Wednesday ended the National Institutes of Health (NIH) Consensus Development Conference on Vaginal Birth After Cesarean (VBAC). In anticipation of the event, Courtroom Mama, an attorney and reproductive justice advocate, has written a powerful call to action on the travesty of hospital VBAC bans.  Henci Goer, author of “The Thinking Woman’s Guide to a Better Birth,” argues that the conference must remind clinicians  of their ethical and professional obligation to treat all women planning a VBAC, because “VBAC is a right, not a preference, a right, let me add, not abrogated by the clinician’s opinion of its wisdom.” Both of these statements were echoed strongly by conference presenters and the audience. As reproductive justice advocates, we must apply these lessons not only to clinical decisions made by doctors and hospitals, but to legislators and other policy makers whose decisions impact women seeking vaginal birth after cesarean. 

Legislators must accept their responsibility to ensure that women who plan a VBAC have access to non-surgical birth with the provider of their choice. Last week, the midwifery community celebrated the victory in Wyoming, the 27th state to succeed in a consumer-led effort to license Certified Professional Midwives.  Yet, the legislation restricts midwives from attending VBACs at home under certain conditions, such as after more than one cesarean, or births closely spaced to the previous cesarean. Why? Ostensibly because some clinicians believe that the risks of VBAC are unacceptable (to whom?) to undertake at home. In no way should the hard work of Wyoming advocates be diminished, nor the successes in Vermont and Idaho, both states where laws were passed with similar restrictions on midwife attended VBAC. Some states require that a woman visit a physician before she is permitted to continue care with a midwife. In Missouri, newly introduced legislation requires that an “intent to home deliver” be filed with the state. Such provisions are insulting to women and to the profession of midwifery.

Legislators have an obligation not to turn their backs on women who choose VBAC at home– a choice sometimes made because women cannot find a provider who will ‘allow’ a VBAC in a hospital. These restrictions force women to “go rogue” and give birth unattended. For women who are already scarred and already pregnant again, unattended home VBAC or mandatory surgery is the compromise they have been forced to accept.

Reproductive justice demands putting the most vulnerable women at the center. In maternity care, the ever-increasing number of women who have had previous cesarean(s) are becoming a marginalized mass.  Instead of meeting their real needs, medical and hospital lobbies are using VBAC women as pawns to negotiate whether midwives will achieve licensure.  VBAC women cannot, must not, be the low hanging fruit.

That women’s reproductive rights and choices are used as bargaining chips in legislative debate is nothing new. The nation has watched as Stupak uses the vehicle of health care reform to restrict women’s ability to access health care services of their choice, even in privately purchased insurance policies. Like Stupak, state legislators, no doubt moved to do so by powerful lobbies, wish to own the choices of cesarean-scarred women. “When we think women’s choices aren’t (immoral-Stupak) or (stupid- VBAC),  we will allow women to make them. Otherwise, we make their choice for them.”  At the end of the day, negotiating about VBAC in licensure debates isn’t about what kinds of births can be safely attended out of the hospital. Women who choose home VBAC know that in the unlikely event of a problem, they may be unable to access timely cesarean surgery (a separate question loomed at the NIH conference as to whether they are actually able to access it in the hospital, either). They also know that planned repeat cesarean brings its own risks. No, this bargaining with midwifery advocates about VBAC is about what kinds of choices women can be trusted to make for themselves.

Advocates are told that we will lose everything unless we compromise the rights of the most vulnerable among us–will lose midwife licensure efforts, lose health care reform. Like physicians, legislators have an ethical and professional duty to protect public health and respect women’s rights, not to bow to the demands of lobbies who wish to own them.