VBAC.com

This week the Centers for Disease Control and Prevention released their report  on preliminary data for 2010 births in the United States. There were 4,000,279 births in 2010, 3 percent less than the year before. The cesarean section rate declined slightly from 32.9 percent to 32.8 percent, the first decline in cesareans since rates started climbing in 1996. Seventeen states and the District of Columbia however, had a higher cesarean rate in 2010 than in 2009.

Recently, there has been a long-awaited call by academics, healthcare quality improvement groups, business groups, hospital associations and state lawmakers to bring down the number of cesareans. To reduce the number of maternal and newborn complications associated with the surgical procedure as well  reduce healthcare costs.

Some in the medical community are also trying to increase access to VBAC by redefining ACOG’s restrictive recommendation to have a surgical team “immediately available” for all women laboring for a VBAC regardless of their risk status. Although there is nowhere near agreement about what the ideal cesarean rate should be, there is an increasing awareness that mothers and newborns should not be subjected to unnecessary health risks associated with the operation when health outcomes are not improved.

More than 4 out of 10 births in the U.S. are paid for by Medicaid  and shrinking state budgets make cesarean section, a high-ticket item,  a logical focus of expense cuts. In 2009 the average cost of a cesarean section ranged from $13,000 to $20,000 compared to $11,400 for a vaginal birth.

Research has shown that non-medically indicated early elective deliveries (between 37 and 39 weeks gestational age)  are associated with short and long-term neonatal morbidities,  increased neonatal deaths and no health benefits for  mothers. Repeat cesarean sections puts mothers at increased risk for death.  There is now a nation-wide focus on reducing elective (medically unnecessary) cesareans before 39 completed weeks of gestation. Elective inductions before 39 completed weeks are also associated with poor birth outcomes.

According to the Leapfrog Group, a leading national non-profit organization that helps employers with value-based purchasing of healthcare, several hospital associations and state health departments have been actively working to  lower their elective delivery rates.

In an editorial in the August 2011 issue of Obstetrics & Gynecology Dr. John T. Queenan’s commentary, How to Stop the Relentless Rise in Cesarean Deliveries, warns colleagues that the U.S. cesarean rate is likely to reach 50% unless cesarean rates are reduced and access to VBAC is increased. Dr. Queenan’s recommendations for lowering cesarean rates include evidence-based patient education on the benefits and risks of cesareans, increasing the number of midwives who attend low-risk women, paying physicians a higher reimbursement rate for supporting VBAC and retraining physicians in the art of vaginal breech birth.

Despite a recommendation by the National Institutes of Health Consensus Development Conference on VBAC that ACOG should reconsider its controversial and confusing guidelines that call for an “immediately available” surgical team for all women who labor for a VBAC, current guidelines have not changed. However, some physicians are looking for ways to increase access to VBAC.

In an article by James R. Scott, MD, titled, Vaginal Birth After Cesarean: A Common-Sense Approach, also published in the August 2011 issue Obstetrics & Gynecology, Scott presents a positive and flexible approach to support women who want to labor for a VBAC without increasing providers’ exposure to malpractice suits. “We need to do what is best for the patient,” he writes despite fear of malpractice suits. This is an ethical approach to caring for women with a previous cesarean that has not been considered for more than a decade.

Scott refers physicians to the evidence-based protocols of the Northern New England Perinatal Quality Improvement Network (NNEPQIN) VBAC Project risk stratification method that hospitals can use to provide care for women who labor for a VBAC in community hospitals, dismissing the assumption that only facilities that care for high-risk childbearing women can provide safe care for VBAC.

In the September 2011 issue of Obstetrics and Gynecology Dr. Howard Blanchette of New York Medical College argues that contrary to common belief, the rise in cesarean sections has led to increased adverse health outcomes for mothers and newborns.”  In his commentary, The Rising Cesarean Delivery Rate in America: What Are the Consequences?, he urges physicians to “reduce the primary cesarean delivery rate and avoid the performance of a uterine incision unless absolutely necessary.” His recommendations for reducing the cesarean rate include promoting support for women who want to plan a VBAC and refraining from performing a cesarean on first-time mothers for failure to progress (dystocia) until they are in the active phase of labor (4 or more centimeters of dilation).  A recent Yale University study found that primary cesarean births (first cesarean) accounted for 50 percent of the increasing cesarean rate in the U.S. and that non-progressive labor was a subjective indication for performing a cesarean which contributed more than other more objective indications (such as placental problems and  malpresentation) to the increase in cesareans.

