experience as a seasoned doula, every one of the medical maternity care providers (OB’s and medicalized midwives) that provided labor and birth service for my client’s, have violated my clients right to bodily autonomy in ways that should be categorized as assault.

Sadly, US medicalized birth culture has normalized assault during labor and birth as “That’s just the way it happens” and “They need to do those things to me to make labor and birth safe”, or “I can’t tell them what to do”. Too often I’ve stood in circles of people retelling, All the while normalizing trauma and assault in their medicalized birth stories.

While I’m sure many will balk at applying this horrendous saying to standard maternity care in most of the United States, Linda’s post resonated with my experience as a maternal health advocate in Iowa. The current reality is that most women seeking prenatal, birth, and postpartum care in Iowa face inadequate care options and degrading experiences, all in the name of so-called health care.

A PROBLEMATIC MATERNITY CARE CULTURE

Of course there are providers, both physicians and midwives, who are the exception to this pattern. Yet even with millions of dollars of federal and state funds being directed to maternal and infant health, the majority of hospital leaders, physician groups, insurance executives, and state leaders show no interest in changing Iowa’s problematic maternity care culture. Why problematic? According to the 2021 Iowa Maternal Mortality Review Report, 100 percent of pregnancy-related deaths were deemed to be preventable, with 40 percent attributed to discrimination.

Nearly every week, some news article highlights maternal mortality in the United States, related racial disparities, growing maternal health deserts, or how midwifery care can improve outcomes. Even so, the United States has fewer midwives than OB physicians compared to its counterparts in other countries.

Iowa’s political and social environment contributes to our state’s worsening infant and maternal health care. Since July, the state has severely restricted lifesaving abortion care. Iowa also keeps reimbursement rates low for midwives and prevents freestanding birth centers from opening or providing sustainable reimbursement. (Iowa doesn’t even have a fee schedule for freestanding birth centers.) The state also allows hospitals to limit family physicians’ ability to practice obstetrics.

MANY CESAREANS, FEW VBACs

Unlike some other states, Iowa does not publicly publish hospital cesarean or VBAC (vaginal birth after cesarean) data. I have been requesting this data for the past four years, and the state has provided it within a data set of five-year aggregates. I assume they have done so to shield specific hospitals from any obvious outrageously high cesarean or low VBAC rates. Even with five year data, you can get a sense of the hospitals increasing patient mortality and morbidity with higher cesarean rates and those not providing true informed consent with low VBAC rates.

While cesareans can be necessary and life saving for some individuals, the 500 percent increase in cesareans since the 1970s has not led to improved outcomes for infants. In addition, it has increased the likelihood that mothers will die in childbirth, as detailed in this article by Dr. Neel Shah. A must-read review of the new book Invisible Labor: The Untold Story of the Cesarean Section provides shocking background on the history of cesareans.

“So much of the harm done in American delivery rooms happens because providers dismiss patients’ concerns or don’t communicate with them at all—some providers pressure, or even force, women into having Cesareans. While women of “all races and backgrounds report being coerced into obstetric inventions,” Somerstein writes, “Black women are more likely to experience this particular form of browbeating.”

A recent study in New Jersey published by the New York Times found Black mothers were 20 percent more likely to have a c-section compared to a white mother with a similar medical history seeing the same doctor at the same hospital. From the article: “The additional operations on Black patients were more likely to happen when hospitals had no scheduled C-sections, meaning their operating rooms were sitting empty. That suggests that racial bias paired with financial incentives played a role in doctors’ decision-making, the researchers said.”

BARRIERS TO VBACs IN IOWA

While preventing the first cesarean is a preferred strategy to reduce cesareans, the high total cesarean rate, largely driven by repeat cesareans, is likely connected to a lack of informed consent on the risks and benefits of both repeat cesarean and VBAC.

Providers using a VBAC calculator as a screening tool instead of how it is intended as an educational tool continues to be a barrier to many pregnant individuals in Central Iowa. This AMA Journal of Ethics article by Dr. Nicholas Rubashkin highlights how race-based medicine continues to negatively impact access to VBAC care for those who want a trial of labor.

Removing race from the VBAC calculator does not fully address the ways that racism continues to cloud the issue of VBAC. In order to make fairer algorithms, we must pay attention to the explicit and implicit ways that racism structures the risk of a primary cesarean, the quality of postoperative care, and clinicians’ willingness to respect women’s care preferences. Bioethicists have recommended that we center women’s preferences in VBAC decision making.²² However, the VBAC calculator demonstrates how relative risk can be used to trump a woman’s preferences for VBAC. Both the new and the old VBAC calculator compromise patient autonomy and undermine the principle of informed consent.

Iowa patients face at least three additional challenges in accessing VBAC care.

