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Unkind Cut

— Tonya Jamois, a housewife from San Marcos, leads an international grassroots movement battling the medical establishment. Dressed in tennies and a raspberry-colored velour track suit, she sits in a purple armchair in the corner of a Starbucks in San Marcos with her legs curled underneath her. She answers questions in a voice that's hard to hear over the din of blenders and milk steamers.

Jamois is a fierce fighter when it comes to cesarean births and promoting the practice of helping women who have had cesareans giving birth to their next child vaginally. This practice, known as VBAC (pronounced VEE-back), an acronym for vaginal birth after cesarean, is falling out of favor with obstetricians and their malpractice insurance carriers.

Jamois is the president of International Cesarean Awareness Network, founded in 1982, she says, "to improve maternal child health by preventing unnecessary cesareans through education, to provide support for cesarean recovery, and to promote VBAC." But she wasn't even aware of the group's existence when her son was born cesarean in 1999. "Starting a week or two before my due date, I started getting pressure to induce, I really didn't understand why, and I resisted it," explains Jamois. "Ten days after my due date, I did go into labor and showed up at the hospital thinking I was really quite far along, and I was only one centimeter. And the hospital offered me an epidural right there, at one centimeter [of cervical dilation]. I wanted to do it naturally, because my mom did it, my grandmom did it; why shouldn't I? But I was completely unprepared, and so at two centimeters, I went ahead and took them up on the offer of the epidural, which put me flat on my back, and I couldn't push him. They tried all they could do to get him with the extractor, the vacuum, and all of that, but they told me that my pelvis was wide enough but not tall enough for the baby to come out. His heart rate took a few dips, so off we went to the operating room because at that point it was considered an emergency. But it could have been avoided. Had I been thoroughly prepared and had I not had an epidural."

A year later, when she found out she was expecting her second child, Jamois resolved to have the baby naturally. "I didn't want to have another cesarean," she says, "and looking at my experience, I knew my best chances would be if I wasn't hooked up to monitors and was able to move around and have a little bit more control over the situation. So I went and interviewed another obstetrician who was really kind of hostile when I asked about her cesarean rates and the way she practiced. So then I decided to call the Best Start Birth Center, which is the only freestanding birth center in San Diego. It is down in Hillcrest, and I lived up here in San Marcos, but I thought it was worth it to drive down to Hillcrest. And they told me that because of new guidelines put out by the American College of Obstetricians and Gynecologists, they couldn't do VBACs at the Birth Center anymore. They said they were really sorry; they had never had a problem with VBACs, but their obstetricians wouldn't back them up anymore because of these guidelines."

The College of Obstetricians' guidelines state that VBACs ought not be performed unless an obstetrician is on hand for the entire labor. Normal practice is for the mother to labor under the care of hospital nurses and the doctor to show up for the final pushing and delivery.

Jamois gave birth to a daughter vaginally in 2001, and her life became very busy, not just because of the new baby, but because she became increasingly involved with the International Cesarean Awareness Network "because," she says, "I wanted to help educate other women on the birth issue -- not only the politics behind VBAC but also safety, so they could make informed decisions. I started a San Diego chapter of ICAN in 2002 and then was asked to join the board of directors for the national organization shortly thereafter. And now I am the president."

Jamois says she spends about 40 hours per week doing this work. She's been pressuring the directors of Pomerado Hospital in Poway to reverse a recent policy banning vaginal births for women who have had cesareans. She wrote an editorial, which appeared in the New York Daily News on December 11, 2004. She's been quoted in New York Times stories. And recently, she got up before 4:00 in the morning to make a live satellite-linked appearance on the Today show. The message she's trying to get across is twofold. "There are two divergent trends," she says. "First is the fact that the cesarean birthrate has risen to close to 30 percent, meaning 30 percent of women who go to the hospital to have a baby will get cut. After that, they have to deal with the VBAC issue, and VBACs have gone from almost 30 percent in the 1990s to less than 11 percent."

Regarding the rising cesarean rate, Jamois acknowledges that part of the increase in cesarean births is attributable to a rise in "elective cesareans," the practice of choosing to have the baby cut out of the uterus in order to avoid the pain and recovery issues associated with natural delivery. "But that only accounts for one to two percent of all of them," she says. "It is a very small number, though it has gotten a lot of attention in the media. But that is not what is driving the high cesarean rate, in my opinion."

The driving force, Jamois says, is "an appalling lack of information given to women about the long-term risks of a cesarean.... [Cesareans] are linked to infertility, miscarriage, ectopic pregnancy, and placenta abnormalities such as placenta accreta, which is when the placenta embeds into the scar tissue in the uterus [from a prior cesarean] and even grows through it. The [pre-surgery] informed-consent documents that women get at the hospital usually pertain to the risks that day of surgery -- blood loss, infection, that sort of thing -- but they don't go into long-term effects. It is not an optimal thing; it is much better not to have one. [Cesarean birth] is definitely life-saving in the right circumstances; it is just overused. The World Health Organization says there is no reason for any region of the world to have a rate higher than 10 to 15 percent. Right now we are pushing 30 percent; some states are well over 30 percent. In California, we are slightly above the national average; we are at 27.9 percent. The national average is at 27.6 percent."

Regarding the decreasing post-cesarean vaginal birthrate, Jamois blames malpractice insurance carriers who see the procedure as more likely to end in lawsuits than cesareans. The irony is that it was insurance companies who fueled a rise in VBACs a decade ago. "In the '90s," she explains, "a lot of health insurance companies were putting pressure on doctors to offer it. It comes back to money, because VBACs are cheaper.... So you've got medical insurance companies and malpractice insurance companies controlling this issue, and it's really got nothing to do with the woman."