A one tenth of one percent decrease in the U.S. cesarean rate, an increased awareness of the health implications of a surgical birth and a call for fewer cesareans and more VBACs is a trend we have not seen in decades. Whether or not this trend will continue and how many years it will take to make a significant dent in the cesarean rate is yet to be seen.

How does a cesarean birth rate nearing or exceeding 50 percent impact society? What will it mean for future generations of women when in our own, many women are disconnected from their own bodies and are afraid to give birth? What does it say about our culture which takes it for granted that maternity care providers find it necessary to protect themselves first and do what’s best for their patients second meanwhile producing poor health outcomes?  What will it take to change the status quo and give the power of birth back to women? Perhaps, nothing less than a revolution. On Thursday, September 1^st watch the launch of One World Birth a free video site, online living documentary, a TV channel about birth and a feature length documentary for worldwide release.

The project creators of One World Birth are Toni Harman and Alex Wakeford. Their mission is to make birth better and safer around the world and to empower women to make informed choices about childbirth.

The documentary film begins with a quote from Thomas Jefferson. “Every generation needs a new revolution.”

One World Birth is a global cross-media film project that is also building a community of birth professionals to connect, inspire and to help deliver change. Featured in the film are world renowned birth professionals, researchers and maternity care academics including Sarah Buckley, Michel Odent, Sheila Kitzinger, Debra Pascali-Bonaro, Ina May Gaskin, Soo Downe, and Elizabeth Davis.

Using social media, the producers aim to encourage local action, campaign for policy change, press for media coverage and when the time comes seize the moment.  The trailer of One World Birth which has been on their website for several weeks has already fired up birth activists around the world to create sub-titles for the film in more than seven languages.

Co-creator Toni Harman makes the important point that; “One World Birth is also about YOU! Everyone loves hearing from the leading experts, but what makes this site even more exciting is that we want to include the midwives, doulas and campaigners who are at the front line of birth as your stories are vital to the bigger global picture!”

One World Birth gives everyone around the world who believes that change in childbirth is long overdue the opportunity to get involved and make changes in their own communities.

Cesarean section is major abdominal surgery can put mothers and babies at risk for several complications.  Pulmonary embolism, a blockage in a lung artery,  is one of the leading causes of maternal mortality.  It is caused by a blood clot in the leg (deep vein thrombosis) that breaks free and travels through the blood stream to the lungs. Cesarean section is an independent risk  factor for deep vein thrombosis.

If given the option to labor for a VBAC, about 75 percent of women would give birth normally and avoid exposure to the risks of a surgical delivery.

On August 22nd ACOG issued this press release to raise awareness about the risk of pulmonary embolism related to cesarean section and published Practice Bulletin #123 “Thromboembolism in Pregnancy” in the September 2011 issue of Obstetrics & Gynecology.

New Recommendations to Prevent Blood Clots
During Cesarean Deliveries Issued

Washington, DC — In an effort to reduce maternal mortality due to blood clots—a leading cause of maternal death in the US—The American College of Obstetricians and Gynecologists (The College) now recommends that all women having a cesarean delivery receive preventive intervention at the time of delivery. The new recommendation was released today along with updated guidance for the prevention, management, and treatment of blood clots during pregnancy.

Thromboembolism—blood clots which can potentially block blood flow and damage the organs—is a leading cause of maternal morbidity and mortality in the US. The majority of blood clots in pregnant women are venous thromboembolism (VTE), usually occurring within the deep veins of the left leg. “Cesarean delivery is an independent risk factor for thromboembolic events—it nearly doubles a woman’s risk,” said Andra H. James, MD, who helped develop the guidelines. Most women who develop clots in the lower extremities will have pain or swelling in the leg. Sometimes, clots travel to the lungs causing a life-threatening condition known as pulmonary embolism. Symptoms include sudden shortness of breath, chest pain, and coughing.

