Debra Pascali-Bonaro: I hope you’ve been enjoying our mini series about Gentle Cesarean Birth. Today, we’re going to talk about VBAC. VBAC stands for Vaginal Birth After Cesarean. I have so many clients who just assume that once a cesarean birth is always cesarean birth for the next baby or babies. But that’s not true. My guest today is going to share the facts, discuss the myths, and how her birth lit a fire for VBAC education. 

Hi, I’m Debra Pascali-Bonaro, Founder and Director of Orgasmic Birth, and host of the Orgasmic Birth Podcast. I am truly honored to have Jen Kamel who’s the CEO and Founder of VBAC Facts whose mission is to increase access to vaginal birth after cesarean. VBAC Facts works to achieve this mission through their educational courses for parents, online memberships for professionals, and continuing education training and consulting services. As an international recognised consumer advocate, Jen speaks at conferences across the world. Presents at Grand Rounds at hospitals, advises on midwifery law and rules that limit VBAC access. She educates legislators and policymakers, and serves as an expert witness and consultant in legal proceedings. VBAC Facts envisions a time when every pregnant person seeking VBAC has access to unbiased information, respectful providers and community support so they can plan the birth of their choosing in the setting they desire. I know you’re all in for a treat, because I’ve been following Jen for years, and your wisdom has really inspired me. 

So welcome, Jen. Such an honor to have you join us today.

Jen Kamel: Thank you so much. I really appreciate that. Hearing you read the vision of VBAC Facts, it still gives me goosebumps. This is my 17th year doing this work. And that is the vision. That is what we’re working towards. We’re working for everyone to have access to accurate information and respectful care. I’m really excited to be here and talk about one of my favorite topics, VBAC.

Debra Pascali-Bonaro: Well, thank you. I always ask my guests to start, because I know that we ended up with this passion because something was personal. I’d love it if you’d share just a little bit about that personal journey with your own birth with us.

Jen Kamel: Absolutely. My first birth, let’s go all the way back. So I was always curious about childbirth. I was that kid who was reading books about childbirth and child care as a very young child. And so when I was pregnant with my first, I was excited. I plan to have a hospital birth with a certified nurse midwife. I was expecting a completely normal, healthy pregnancy. And then late in my pregnancy, my baby was breech. I had an external cephalic version where they tried to turn the baby into a head down position, and that didn’t work. And so I left that procedure with a piece of paper that had this date where my baby was going to be born, and I was just so sad. I was a complete weirdo in many ways that I was excited to experience birth. I had heard so much about it, and I was really curious, what was it going to feel like? What was it going to be like? And so to have all of that taken away was really upsetting. But I was very grateful that my OB planted the seed that VBAC was an option after my cesarean. He said, you had a C section for breech, there’s no reason why you can’t go have a VBAC the next time. And that was an important piece of information. Because when I left that hospital, and I’m sure so many of your audience, so many of the people listening have experienced the same thing. Once you have your C section, you go home, and everyone’s like, oh. But next time we’ll be so easy. You can just have another C section and I was like, well, no, my doctor said I’d be a great candidate for VBAC. And people looked at me like I didn’t care about the safety of my baby. And I was like, okay, so what am I missing? My OB says I’m a great candidate. He says, this is a great option. I was so fortunate to have him plant that seed early on, because that’s what really enabled me to counter my friends and family and say, no, this is an evidence based option. So that’s really started my journey. I was pregnant with my next baby. Had a wonderful victory at VBAC. Came out of that with the knowledge that there was nothing in this world I couldn’t do. That is the power of transformation, and that’s not something you can only get through birth. There are so many challenging things that we can all endure in our lives. But for me, that was one of those moments for me. I am powerful, I can do anything. 

Back up a little bit. After my C section, I hadn’t encountered firsthand how difficult it was to collect accurate information. I saw so many parents and so many birth professionals saying things, and I just started to collect information for my own clarification. And after my VBAC, the injustice in the birth system really crystallized for me how many people are denied this transformational opportunity. How many people are denied access to evidence based care? How many people are completely misled and taken advantage of in the most vulnerable times of their lives? And so two weeks postpartum for my VBAC, I started looking into things like, how can I help? I registered VBAC Facts as a domain, and I got to work. I started sharing the information that I was collecting. Few years later, I started speaking around the country. I became a nursing continuing educator and on, and on, and on. An expert witness and legal cases, I worked on policy across the country. I am a VBAC subject matter expert, and this is my passion because everyone is entitled to respectful care and accurate information. And that’s what we’re there to provide.

