Author: Elena Skoko, HRiC Political Activism Coordinator in Italy
We urge the international community to express their opinions on this issue. Your comments will be much appreciated, please write to firstname.lastname@example.org
In July 2014 the National Federation of Midwifery Boards (FNCO) has issued a technical statement on the practice of vaginal birth after cesarean sections (VBAC) at home. The statement discourages midwives to support and assist women in this choice and it openly declares that women cannot exercise their rights in childbirth, stating that:
“[…] the midwife must not suggest nor go along with the woman’s wishes for a VBAC at home. This conduct has to be followed even in case where there is a specific written informed consent because the disproportion between the risks and the benefits makes the exercising of this right unavailable for the woman.”
The FNCO is the highest regulatory board of the midwifery profession in Italy, thus it can have a word on duties and obligations concerning midwives. Yet, the fact that a regulatory board of a certain profession assumes it can rule over constitutional and human rights of people in general, and women in particular, it is at least disturbing, however it can be cause for concern. In fact, the FNCO does not have the authority to decide about these rights. Both women and midwives in Italy can actually practice VBAC at home if this is their choice, but if something goes wrong, for any reason, the midwife who assisted may be accused by her own board. Also, the court may take into consideration that there was a ban on the practice of VBAC at home and thus confirm the common (unscientific) prejudice that if home birth is dangerous, the VBAC at home is not even a choice, as stated by FNCO. This statement has no power over the autonomy of midwives and women in theory, but in practice it may limit legitimate women's options at birth by leaving them without midwives, who may not be willing to take the risk to go against their regulatory board. On the other side, it creates a precedent for a health-related professional board to have a word on basic and constitutional rights of women, motivated only by cultural bias and defensive medicine.
It is interesting that the FNCO statement draws peculiar conclusions from its own premises, when it declares that: “[…] The likelihood of uterine rupture after a single low transverse incision is identical compared to women with the uterus intact. […] The uterine rupture (UR) is a very rare event with an incidence between 0.2% and 1.5% and it is the only serious complication in TOL for women with previous C-sections”. If the uterine rupture is the only concern for the VBAC and this concern is minimal, why then such drastic measures against home birth after cesarean?
Associations and groups of women and mothers (Innecesareo Onlus, Rinascere al Naturale Onlus, Noi vogliamo un vbac and Partonaturale.net) have issued a petition addressed to the FNCO expressing their concern about the midwifery profession and its relation to pregnant women. Is the Federation declaring midwives shall abandon women on their own if they don’t obey the rules and opinions of the FNCO, an institution they are not even part of? Is the Federation going to persecute midwives who stand with women and their choices in order to offer maternity services while respecting women’s rights? And more specifically, how the Federation intends to stop women in their choices? The petition remained unanswered.
Mothers are starting to consider if midwives are standing with them or against them. In a country with almost 40% of c-sections, where half of these surgical operations are declared unnecessary, denying women a chance to have a normal and respectful assisted birth at home is cruel and unwise.
The only midwife who publicly addressed the FNCO regarding its statement was Verena Schmid, who wrote an open letter where she invited the Federation to respect the international code of ethics for midwives, calling for a consensus conference concerning the issue. She argues that bans and impositions shall not be ruled from the above by a presumed medical authorities, but that best evidences and practices shall be discussed among childbirth experts, namely midwives and women, instead.
Although the FNCO is informed, from the inside (the midwives) and the outside (the mothers) that this statement shall be removed or changed, it still remains unaltered and the Federation is firmly defending it.
We urge the international community to express their opinions. We ask the mothers in Italy to send us their stories of VBAC/HBAC and to get in touch with us if they want to work together on this issue. You will find the translation in English of the original statement here below.
If you feel inclined to write directly to FNCO, expressing your opinion or informing the Federation how their statement influences your personal rights or choices, please use this mailing and/or email address:
To the attention of President Miriam Guana
FEDERAZIONE NAZIONALE DEI COLLEGI DELLE OSTETRICHE
Piazza Tarquinia 5/D - 00183 Roma (RM) – Italy
FEDERAZIONE NAZIONALE COLLEGI OSTETRICHE
(National Federation of Midwifery Boards)
Is Homebirth Assistance Dangerous for Women with Previous Caesarean Sections?
