In early March, the National Institutes of Health convened a special consensus conference panel to craft an official statement reflecting expert assessment of current data on and access to vaginal birth after cesarean (VBAC). The panel concluded that VBAC is a safe alternative to repeat cesarean for most women and that most women opting for one do so successfully. It also acknowledged that women face unacceptable, non-medical obstacles to avoiding repeat cesarean surgery.
The panel explored causes for the plummeting VBAC rate since the first 1980 NIH VBAC panel recommended providing women with access to a trial of labor (TOL) after a previous cesarean. Beginning in 1996, VBAC rates started and have continued to decline to fewer than one in ten women.
Given cesarean section has the potential to save a woman and / or baby’s life, why are VBAC rates of interest? Because cesarean section is over-employed – meaning the risks are too often greater than the perceived potential benefits. These risks increase with each surgery and stretch beyond postpartum recovery.
After eleven consecutive years of growth, the national rate for cesarean section reached 31.8% in 2007, double what it was a decade ago. These outcomes run counter to national and international health guidelines recommending a rate of 15%. While primary cesareans drive the growth, repeat cesareans and the lack of alternatives play a significant role. Inaccessibility to VBAC also has significant but generally unacknowledged implications for women’s reproductive rights.
Access to VBAC is critical to restoring cesarean section to its role as an intervention of medical necessity. Fortunately, Lane County women have access to providers and locations in which VBAC receives proper support.
The second NIH VBAC panel unfolded against a backdrop of growing concern about the connection between over-use of cesarean section and maternal mortality. The Joint Commission, the leading health care accreditation body, recently issued Preventing Maternal Death highlighting preventable errors specific to cesarean section: (1) failure to pay attention to vital sings following Cesarean section and (2) hemorrhage following Cesarean section.
On the heels of the Joint Commission alert, news broke that a special California task force found mortality rates for California women dying from causes directly related to pregnancy tripled in the past decade. (ABC News coverage) According to task force investigator Elliott Main, MD as reported to California Watch:
it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.
So, why the VBAC slump?
In the past decade, at least a third of hospitals have implemented official policies banning VBAC. Additional hospitals have no specific ban but also have no physicians willing to attend one. Official and de facto bans are generally attributed to legal, non-medical concerns:
- Hospitals desire to avoid high-dollar lawsuits in the event of a catastrophic uterine rupture. (Uterine rupture has been found to occur at a rate of less than one percent.)
- Insurers raise malpractice premiums for providers offering VBAC.
- Health care facilities are incapable of adhering to the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists 2008 recommendation that VBAC occur only in facilities capable of maintaining an emergency response team. Obstetric procedures with comparable risk regularly occur in facilities incapable of retaining such a team.
What should be done?
The NIH recommends that hospitals, maternity care providers, liability insurers, consumers and policymakers collaborate to remove barriers to VBAC as follows:
- Medical providers should reconsider the litigation-wary policies blocking women from a real choice between vaginal and cesarean birth
- Doctors are encouraged to facilitate informed consent through the provision of unbiased, evidence-based information about the risks and benefits of repeat cesarean and VBAC
- The American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists are encouraged to reassess the requirement for emergency responses teams
- Healthcare organizations and providers ought to make transparent their TOL policy and VBAC rates
- Policymakers and liability insurers must develop pathways to eliminate the damaging effect of the medical-legal environment on access to care
As mentioned in the “about” section, I am working toward a childbirth educator credential. As I fulfill written requirements, I will post them here. Up next? Analyses of VBAC research. These write-ups might be useful to women beginning to contemplate the path to birth following cesarean.
In the meantime, you might peruse NIH panel coverage in the mainstream coverage:
National Public Radio
The Los Angeles Times
The New York Times