Debra Pascali-Bonaro: Jen, oh, my goodness, your story from having that first cesarean to really following your passion for a VBAC, and putting it into such action. Oh, my goodness. You really can feel it coming across the screen. To those listening, can you guide us because you’ve done so much work, so much research, what are some basic facts about VBAC?

Jen Kamel: I think one of the main things is that VBAC is often seen as some alternative choice. People get this notion that, well, the evidence weighs this way and that way. Sometimes, VBAC is hot. And sometimes, VBAC is not. It’s not really something that science based people choose. But I’m here to tell you that the evidence has supported VBAC for decades. And yes, we’ve learned more about the rising risks associated with repeat cesareans. But the back has always been a reasonable choice. The risk has always been low. Medical ethics has always supported your right to decline a repeat cesarean. So it’s just there as a distortion that happens when we look at medical research and national guidelines, and what those things actually say. And then the little news bites that the public receives. The biases that many physicians have that impact how that research and those national guidelines are communicated to the public. And so even now, even 17 years after my C section, when VBAC has been supported by national guidelines, supported by medical evidence, people are still told, well, next time you can just have a C section. Don’t worry, that’s the safest choice. And that’s just not true. VBAC is a safe, reasonable and evidence based option. 

And most importantly, well, maybe not most importantly, but I was going to say it’s mainstream. I don’t like how VBAC is described as an alternative. It’s not an alternative medicine. It is an evidence based choice that is solid in the evidence. So if you are curious about VBAC, come join us at VBAC Facts and learn more. I want to say another big myth is the risks associated with VBAC are low. So I phrased that a little bit weird. The risks associated with VBAC are low. That is not a myth. That is the truth. And just like a repeat cesarean, most people will birth their baby with no complications. So this idea that if you plan a VBAC, you know this is an excessively risky choice. It’s just not some other basic information. The risks of VBAC are generally exaggerated, and the risks of cesareans are generally minimized. Another thing is that most people are candidates for VBAC. You hear a lot about VBAC candidacy. Who can or cannot plan a VBAC? I say that everyone has a VBAC candidate. That might rock the world to some of the listeners here today, but everyone is a candidate for VBAC. Why do I say that? Because fundamentally, who makes medical decisions? Is it the birthing person? Is it that woman? So what is the role of the provider or the clinician? Their role is to provide risks, benefits, and also a recommendation. So here are the risks and benefits based on the science. Here’s your individual situation. So here’s what I recommend you do. But then who makes the ultimate decision? Is that a woman or birthing person? So when we talk about VBAC candidacy, who decides if you’re a candidate for VBAC? It’s you. It’s your birthright. You are the one who has that right. And even if your provider says, well, hey, look, the risks are unknown. Or the risks are excessive. Or the risks are really high. You still have the right to make that decision. 

Now with that responsibility also comes ownership of the outcome. Because I think part of why we see so much litigation, especially about obstetrics and VBAC in particular, is that OBs hold themselves out like, I am the one who will save you. Do what I say, and I will save you. And the problem is that there are times that when someone has a uterine rupture, even with the best care, they can have a bad outcome. No one can guarantee how your birth is going to play out. So that locus of control, that locus of responsibility that needs to be with the birthing person, yes, you can make this choice associated with higher risk. And yes, you are also the one who owns the outcome. And your provider, your clinician will do everything they can to ensure that in the event of an emergency, you get the best care, but there are no guarantees. So this is the push and pull that we see up play when we’re talking about litigation. Who owns the responsibility? Who owns the power? And I think that if we move the locus of control from the clinician to the birthing person, we’re going to see more people taking charge of their own health care, and more people taking responsibility for their own health care. And when physicians reposition themselves from Gods to lifeguards, I am here to support you, I am here to keep you as safe as possible, but I’m also not going to force you to do anything that completely changes the dynamic. And this is a huge social change. That is not going to happen overnight. But I think as more and more people consider this new perspective, we might see an opportunity for more respectful care, less paternalistic care, less lawsuits, and possibly even better outcomes because we’ll have more people choosing VBAC. More people having access to VBAC, and thus will have fewer people subject to the complications, the rising complications with multiple repeat cesareans, which include things like placental abnormalities, hysterectomy, ICU admission, blood transfusion, and also maternal mortality. I kind of went off there a little bit.