Providers often set body-mass index (BMI) restrictions on who can receive VBAC care, even though BMI is not evidence based. Guidelines on VBAC from the American College of Obstetricians and Gynecologists (ACOG) specifically state BMI should not rule out the option for a trial of labor after cesarean (TOLAC).

Some hospitals do not allow the range of inductions methods for VBAC that are supported in ACOG’s VBAC guidelines, such as a foley bulb, cook catheter, or low-dose pitocin. This is especially concerning for providers that set a “due date” maximum for birth under their care. It is common for providers to claim they support VBAC, but when 39 weeks comes around they start talking about scheduling a c-section if spontaneous labor has not started. This leaves patients with no medical issue in a difficult position to choose between a coerced unnecessary surgery or to wait against their provider’s preference. It is important to note that ACOG VBAC Practice Guidelines do not advise against offering a labor after cesarean for postterm pregnancies.

Many Iowa providers do not support VBAC for shorter interpregnancy intervals, defined as the interval between one live birth or pregnancy loss and the start of the next pregnancy. In addition to limitations on VBAC care for interpregnancy intervals, some providers discuss birth-to-birth intervals, which would not take into account pregnancy loss.

A VBAC BAN AT BROADLAWNS

Polk County’s public hospital prohibits VBAC by not allowing its OBs or midwives to provide prenatal care to patients with a prior cesarean, unless they are planning a repeat cesarean. Andrea Arkland recently spoke at the October Broadlawns Trustees meeting after organizing a petition calling on Broadlawns to end its VBAC ban and at a minimum allow its current patients the ability to plan a VBAC with the midwives.

In a written response, Broadlawns informed Arkland their reason for not providing VBAC care is that they are following ACOG practice guidelines. Their two main points: 1) they don’t have a neonatal intensive care unit (NICU) and 2) they don’t have the resources for an OB or anesthesia to be available around the clock, seven days a week.

The problem with Broadlawns’ response is neither of those are recommendations in ACOG’s 2019 Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery (PB #205). At no point does PB #205 suggest a hospital requires a NICU to provide VBAC care. Nor does it require an obstetrician and anesthesiologist must be on site at the hospital 24/7 to provide VBAC care. Since 2010, ACOG guidelines on VBAC have clarified the “immediately available” language in the guidance was never intended to restrict access.

PB #205 states the following relevant summary recommendations (based on consensus and expert opinion):

“Most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about and offered TOLAC.”
“Given the overall data, it is reasonable to consider women with two previous low-transverse cesarean deliveries to be candidates for TOLAC and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.”
“After counseling, the ultimate decision to undergo TOLAC or a repeat cesarean delivery should be made by the patient in consultation with her obstetrician or obstetric care provider. The potential risks and benefits of both TOLAC and elective repeat cesarean delivery should be discussed. Documentation of counseling and the management plan should be included in the medical record.
“Trial of labor after previous cesarean delivery should be attempted at facilities capable of performing emergency deliveries.”
“Women attempting TOLAC should be cared for in a level I center (ie, one that can provide basic care) or higher.”
“Because of the risks associated with TOLAC, and because uterine rupture and other complications may be unpredictable, ACOG recommends that TOLAC be attempted in facilities that can provide cesarean delivery for situations that are immediate threats to the life of the woman or fetus. When resources for emergency cesarean delivery are not available, ACOG recommends that obstetricians or other obstetric care providers and patients considering TOLAC discuss the hospital’s resources and availability of obstetric, pediatric, anesthesiology, and operating room staffs.”

It should also be noted that PB #205 states,

However, none of the principles, options, or processes outlined here should be used by centers, obstetricians or other obstetric care providers, or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC available and as safe as possible for those who choose this option. In settings where the resources needed for emergency delivery are not immediately available, the process for gathering needed staff when emergencies arise should be clear, and all centers should have a plan for managing uterine rupture. Drills or other simulations may be useful in preparing for these emergencies.

Additionally, as a Level 1 Maternal Center, if not providing VBAC care for the stated reasons, Broadlawns is also not meeting the level of care necessary if it is unable to “begin emergency cesarean delivery within a time interval that best considers maternal and fetal risks and benefits with the provision of emergency care.”

According to ACOG’s Obstetric Care Consensus Number 9 on Levels of Maternal Care, a Level 1 Basic Care hospital should have capabilities including, but not limited to:

“Capability and equipment to provide low-risk and appropriate moderate-risk maternal care and a readiness at all times to initiate emergency procedures to meet unexpected needs of women and newborns within the center. This includes:
- Ability to begin emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits
Stabilization and ability to facilitate transport to a higher-level of hospital when necessary.”

