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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.”

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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.

Although three out of four women who labor for a VBAC have safe normal births, routine repeat cesareans are still the norm in many countries. In the United States, women with a prior cesarean who want to plan a VBAC are at the mercy of the few providers and hospitals who will “allow” them to labor and reduce their own and their infants’ exposure to the adverse health outcomes associated with a surgical birth.

The number of women who do give birth vaginally after a prior cesarean vary widely among providers, hospitals, states, and countries.  To better understand the non-clinical factors that encourage women to labor after a prior cesarean and which models of care influence physicians and hospitals to support VBACs, researchers from Australia conducted a systematic review of 700,000 births in studies published up to 2008 that included data from several countries.  The review was published in the August 2011 issue of the Journal of Advanced Nursing.

Although studies have shown that clinical factors such as induction of labor, use of labor epidurals, and x-ray pelvimetry can impact VBAC success, the authors of this study focused on non-clinical, system-led interventions such as practice guidelines and physician characteristics that promote VBAC and increase the number of women who do end up having a normal birth.

Researchers found several non-clinical interventions that had a significant impact on increasing VBAC rates.

Provider Guidelines, Policies, and Programs for Cesarean or VBAC

After the publication of the first U.S. National Institutes of Health Consensus Development Conference on VBAC in 1980, the VBAC rate in ten hospitals increased from 11% to 29% and the overall VBAC rate rose from 6% to 16%.  When in 1992 Florida state legislation mandated the distribution of cesarean practice guidelines to all obstetricians the state VBAC rate increased from 22% to 31%. A 1996 study showed that across 55 U.S. hospitals VBAC rates increased from 12.6% to 18.5% when the then current ACOG guidelines were widely distributed. (The ACOG recommendation that emergency services be “immediately available” for all women laboring for a VBAC in hospital was first introduced in 1999 and has led to the most recently reported 8.4% national VBAC rate.)

When a small Canadian community hospital changed its practices following the National Canadian Consensus Conference on Aspects of Cesarean Birth (1985) the number of women who labored for a VBAC increased from 7% to 79%.

Local guidelines developed by individual U.S. hospitals also had an impact. When clinicians were encouraged to take a more conservative approach to cesareans, the number of women who labored for a VBAC increased from 32% to 84% and the number of women who did have a vaginal birth increased from 65% to 84%.

The successful approach to increasing VBAC in two studies (published in 2006 and 2008) had a long-term impact. After six years, despite the fact that the number of women with a prior cesarean doubled (7-14%) the number of women who labored for a VBAC remained high and VBAC births increased from 53% to 70%.  Only one study published in 2001 reported negative results, a 7% decline in VBACs despite hospital and management policies that encouraged physicians to support VBAC. This study reflected the national trend of declining VBACs following the 1999 ACOG guidelines.

Audit and Feedback

The audit and feedback approach establishes regular audits of individual physicians’  cesarean rates and the results are reported back to the physicians with the expectation that the high cesarean rate physicians would change their practice patterns and support VBAC.  Researchers found that in the three studies they reviewed, this approach was not very successful.  However, in one study in which physicians were audited and asked to defend their decisions to perform cesareans, over a 10-year period the cesarean rate decreased and the number of women who labored for a VBAC increased from 35.6% to 54.5%.

Style of Care

Researchers also looked at how VBAC attempts and rates differed with different hospital characteristics (size, tertiary or non-tertiary), physician practice style and women’s insurance status. Two studies showed that VBAC was more likely to occur in university/teaching hospitals but one study showed no difference. One study found that although VBAC rates varied from hospital to hospital, hospitals where women were allowed to labor longer had higher rates of successful VBACs regardless of the number of women who labored after a cesarean.

When looking at hospital characteristics researchers found that women were more likely to have a VBAC in hospitals with intermediate or high obstetric resources including a higher number of beds, births, and obstetricians. Women were also more likely to have a VBAC with a female physician, with an obstetrician rather than with a GP and in hospitals with an overall lower cesarean rate. In contrast, one study reported women under the care of a family physician  (81%) were much more likely to labor for a VBAC than women under the care of an obstetrician (51%) and were more likely to actually have a vaginal birth (76% vs. 64%).  In one study published in 1998, women were more likely to try for a VBAC (76%) when their obstetrician’s cesarean rate was below 15% compared to those whose overall rate was greater than 15% (45%).  Women cared for by the low cesarean rate physicians were also more likely to end up with a VBAC (83% vs. 66%).

With regard to insurance status, researchers found inconclusive results. When comparing women with private health insurance with women covered by the public health system, two studies found no difference between the groups. One reported that privately insured women were less likely to attempt a VBAC (50% vs. 64%), another showed a significantly lower VBAC rate in privately insured women (8.1%) than in women insured by the public health system (25%) and one reported a seven times higher repeat cesarean rate for women who were privately insured.

Information Provided To Expectant Mothers

Does providing information about elective repeat cesarean and VBAC during the prenatal period make a difference on women’s choice of birth after a prior cesarean? In a Canadian study of 11 hospitals where women were randomized to either receive an educational pamphlet or to have an individual discussion with a professional, slightly more women (53%) chose to labor for a VBAC after a discussion than after having received a pamphlet (49%).  A U.K. study looked at the effects of   two computer-based decision aids on decisional conflicts compared to usual care. Women who received usual care were somewhat less likely to have a VBAC  (30%) than women who were given the computer-based decision aids ((37%).  In one study a significantly higher number of women ((63%) who participated in a prenatal educational counseling program on choice of birth after a cesarean chose to labor compared with only 38% in the control group.

Overall Conclusions

The researchers who  reviewed these studies that covered a span of 20 years concluded that non-clinical factors do have a significant impact on women’s choice for VBAC and the number of women who subsequently do have a vaginal birth. The most significant difference seems to be local “ownership of the desire to reduce CS rates or increase VBAC rates.”  Also, individual physician characteristics may impact the number of women whose choose to labor for a VBAC and have a normal birth. The study also concluded that involving women more fully in decision-making and providing evidence-based information about their options should be incorporated into the care of all women with a previous cesarean section.