Debra Pascali-Bonaro: That’s perfect. Your passion comes out, and you give so much information. I love your quotes there, to go from Gods to lifeguards, because I think that just really said so much. And I agree with you. We’re at this time that personal responsibility is so important, and we’ll make such a difference. But for people who are listening, maybe who are pregnant and kind of debating, you gave them a good handful of some of the risks of repeat cesarean, can you help them? What are a few things they could do if they gather the data you’ve shared that VBAC is safe? What can they do? What would you recommend a few things they prepare?

Jen Kamel: I think one of the most important things is to get the facts so you can make an informed decision. So come join up with us at VBAC Facts. We’ve got lots of free resources. We also have courses for parents if you want to dive deeper, and you want to have me just personally guide you through everything. I wish I knew after my cesarean and everything that I’ve learned the most important things I’ve learned in the 17 years. Actually, it’s been almost 20 years since my C section. There’s a lot that I’ve learned and wish that I had the opportunity to have someone hold my hand and walk me through why hospitals banned VBAC. What are the most important things to consider when you’re looking at VBAC and repeat cesarean? So that’s one step. Another step is once you do that, think about who you want on your birth team? Do you want a doula? Do you want a midwife? Do you want a community birth? Are there wonderful physicians in your community who really support VBAC? Go over and interview them. Ask them questions. We have a whole list of questions at vbacfacts.com/questions. But I think the most important question to ask is, how do you feel about VBAC? Just let them talk, watch their body language, look at what their face looks like. Do they stiffen up? Do they get all hard? Or are they like, yeah, VBAC is a great option. Let’s talk about your options and have them speak. And the other question that I get a lot is, how can I find a supportive VBAC provider in my area? 

Well, in the next few months, we’re revamping the website vbacfacts.com. It’s going to be beautiful, and it’s also going to include a list of the professionals who have completed our training. So you can go to vbacfacts.com. Look at our provider or clinician database, not quite sure what we’re going to call it. We’re probably going to call it like a birth professional database or something like that. Look and see who is in your area and then call them and say, hey, I want a VBAC. Can you help me, direct me to a VBAC supportive provider? If you don’t have someone who’s completed one of our trainings in your community, the next best thing would be to call your local hospital, ask for the L&D charge nurse and say, hi, I’m planning a VBAC, and I wanted to know which midwife or physician at your facility are most supportive of VBAC. And just listen. We don’t need a list of questions to see what people feel. You will immediately tell from the tone of their voice and how they respond. Are they supportive of VBAC? Or are they now going to be like, oh, yeah, no one does VBAC here. Or we have a VBAC ban. Okay, you’ve got your answer. But if they say they do have a physician or midwife who’s really supportive, the next question is, and this one is key. So when I come into the hospital and labor, what nurse should I ask for? Who’s really excited and passionate about the VBAC? That way, you already have the name of someone in mind. Maybe you can ask for the next second best person, and you already have a couple names. So when you go into the hospital, you can already ask for Lexi or Kristen and say, I heard that you’re really supportive of VBAC. And I would love it if you could support me during this labor. You immediately have someone on your team. So those are some really important tips. So I think I mentioned a few. 

Another hot tip is disregard what you hear from unsupportive people. And this is a real challenge because your aunt Susie’s got an opinion, the cashier at Targets got an opinion, everyone’s got an opinion, your boss has an opinion. But how many of those people actually know what they’re talking about? Or are they just sort of regurgitating the conventional wisdom we see in our society about what people should do after they have a prior cesarean. So once you have the facts, once you have confidence in your information, you have confidence in your decision. You don’t need to justify that to anyone. It’s not your job to educate the world unless you decide it is. And if you want to take that on, you do it. But don’t feel that publication when you’re pregnant, you have enough going on. And I think this is like a larger issue, particularly in women of our need. And I’ll speak for myself, my past need of needing to justify my decisions to other people. Here’s the thing, I don’t have to justify anything to anyone. That’s my business. And I think a lot of women fall into this trap of like, well, I need everyone to understand why I’m doing what I’m doing. You don’t. It’s none of their business. You can just say, you know what? It’s really surprising. My midwife or my OB really supports VBAC, and that’s because it’s an evidence based choice and it has been for years, can you believe that? I think a little bit of humor can go a long way in terms of defusing people. And then if they want to learn more, you can just say, go to vbacfacts.com. Learn more, and take that load off your plate because you don’t need to be taking that on. You’re busy, right? You’re busy raising a baby, you might have several other children run around, you might be working outside the home, you might be busy baking bread. I’ve done all those things. All of those things are hard work, and you’re growing a baby on top of it so don’t feel like you have to educate the world.