ACOG guidance also says that a Level 1 hospital should be capable to care for “low-risk women with uncomplicated pregnancies and women with higher-risk conditions such as

Uncomplicated twin gestation
Labor after cesarean
Uncomplicated cesarean delivery
Preeclampsia
Well-controlled gestational diabetes

Broadlawns’ stated reasons for rejecting VBAC suggest the hospital does not have the resources for emergency cesarean delivery in situations such as cord prolapse, fetal distress or for managing uterine rupture, which while rare, can occur in patients without a prior cesarean. Additionally, Broadlawns seems to imply it is unable to meet ACOG’s Level 1 basic care capabilities.

Polk County taxpayers deserve to understand any staffing limitations or financial challenges that prevent Broadlawns from offering the basic level of care required of a Level 1 maternal health hospitals, which include providing care for patients who decide to have a trial of labor after cesarean.

OTHER RESTRICTIONS ON VBAC IN IOWA

Broadlawns is not the only hospital inappropriately restricting access to VBAC. UnityPoint Des Moines currently does not allow its nurse midwives to provide VBAC care, even though it is within their scope of practice. Additionally, the OB group allows induction for VBAC only if you have met a high enough bishop score, something that is not consistent with ACOG VBAC practice guidelines.

For a hospital delivering as many babies as UnityPoint does, with the resources it has available as a Level IV hospital, VBAC care for those with one or multiple prior cesareans should not be as hard to navigate as it currently is. Many in the Des Moines metro area travel for two or more hours in search of supportive VBAC care.

There is no legitimate reason for VBAC care not to be accessible at UnityPoint with the midwives, or for induction to be an option for those planning a VBAC who want it. While inductions are notoriously being overused for nonmedical reasons, if a patient is only provided the option of a repeat cesarean at 41 weeks because her provider won’t induce for VBAC, that is problematic in ensuring bodily autonomy and informed consent.

It is important to note that even with these barriers at some hospitals, informed refusal is always an option. Iowans can learn more about birth rights in this guide from the Birth Rights Bar Association.

However, that can be tricky when living in smaller communities with only a couple of health care providers. What happens if you refuse your provider’s recommendation for a cesarean and they subsequently drop you from care? What if they are the only provider accepting your insurance, or the only provider in your rural area? Informed refusal can be easier said than done in a maternal health desert, like much of Iowa. Providers and insurance companies have the power in Iowa when it comes to access to care.

While having a HBAC (Home Birth After Cesarean) is an option for some, not everyone is a candidate for home birth. Also, some people want access to an epidural, or don’t have insurance coverage for a home birth. Medicaid, which covers nearly 40 percent of births in Iowa, has terrible reimbursement rates for home birth midwives. As a result, only two home birth practices in the entire state accept Medicaid.

Ironically, most OBs in Des Moines will tell you trying for a home birth VBAC is not safe, yet they limit or ban VBAC at their hospital. The research shows adverse outcomes for planned VBACs are rare, both in the hospital setting and home birth setting.

When it comes to time between pregnancies, ACOG’s VBAC Practice Bulletin is clear that short interpregnancy intervals should not exclude someone from VBAC care. Unfortunately a lot of providers interpret the ACOG interpregnancy counseling guidance, which recommends an interval of more than 18 months, to mean VBAC is not recommended.

It is somewhat understandable that providers would do this, because the interpregnancy counseling guidance cites outdated and poorly conducted research. That research is no longer used in the ACOG VBAC Practice Bulletin, nor has it been included in more than a decade. While the interpregnancy counseling guidance is publicly available, the VBAC Practice Bulletin is behind a paywall. A quick search on Reddit will help you find the current version, last updated in 2019—but it is obvious many Iowa providers have not taken the time to seek it out.

ADVOCATING FOR BETTER GUIDANCE

Earlier this year, the International Cesarean Awareness Network (ICAN), of which I’m a local chapter leader, wrote to ACOG and the Society for Maternal-Fetal Medicine, detailing the issues related to VBAC in the Interpregnancy Care Obstetric Care Consensus Number 8 and how it contradicts the ACOG VBAC Practice Bulletin. The letter was also sent to the American College of Nurse-Midwives and the National Association of Nurse Practitioners in Women’s Health, who have endorsed the interpregnancy care guidance. You can read ICAN’s letter in full here.

ACOG responded quickly by citing new research on interpregnancy intervals, which shows a slightly lower uterine rupture rate for intervals greater than 18 months. Setting aside the fact that this new research is not cited in either the VBAC Practice Bulletin or the Interpregnancy Guidance, the new research actually indicates that even a possible “increased risk” for VBAC shorter interpregnancy intervals is still lower than the risk used for Trial of Labor After Cesarean (TOLAC) in ACOG’s VBAC Practice Bulletin.

ICAN sent a follow up letter detailing further questions about the new research. ACOG’s response was disappointing, acknowledging receipt with no further reply. If ACOG is as serious about improving maternal health as it claims, ensuring consistency between its Practice Bulletins and Consensus Guidance and ensuring quality and up-to-date research is being cited should be a low bar to clear.