“Fitting inflatable compression devices on a woman’s legs before cesarean delivery is a safe, potentially cost-effective preventive intervention,” said Dr. James. “Inflatable compression sleeves should be left in place until a woman is able to walk after delivery or—in women who had been on blood thinners during pregnancy—until anticoagulation medication is resumed.” The College notes, however, that an emergency cesarean delivery should not be delayed for the placement of compression devices.

Pregnancy is associated with a four-fold increase in the risk of thromboembolism. Clotting problems are more common among pregnant women because of the physiological changes that accompany pregnancy, such as blood that clots more easily, slower blood flow, compression of pelvic and other veins, and decreased mobility. Other risk factors include a personal history of VTE, an increased tendency for excessive clotting (thrombophilia), and medical factors such as obesity, hypertension, and smoking.

“VTE is a major contributor to maternal mortality in this country. The risk of VTE is increased during pregnancy and the consequences can be severe,” said Dr. James. The recommendations explain how to monitor women for these events, address certain risk factors, and treat suspected or acute cases of VTE. “It’s important for ob-gyns to adopt these recommendations to help reduce maternal deaths.”

The College recommends preventive treatment with anticoagulant medication for women who have had an acute VTE during pregnancy, a history of thrombosis, or those at significant risk for VTE during pregnancy and postpartum, such as women with high-risk acquired or inherited thrombophilias. Women with a history of thrombosis should be evaluated for underlying causes to determine whether anticoagulation medication is appropriate during pregnancy. Most women who take anticoagulation medications before pregnancy will need to continue during pregnancy and postpartum.

“Because half of VTE-related maternal deaths occur during pregnancy and the rest during the postpartum period, ongoing patient assessment is imperative,” Dr. James noted. “While warning signs in some women may be evident early in pregnancy, others will develop symptoms that manifest later in pregnancy or after the baby is born.”

# # #

According to a World Health Organization report on maternal mortality, in 2010 the United States ranked 50th among 59 developed countries.

In the September issue of Obstetrics & Gynecology, Howard Blanchette, MD of New York Medical College wrote an article entitled, The Rising Cesarean Delivery Rate in America, What Are the Consequences?

He writes, “In 1998 when the cesarean delivery rate was 21.2% in the United States, the maternal mortality rate was 10 per 100,000. In 2004, with a cesarean delivery rate of 29.1%, the maternal mortality rate increased to 14 per 100,000…To reverse the trend of the rising cesarean delivery rate in America, we as obstetricians must reduce the primary cesarean delivery rate, and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications. For women with one previous low transverse cesarean delivery we must promote a trial of labor after previous cesarean delivery…We must constantly remind ourselves, Primum non nocerum (First do no harm).

Hélène Vadeboncoeur’s book, Birthing Normally After a Cesarean or Two, is written with the compassion, sensitivity and personal guidance of a mother who has herself experienced a traumatic first birth by cesarean and a second empowering and healthy normal birth. It is also written with the credibility of evidence-based research. Vadeboncoeur does not pass judgment on women’s choices and chooses to use the word “normal” simply as a substitute for vaginal birth. Written specifically for mothers, this comprehensive, well-researched and well thought-out book can also be a valuable resource for midwives, nurses, childbirth educators and doulas. Vadeboncoeur’s book was originally published in French.

Dr. Vadeboncoeur searched long and hard through her personal journey to better understand what led to the cesarean birth of her first child and why that experience impacted her life so profoundly. Her pursuit of a Ph.D. after the birth of her children was in great part a means to conduct research into the maternity care system and the high rate of cesareans .  Although it was challenging for her to find a care provider to support her wish for a normal birth in her second pregnancy, she found that experience to be transformational. That is why she wants women to know that it’s possible for them to avoid a routine repeat cesarean and have a safe normal birth.

The book begins with an assessment of the historical and current perspective on cesarean and VBAC. How the beliefs of the day regarding the safety and indications for cesareans have changed in the last three decades and how widespread non-medical indications for cesarean have increased the cesarean rate. Cesarean section, the most common major operation in the world is examined within the current climate of fear of childbirth, the undervalued process of normal birth and the highly charged medico-legal climate in the United States.

