Once a Caesarean, Always a Caesarean? National Institutes of Health says not necessarily.

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Once a Caesarean, Always a Caesarean? National Institutes of Health says not necessarily.

The number of women giving birth vaginally after a previous Caesarean section delivery has declined almost 20% since 1996, contributing to the dramatic rise in our national C-section rate. The National Institutes of Health (NIH)—the primary U.S. agency charged with conducting medical research—organized a conference this week to look at the reasons for this decline. At the conference, an independent panel looked at reports, listened to experts, and issued a statement based on their findings. The panel’s statement concluded that given the evidence available, vaginal birth is a “reasonable option” for women who previously delivered a child via Caesarean section. This is an exciting development for those concerned that C-sections are being overused to the detriment of maternal and infant health.

The NIH panel states that because both repeat caesareans and VBACs carry risks—the most serious being the former’s increased risk of maternal mortality and the latter’s increased risk of uterine rupture—expectant mothers should discuss their individual situation in detail with their caregivers. Caregivers are encouraged to use evidence-based information when consulting with their clients, in light of studies that show how much women’s decisions are influenced by their providers.

One of the major reasons fewer women are having vaginal births after caesareans (also called VBAC) is that it has become harder to find a care provider willing to assist at these births. According to surveys the NIH panel consulted, 50% of physicians and 30% of hospitals do not offer VBAC. When these doctors and hospitals are asked why they don’t provide VBAC, they mention their fear of malpractice lawsuits and point to guidelines issued by the American College of Obstetricians and Gynecologists (ACOG).

While ACOG used to encourage VBAC, in 1999 they issued practice guidelines stating that women who had a prior caesarean should be offered the opportunity to labor vaginally only if there are no contraindications, if they labor in an institution equipped to deal with emergencies, and if physicians able to perform C-sections are “immediately available.” In a 2008 statement issued jointly with the American Society of Anesthesiologists, ACOG reiterated these guidelines and added another recommending that obstetric anesthesiologists also be immediately available. Because many physicians and hospitals could not fulfill these recommendations, they stopped offering VBACs.

In a very hopeful move, the NIH panel’s statement calls for ACOG and the American Society of Anesthesiologists to reevaluate their recommendations. The panel also encourages hospitals, insurance agencies, consumers, and policymakers to collaborate in an effort to reduce barriers to women who want to attempt VBAC.

While it’s wonderful that the NIH is promoting ACOG guideline review and a more informed decision-making process for expectant mothers, it is troubling that they do not unequivocally support a woman’s ability to decide what happens to her in all situations. “Whenever possible, the woman’s preference should be honored,” they write—the concern here being with the “whenever possible.” Why should a woman’s fully informed decisions regarding what happens to her body ever NOT be honored? When asked by attorney and birth activist Susan Jenkins why the panel did not take a position affirming the mother’s right to informed refusal in all situations, the ethicist on the panel responded, “The claim that the right to refuse is absolute is a controversial claim, it’s not at all settled in the law or medical ethics….[and it] is way beyond the scope of this group.” (Thanks to Courtroom Mama at the Unnecesarean for her transcript of this interaction: http://www.theunnecesarean.com/blog/2010/3/10/nih-vbac-consensus-develop…).

This gets to the root of many of the problems with current maternity care: while experts are willing to recognize the role women must play in making decisions about their care, they are not willing to cede ultimate authority over what happens in the birth room to women. What is the message we send our mothers if we say that it’s important that they be informed—but don’t trust them enough or give them the power they need to make final decisions with that information?

This question becomes even more charged when examined through the lens of race and class inequities. As with other areas of maternal health care, access to VBAC is skewed demographically. The panel notes that Hispanic and African-American women are less likely to deliver vaginally after a C-section than non-Hispanic white women. Older women, women with less than 12 years of education, and women who deliver at rural hospitals also have a decreased likelihood of VBAC. What are the chances that a care provider’s estimation of each patient’s intelligence and fitness to be a mother—based on his or her own personal prejudices or those of the institution he or she works for—will influence his or her presentation of the risks and his or her willingness to accommodate each mother’s preferences? Unless the NIH proposes specific remedies, its panel’s recommendations are likely to impact VBAC rates across the board without correcting these discrepancies. That is, the groups that currently have the highest rates of VBAC will continue to have most access to this care—while those with lower rates will continue to lag behind.

Thanks to wide news coverage of the NIH panel’s recommendations, more women across the country who have had C-sections now have the information (and hopefully therefore confidence) to pursue vaginal birth for future deliveries. What kind of impact do you think this will have on the VBAC rate in the U.S.? What additional steps do you think are necessary to achieve a higher VBAC rate for all women regardless of race, education, age, and geographic location?

For more information, please see:

NIH’s full statement: http://consensus.nih.gov/2010/vbacstatement.htm

NIH press telebriefing: http://consensus.nih.gov/2010/vbacmedia.htm.

The New York Times: http://www.nytimes.com/2010/03/11/health/11birth.html

NPR: http://www.npr.org/templates/story/story.php?storyId=124559259.

The Unnecaesarean blog:

AlterNet blog: http://blogs.alternet.org/speakeasy/2010/03/11/once-a-cesarean-rarely-a-…

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