Debra Pascali-Bonaro: Great advice. So many good nuggets there. So I hope everybody listening, you may have to go back and re listen to those. I want to take you deeper. I’m in New Jersey, and so it’s really interesting that I literally live on the border in New York State. This is where you kind of talked about what we have in policy, what we have in science doesn’t line up and I sit literally that a mile to the north of me. We can have home VBAC. And where I live just a mile away, we cannot. Where people can VBAC? Can vary greatly by state lines. Can you talk about that and the accessibility to VBAC?

Jen Kamel: There are so many layers to this. First, when we talk about VBAC, how can midwifery legislation vary so much by state lines? Well, the American College of OB GYN has hundreds of thousands of dollars set aside quarterly to work on to hire lobbyists. And one of the things that they have worked tirelessly on is legislation, laws or regulations, rules in each state limiting a midwife’s ability to attend VBAC. And this is incredibly problematic because not only do we live in a country where we have huge swaths of area that have absolutely no maternity care providers, no hospitals, no physicians, no midwives, nothing. We also live in a country where we have huge areas that have no VBAC access in hospitals. And then we have states that have these restrictive laws and rules in terms of midwives, and who can attend a VBAC, and where all of these things come together. It not only hurts everyone who is pregnant, but it has special implications for those who are pregnant after a cesarean. And when you were pregnant after a cesarean, you’re trying to find a hospital, or a midwife, or a community birth midwife in your community. If you’re looking at hospital birth, you’re trying to find someone who takes your insurance that can also limit VBAC access. Because you might have a facility in your community that offers VBAC, but doesn’t take your insurance. Okay, so that’s a problem. And then we look at Community VBAC, insurance often doesn’t cover community VBAC. However, that is something you can work with with a biller to try to get reimbursement for that, and your midwife can certainly assist you in directing you on how to do that. But all of these factors together contribute to our very low VBAC rate nationally. Debra, do you know what our VBAC rate is nationally?

Debra Pascali-Bonaro: I was gonna ask you that right now.

Jen Kamel: Okay. So your best guest, what percentage of people do you think have a VBAC in our country? In the US?

Debra Pascali-Bonaro: I would guess 10% of all the people that are eligible to VBAC.

Jen Kamel: Right now, the rate is 14%.

Debra Pascali-Bonaro: Okay, a little better than I thought. A little bit better.

Jen Kamel: It’s still terrible. I was actually just doing some research for our vaginal birth after classical cesarean training that I have up in professional membership. So vaginal birth after classical cesarean, and I was reviewing that, and I’m going to integrate it into our existing training. But one of the things that I learned within the process of reading the study which is based out of Denmark is that the Denmark lack rate. So the number of people who labor after a cesarean, if we have a 14% VBAC rate in the US, that means we have about 20% labor after cesarean rate. So that’s the number of people who plan a VBAC. So about 20% in the US, I think it’s 19.6%, actually. So when we look at Denmark, 69% of people labored after a cesarean versus 19%. The US, we taught ourselves, oh, we have the best health care system. I have news for you. If the bubble hasn’t already popped for you. Here’s the truth, we do not have the best health care system. Because when you have an evidence based option and only 19% of your population exercise that right to that option, that’s telling you that there’s a lot of barriers keeping them from being able to plan a VBAC. And especially when we look at countries like Denmark where the planned VBAC rate is 69%. That gives us an idea of what it could look like. And it gives you an idea of how far off the mark we are in the US because of things like litigation concerns and misinformation. So I have lost my train of thought, and I can’t remember what your original question was.

Debra Pascali-Bonaro: Fantastic, because there’s so much here. I was asking about the variation between state to state. It shows us that we’re not evidence based, but also as you did such a good job. It is so much about laws and regulations, and variation. And I love the Denmark study.