The author believes that birthing decisions  should be made by women and their partners and writes in her Introduction, “We women need to have our say because we’re the people most immediately affected by birth.” Vadeboncoeur’s respect for women’s autonomy and empathy for each woman’s  personal journey towards making a decision about how she wants to give birth is reflected throughout the book.

She presents factual information and her personal point of view without judgement. Her guide offers women a balanced view of the benefits and risks of repeat cesarean and VBAC. Even women who decide that a repeat cesarean is best for them can benefit from the advice given about how to have a satisfying cesarean birth.

Mothers considering a VBAC will get an honest estimate of the level of risk  that they are likely to face and how likely they are to give birth on their own.  The author also covers a wide range of issues that are likely to affect a VBAC – having had one or more cesareans, the time interval between the current pregnancy and the prior cesarean, whether or not labor is induced, having had a vaginal birth and if single or double layer sutures were used to close the cesarean incision.

Dr. Vadeboncoeur makes a convincing case  for why it’s worth the effort to consider a normal birth after a prior cesarean. Overall, VBAC is safer for women than major abdominal surgery especially if they are considering having several children. Normal birth makes it easier for babies to adapt to extra-uterine life, breath on their own and begin breastfeeding. Mother-infant attachment is more likely to be successful.  Emerging research is also helping us to understand the complex science of hormones and the significant part they play for mothers and babies during the process of normal birth.

Throughout the book Vadeboncoeur shares with women that giving birth normally can be an empowering, transformative and fulfilling experience when they work together with their care provider to plan the birth experience they want. Women considering a VBAC will find useful and realistic information about how best to prepare for a VBAC- before and during pregnancy as well as during labor and birth.

Given how difficult it is in North America today to have access to caregivers and hospitals who support vaginal birth after cesarean the author also provides her readers with advice about how to increase their odds of finding a supportive provider and how to reassess the need for medical interventions proven to reduce their chances of having a normal birth.

Birth is a powerful emotional and psychological experience that impacts women’s well being, their self-confidence and self-esteem and their capacity for early parenting. To help women explore and understand how their cesarean  may have impacted them and to help them heal from a traumatic birth Vadeboncouer writes  with compassion and wisdom about the value of revisiting their experience so as to better prepare for a normal birth. “It is possible that some of this book will shock you,” she writes. “That emotions about your previous cesarean(s) will resurface for the first time, or that they will re-emerge, even if you think you’ve put those feelings behind you. Don’t let that stop you. As you will see when you read the birth stories in this book…this is perfectly normal.”

The book is enriched by many  birth stories of women who have had a wide range of birth experiences. Personal accounts of women who began searching for a VBAC-friendly provider soon after their first cesarean as well as of women who, reluctant at first eventually did labor for a  VBAC. We also read about the women who labored for a VBAC but ended up needing a cesarean. Vadeboncoeur’s own personal birth experience and the stories that are weaved throughout the book give an honest account of what women experience when seeking providers, a safe place for birth, and support for labor.  Above all, the stories are testimony to what women can accomplish despite the many obstacles they find in a health care system that stacks the odds against them.

Fathers as well as mothers will also find Vadeboncoeur’s partner’s honest account of his experience of the birth of his two children very valuable. Although both children are now adults, it is revealing to find out how birth is also vividly remembered by fathers. Although Steve was a constant companion throughout both of  Hélène’s pregnancies and births he admits that during the first long birth that ended with a cesarean under general anesthesia he at times felt “a sense of impotence.”  When finally the couple found a supportive provider that would “allow” laboring for a VBAC  the conditions at the hospital were not quite as expected. The staff reflected anxiety and fear. “We did not experience this VBAC in peace and harmony,” Steve writes. “It was almost as if we felt that having a VBAC was a sin.”

This valuable book is available in both an American and a British edition. My only reservation is that having read Vadeboncoeur’s book in French, as originally published in Canada, occasionally I found myself, while reading the American translation, occasionally stumbling over a sentence or two that lacks the natural flow and cadence of the English language.  Overall, this comprehensive, well-researched and sensitively written book is a real find.

To find out more about Hélène Vadeboncoeur’s book and her  perspective on normal birth and cesareans, read her Three-Part Interview on Lamaze International’s Science & Sensibility blog.