Technical opinion written and shared by the Central Committee of National (Italian) Federation of Midwifery Boards (FNCO) and validated by experts in legal controversy
Rome, July 2014
[Disclaimer: This is an unofficial translation provided for reference only.
The link to the original document:http://www.fnco.it/news/l-assistenza-al-parto-a-domicilio-nelle-donne-precesarizzat.htm]
- The Agency for Health Research and Quality (AHRQ) in the 2010 report, in consideration of the serious damages caused by multiples C-sections, expresses a strong support for the vaginal birth after caesarean (VBAC), after an accurate analysis of the indications and contraindications for a trial of labour (TOL). The likelihood of uterine rupture after a single low transverse incision is identical compared to women with the uterus intact (RCOG 2007, ACOG 2004). The uterine rupture (UR) is a very rare event with an incidence between 0.2% and 1.5% and it is the only serious complication in TOL for women with previous C-sections. The main evidences provided by the most important and the most recent guidelines (RCOG/2007 and ISS/2012) recommend to give specific information to a woman who is a candidate for a TOL. The woman should be informed about the characteristics, the organization and the standard procedures of the maternity ward she has chosen because these aspects can modify maternal and foetal-neonatal outcomes. The midwife, who is the health care provider expert in physiology, should promote TOL for every woman with previous C-section, in absence of contraindications, in a setting that offers maximum security for the woman and her baby. ACOG in 2010 and RCOG in 2007 issued guidelines recommending that TOLAC (trial of labor after caesarean) should take place only in settings where professional resources and adequate technologies are available in order to provide continuous monitoring of possible complications and immediate emergency care.
- The midwife … “assists and advises the woman during pregnancy, birth and postpartum, she manages and follows out spontaneous births under her own responsibility, and she gives neonatal care”. 1 comma 1 - Decreto Ministeriale 14 settembre 1994, n. 740 “Regolamento concernente l’individuazione della figura e relativo profilo professionale dell'ostetrica/o”
- Midwives are authorized to perform the following activities: … e) caring for and assisting the mother during labour and monitoring the condition of the foetus in utero by the appropriate clinical and technical means; recognising the warning signs of abnormality in the mother or infant which necessitate referral to a doctor and assisting the later where appropriate; taking the necessary emergency measures in the doctor's absence” Decreto Legislativo 6 novembre 2007, n. 206 “Attuazione della direttiva 2005/36/CE relativa al riconoscimento delle qualifiche professionali.” Comma 2, lettere e), f), g) dell’art. 48 “Esercizio delle attività professionali di ostetrica….”.
- Art 2.6… “The midwife in exercising her profession is committed to performing with carefulness, diligence and competence in order to protect the beneficiaries” art 3.3 “The midwife acts in the direction of providing adequate care based on scientific evidences and appropriate to the different levels of necessity”… art 3.10 “The midwife, in cases of no-emergency state, before performing any professional act on a person, guarantees an adequate information so to obtain the informed consent, based on real therapeutic alliance with the person in her care. Codice deontologico dell’ostetrica/o 2010
- “NASCERE IN CASA" Associazione Nazionale Culturale Ostetriche Parto a Domicilio e Casa Maternità (“BORN AT HOME” National Association of Homebirth and Birth Centers Midwives) guidelines 2013 state that among the contraindications to homebirth, to be identified prior to the labor, there are a precedent CS and every previous surgery where the uterus was sliced.
- Legge 8 novembre 2012, n. 189 “Conversione in legge, con modificazioni, del decreto-legge 13 settembre 2012, n. 158, recante disposizioni urgenti per promuovere lo sviluppo del Paese mediante un più alto livello di tutela della salute (Law […] containing urgent dispositions to promote the Nation’s development through an improvement in health protection)” says at art.3.1: “the health professional who during her activity follows guidelines and good practice as validated by the scientific community cannot be charged for negligence…”
- Delibera della Giunta Regionale (The Regional Committee Resolution) 21/04/2008 n 533/2008: Direttiva alle Aziende sanitarie in merito al programm percorso nascita (Directive to the Hospitals about birth protocols) – Regione Emilia-Romagna. This document presents 11 goals for the hospitals, namely the n. 4: “Promoting and consolidating the acceptance of guidelines about “The control of foetal wellbeing during labour” in order to evaluate and modify the sanitary routines about birth for more appropriate interventions”… and n. 9: - “To guarantee a qualified care to physiological labour and birth out of hospitals”.