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— Tonya Jamois, a housewife from San Marcos, leads an international grassroots movement battling the medical establishment. Dressed in tennies and a raspberry-colored velour track suit, she sits in a purple armchair in the corner of a Starbucks in San Marcos with her legs curled underneath her. She answers questions in a voice that's hard to hear over the din of blenders and milk steamers.

Jamois is a fierce fighter when it comes to cesarean births and promoting the practice of helping women who have had cesareans giving birth to their next child vaginally. This practice, known as VBAC (pronounced VEE-back), an acronym for vaginal birth after cesarean, is falling out of favor with obstetricians and their malpractice insurance carriers.

Jamois is the president of International Cesarean Awareness Network, founded in 1982, she says, "to improve maternal child health by preventing unnecessary cesareans through education, to provide support for cesarean recovery, and to promote VBAC." But she wasn't even aware of the group's existence when her son was born cesarean in 1999. "Starting a week or two before my due date, I started getting pressure to induce, I really didn't understand why, and I resisted it," explains Jamois. "Ten days after my due date, I did go into labor and showed up at the hospital thinking I was really quite far along, and I was only one centimeter. And the hospital offered me an epidural right there, at one centimeter [of cervical dilation]. I wanted to do it naturally, because my mom did it, my grandmom did it; why shouldn't I? But I was completely unprepared, and so at two centimeters, I went ahead and took them up on the offer of the epidural, which put me flat on my back, and I couldn't push him. They tried all they could do to get him with the extractor, the vacuum, and all of that, but they told me that my pelvis was wide enough but not tall enough for the baby to come out. His heart rate took a few dips, so off we went to the operating room because at that point it was considered an emergency. But it could have been avoided. Had I been thoroughly prepared and had I not had an epidural."

A year later, when she found out she was expecting her second child, Jamois resolved to have the baby naturally. "I didn't want to have another cesarean," she says, "and looking at my experience, I knew my best chances would be if I wasn't hooked up to monitors and was able to move around and have a little bit more control over the situation. So I went and interviewed another obstetrician who was really kind of hostile when I asked about her cesarean rates and the way she practiced. So then I decided to call the Best Start Birth Center, which is the only freestanding birth center in San Diego. It is down in Hillcrest, and I lived up here in San Marcos, but I thought it was worth it to drive down to Hillcrest. And they told me that because of new guidelines put out by the American College of Obstetricians and Gynecologists, they couldn't do VBACs at the Birth Center anymore. They said they were really sorry; they had never had a problem with VBACs, but their obstetricians wouldn't back them up anymore because of these guidelines."

The College of Obstetricians' guidelines state that VBACs ought not be performed unless an obstetrician is on hand for the entire labor. Normal practice is for the mother to labor under the care of hospital nurses and the doctor to show up for the final pushing and delivery.

Jamois gave birth to a daughter vaginally in 2001, and her life became very busy, not just because of the new baby, but because she became increasingly involved with the International Cesarean Awareness Network "because," she says, "I wanted to help educate other women on the birth issue -- not only the politics behind VBAC but also safety, so they could make informed decisions. I started a San Diego chapter of ICAN in 2002 and then was asked to join the board of directors for the national organization shortly thereafter. And now I am the president."

Jamois says she spends about 40 hours per week doing this work. She's been pressuring the directors of Pomerado Hospital in Poway to reverse a recent policy banning vaginal births for women who have had cesareans. She wrote an editorial, which appeared in the New York Daily News on December 11, 2004. She's been quoted in New York Times stories. And recently, she got up before 4:00 in the morning to make a live satellite-linked appearance on the Today show. The message she's trying to get across is twofold. "There are two divergent trends," she says. "First is the fact that the cesarean birthrate has risen to close to 30 percent, meaning 30 percent of women who go to the hospital to have a baby will get cut. After that, they have to deal with the VBAC issue, and VBACs have gone from almost 30 percent in the 1990s to less than 11 percent."

Regarding the rising cesarean rate, Jamois acknowledges that part of the increase in cesarean births is attributable to a rise in "elective cesareans," the practice of choosing to have the baby cut out of the uterus in order to avoid the pain and recovery issues associated with natural delivery. "But that only accounts for one to two percent of all of them," she says. "It is a very small number, though it has gotten a lot of attention in the media. But that is not what is driving the high cesarean rate, in my opinion."

The driving force, Jamois says, is "an appalling lack of information given to women about the long-term risks of a cesarean.... [Cesareans] are linked to infertility, miscarriage, ectopic pregnancy, and placenta abnormalities such as placenta accreta, which is when the placenta embeds into the scar tissue in the uterus [from a prior cesarean] and even grows through it. The [pre-surgery] informed-consent documents that women get at the hospital usually pertain to the risks that day of surgery -- blood loss, infection, that sort of thing -- but they don't go into long-term effects. It is not an optimal thing; it is much better not to have one. [Cesarean birth] is definitely life-saving in the right circumstances; it is just overused. The World Health Organization says there is no reason for any region of the world to have a rate higher than 10 to 15 percent. Right now we are pushing 30 percent; some states are well over 30 percent. In California, we are slightly above the national average; we are at 27.9 percent. The national average is at 27.6 percent."

Regarding the decreasing post-cesarean vaginal birthrate, Jamois blames malpractice insurance carriers who see the procedure as more likely to end in lawsuits than cesareans. The irony is that it was insurance companies who fueled a rise in VBACs a decade ago. "In the '90s," she explains, "a lot of health insurance companies were putting pressure on doctors to offer it. It comes back to money, because VBACs are cheaper.... So you've got medical insurance companies and malpractice insurance companies controlling this issue, and it's really got nothing to do with the woman."

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