Jen Kamel: Oh, my gosh, I’m so excited to share that with my professional members because there’s so much good stuff in there. It’s all like technical ICD-10 Coding in terms of uterine rupture and how we code that into national registries, and then researchers will pull that data out. The problem is, as I uncovered uterine dehiscence which are asymptomatic and do not pose any threat to either the birthing parent or the baby are often coded as uterine ruptures. So when researchers pull research out of these databases and they report uterine rupture rates, they are reporting drastically inflated uterine rupture rates, which is why it’s so important. One of the things to look at when you’re looking at medical research relative to VBAC is to look at medical research that relies on medical records, not on these large databases. Now, of course, we love large databases, right? Because especially in terms of vaginal birth after classical cesarean, we don’t have a study that has enough people in order to really make that study’s conclusions strong. So we look at these large databases so we can pull data out of it, and we can come up with these conclusions about risk. But the problem is, and I’ve always been aware of this coding issue with databases, but I had no idea. It was so significant in terms of uterine rupture.

Debra Pascali-Bonaro: Thank you. Well, you’ve given us so much to think about. I’m going to ask you if there’s one more thing you want to share for all the people that are learning about VBAC today?

Jen Kamel: I would say that it’s very likely what you think the research says about VBAC is wrong. I say that to not only parents, but also professionals. I have had countless professionals go through my professional membership, including doulas and labor delivery nurses and midwives. And one nurse in particular said, I cannot believe how comprehensive this training was relative to the training that she received about VBAC in her nurses training. Because how she was taught was that VBAC was excessively risky, and it wasn’t a very safe option. And so when you learn this in an academic setting, it absolutely colors how you view VBAC when you go out into the world. And so that’s why I provide professional membership as a counterpoint. We go through the research, and you can tell how passionate I am about it. I super geek out over medical research. I was actually with a group of people a couple of weeks ago and I said, I love reading medical research. And someone else said, you do? And I was like, yes, I do. And seeing if you attend my training, this same level of enthusiasm, and it’s like I take you through the story. I transform medical research from something dry, academic and full of medical jargon. And I make it accessible, interesting and fascinating. And so that is how our training differs from other training. they’re engaging the energy that I bring, the curiosity that I pull out of you, that is what drives the continuing education, and it becomes something so much more than like, reading the summary and taking a test. You come away understanding this topic top to bottom. And that is what we need if we’re going to increase VBAC access in our country.

Debra Pascali-Bonaro: Yes, definitely. Well, Jen, we are blessed to have you. I know all our listeners want to know more. You’ve said vbacfacts.com, but tell us what they do, especially for people that are pregnant, where they can find you there? Can they find you on social media? What do you have for them?

Jen Kamel: So vbacfacts.com is our website. You can learn more about our course for parents called The Truth About VBAC for Families. You can also book a one on one call with me. I am not a clinician, however, I am someone who is intimately knowledgeable about medical research. I’m also someone who has been there. I have had a C section, I have felt all the things that some people feel about their C sections. I had a VBAC. I’ve walked that journey, and so I’m someone who you can debrief your birth with. I’m someone who can review your list of questions. I’m someone who gets it. So go to VBAC Facts for that. You can schedule those consulting calls, you can learn more about our classes. We also are on Facebook, Instagram and LinkedIn. That is, frankly, as much social media as I can handle right now. Everyone’s like, you should be on TikTok. It’s like, I don’t know, maybe someday. Here’s the deal. I want to get information out to people, and also social media can turn into such a time suck. I’m here answering questions on social media, but what drives my business is reading the research and getting that out to people. So there is always this push and pull of trying to reach people, but also conserving my time and energy for actually doing the work so I can broaden my knowledge, and I can bring that back to people.

Debra Pascali-Bonaro: Thank you so much, Jen. This was so informative, such a pleasure. It was an honor to have you here. And to all our listeners, please, we’d love to hear from you. What are your questions, your takeaways, tag us all on social, or reply to us at our email, or reach out to Jen. She’s the expert on this. So we really appreciate you being with us today. And to all our listeners, thank you for following us. We hope that you’ll like this podcast, leave and rate, and leave a review. It makes such a difference for us and helps us reach more people so they can positively prepare for birth. And we hope you’ll join us for the next episode of the Orgasmic Birth Podcast.