Considering the content expressed in the guidelines provided by the National (Italian) Health Institute (ISS) (2012) and the Associazione Nazionale Culturale Ostetriche Parto a Domicilio e Casa Maternità (2013), and the accredited evidence-based literature; considering the present legislation on professional responsibility and the professional code of conduct, it is a midwife’s duty to offer to the woman with previous C-section, in absence of contraindications, every information about TOL underlining the real, presumed, immediate and future dangers that could derive from the professional service.
In this prospective the midwife has the obligation to communicate to the woman that a VBAC at home is to be considered impracticable. To confirm this we recall all the qualified scientific literature according to which the TOL in women with previous C-section must take place only in settings where professional resources and adequate technologies are available in order to provide continuous monitoring of clinical maternal-foetal conditions, prompt identification of possible complications and immediate emergency care in case of uterine rupture.
Even though the UR is a rare complication, nevertheless it is to be considered a dramatic and potentially fatal event both for the woman and the baby. For this reason only a hospital facility with an immediate access to the operating theatre is considered to be the ideal setting in order to assure absolutely safe assistance, considering as well the accessibility of the emergency room and the availability of the blood transfusion, in case of an emergency C-section.
In conclusion, since the midwife is committed to protect the health of her beneficiaries, to operate with carefulness, diligence and competence respecting the fundamental principles of the quality, pertinence and safety of care during her clinical practice, she has to conform to guidelines and good practices accredited by the scientific community as they represent a reliable source for standard care: this is also valid against any possible legal issues. It follows that, in accordance with the above mentioned, the midwife must not suggest nor go along with the woman’s wishes for a VBAC at home. This conduct has to be followed even in case where there is a specific written informed consent because the disproportion between the risks and the benefits makes the exercising of this right unavailable for the woman.
It seems useful to recall that the violation of the indications mentioned above exposes the health professional to a direct criminal, civil and professional liability, and (in case of public employee) to the administrative-accounting liability (for gross negligence).
Bibliography and Online References
- Codice Deontologico dell’ostetrica anno 2010
- Codice Penale
- Linee guida di assistenza al travaglio e parto fisiologico a domicilio e casa maternità, anno 2013, approvate da “N A S C E R E I N C A S A" Associazione Nazionale Culturale Ostetriche Parto a Domicilio e Casa Maternità,
- http://www.guideline.gov/syntheses/synthesis.aspx?id=25231 : Guideline Syntheses ; Vaginal Birth After Cesarean (VBAC) Guidelines Being Compared: Visitato il 17-6-2014
- American College of Obstetricians and Gynecologists (ACOG). Vaginal birth after previous cesarean delivery. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Aug. 14 p. (ACOG practice bulletin; no. 115).
- Royal College of Obstetricians and Gynaecologists (RCOG). Birth after previous caesarean birth. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2007 Feb. 17 p. (Green-top guideline; no. 45).
- Agency for Healthcare Research and Quality. Vaginal birth after cesarean: new insights. AHRQ Publication 2010;10- E003. Disponibile all’indirizzo: http://www.ahrq.gov/downloads/ pub/evidence/pdf/vbacup/vbacup.pdf (visitato il 10- 05-2011
- VIII Rapporto CeDAP Ministero della salute anno 2013
- Linea Guida n. 22 “Taglio cesareo: una scelta appropriata e consapevole: Seconda parte” Istituto Superiore di Sanità Data di pubblicazione: gennaio 2012
- La Legge 8 novembre 2012, n. 189 “Conversione in legge, con modificazioni, del decreto-legge 13 settembre 2012, n. 158, recante disposizioni urgenti per promuovere lo sviluppo del Paese mediante un più' alto livello di tutela della salute”
- Delibera della Giunta Regionale del 21/04/2008 n 533/2008: - Direttiva alle Aziende sanitarie in merito al programma percorso nascita- REGIONE EMILIA-ROMAGNA
- http://www.nascereacasa.it/wp content/uploads/2014/03/linee_guida_Parto_a_domicilio_2013.pdf