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Women Are Poorly Informed By Their Careproviders About the Benefits of VBAC and Risks of C-Section

12 Sep

Although VBAC is encouraged by ACOG and viewed by the National Institutes of Health as a reasonable option to a repeat cesarean, less than 10% of women with a prior cesarean had a VBAC in 2010.  A study published in the September issue of the American Journal of Obstetrics and Gynecology suggests that care providers  are not educating their patients about the benefits of VBAC and women are not making an informed decision when they elect to have a repeat cesarean section.

Researchers surveyed women with one prior cesarean birth who were being admitted at St. Luke’s Roosevelt Hospital Center in New York City to have a repeat cesarean or to labor for a VBAC. Women had already made their  decision about how they wanted to give birth. The expectant mothers were surveyed between November 2010 and July 2011, after ACOG’s guidelines recommending that women receive “thorough counseling” that included the benefits and risks of VBAC.

Although the hospital has a comparatively high VBAC rate of 33%, the authors found only 13% of women who chose to have a VBAC and 4% of women who chose to have a repeat operation were aware that 60-80% of women who labor after a cesarean have a normal birth. Only one in two women who labored and one in four women who had a repeat cesarean knew that the risk of separation of the prior uterine scar was “0.5-1%.”

Of the women who had a repeat operation, more than half  did not know that recovering from a repeat cesarean was longer than after a VBAC and 46% did not know that the rate of complications increases with each successive cesarean. Only half of the women knew that there is greater risk of damage to organs, excessive bleeding, and infection with an elective repeat cesarean and two thirds were not aware that an elective repeat cesarean is associated with an increased risk of maternal death, neonatal respiratory complications and admission to a neonatal intensive care unit (NICU).

Of the women who perceived that their providers favored an elective cesarean, 86% selected to have a repeat operation. Three out of four women who felt that their providers favored a VBAC chose to labor.  Half the women who didn’t think their provider had a preference chose a repeat cesarean and half chose to labor. The researchers suggest that “provider bias may be affecting the opinion of some patients, with undue influence on a patient’s voluntary decision-making.”

The authors of the study, who hypothesized that current low VBAC rates were a result of poor patient education, concluded that despite the fact that this group of women represented “a better informed population,”  they “showed insufficiencies in the area of comprehension, a major trend in informed consent. They lacked awareness and understanding of their situation and possibilities.”

To make an informed decision about how to give birth after a prior cesarean women need complete and accurate information about the risks and benefits of both options.


Sources of reliable information on VBAC and elective repeat cesarean.

Childbirth Connection,   VBAC or Repeat Cesarean?

Lamaze Giving Birth With Confidence Blog,  A Woman’s Guide to VBAC

Queensland, Australia-Center for Mother and Babies, Vaginal Birth After Cesarean (VBAC)

Optimal Birth, British Columbia,  VBAC Brochure

Vermont/New Hampshire VBAC Project, VBAC Patient Education

Society of Obstetricians and Gynecologists of Canada, Vaginal Birth After Cesarean

Royal College of Obstetricians and Gynaecologists, U.K., Birth After Caeserean: Information For You

Power to Push Campaign, British Columbia, Vaginal Birth After Cesareanvideos and birth stories, Ten Birthing Misconceptions

Breastfeeding, Birth Practices, and Cesarean Section: Is There a Link?

10 Aug

August is the month dedicated to increasing awareness about the benefits of breastfeeding for mothers and babies and to making commitments to support, protect, and promote the best feeding option for infants. Breastfeeding provides optimal health, nutritional, immunologic and developmental benefits to newborns as well as protection from postpartum complications and future disease for mothers. In 1991 the World Health Organization and UNICEF introduced the WHO Baby-Friendly Hospital Initiative outlining Ten Steps for birth facilities and maternity care professionals to follow to ensure that mothers and babies get the best start after birth for initiating and continuing breastfeeding. Since then, evidence has been mounting showing that the likelihood of initiating and continuing breastfeeding is determined even before the baby is born.

In 2003 the WHO and UNICEF established that birth practices impact breastfeeding. New guidelines recommended that to maximize the establishment of successful breastfeeding, women in labor regardless of birth setting, should have access to the following birth care practices:

  • Care by staff trained in non-drug methods of pain relief and who do not promote the use of analgesic or anesthetic drugs unless required by a medical condition;
  • Care that minimizes routine practices and procedures that are not supported by scientific evidence including withholding nourishment, early rupture of membranes, use of IVs, routine electronic fetal monitoring, episiotomy and instrumental delivery; and
  • Care that minimizes invasive procedures such as unnecessary acceleration or induction of labor and medically unnecessary cesarean sections.

Minimizing the use of drugs and interventions reduces the odds for complications including infection, increased pain, stalled labor and abnormal fetal heart tones. Recommendations also emphasized that care givers should respect women’s choices:

  • Care should be sensitive and responsive to the specific beliefs, values, and customs of the mother’s culture, ethnicity and religion;
  • Women should have access to birth companions of their choice who provide emotional and physical support throughout labor and delivery;
  • Women should have the freedom to walk,move about, and assume the positions of their choice during labor.

Supporting women in labor with this model of care is more likely to lead to an uncomplicated vaginal birth.

In 2009 the Centers for Disease Control published the CDC Guide to Breastfeeding Interventions, confirming that hospital birth practices have a significant impact on the initiation and continuation of breastfeeding. The report states that the use of medications during labor and cesarean birth have a negative effect on breastfeeding. So does the separation of mother and baby after birth and during the hospital stay.

The CDC found that a woman’s birth experience exerts a unique influence on both breastfeeding initiation and later infant feeding behavior. Although the hospital stay is typically very short, events during this time have a long and lasting impact. Medications and procedures administered to the mother during labor affect her infant’s behavior at the time of birth, which in turn affects her infant’s ability to suckle in an organized and effective manner at the breast.

Use of analgesics, epidural anesthesia and cesarean birth have a negative effect on breastfeeding, making it more difficult for mothers to initiate nursing and establish a successful breastfeeding pattern before leaving the hospital.

Babies are more likely to be breastfed and for a longer period of time if they have early skin-to-skin contact.  With a cesarean babies are more likely to be taken to the nursery for observation and monitoring for potential problems during the first hour of life, the “golden hour” when breastfeeding is best initiated.  Babie are also more likely to spend time in a newborn nursery than rooming in with their mothers. The separation seems to have an impact on the mother’s initial ability to respond to and care for her infant. When mothers and babies are together, skin-to-skin, babies cry less, it improves the mother’s perception of her infant, and enhances her confidence in her mothering skills.

Some hospitals like San Francisco General in California, a Baby-Friendly designated facility, have established pro-breastfeeding cesarean guidelines to increase the number of mothers who successfully initiate breastfeeding. Operating room policies now include routine skin-to-skin contact as soon as possible and within 90 minutes after a cesarean delivery. Babies who experience skin-to-skin in the operating room are better able to latch on to the breast and less likely to receive formula before discharge.

Birth practices for labor, birth, and postpartum can facilitate or hinder the initiation, establishment, and continuation of breastfeeding. According to a CDC report many birth facilities have policies and practices that are not evidence-based and are known to interfere with breastfeeding. Maternity care providers have an obligation to care for women and newborns in a way that provides both with the best possible health outcomes.


UNICEF-U.K. , Care Pathways for Breastfeeding

Baby-Friendly U.S.A.

U.S. Surgeon General’s Call To Action to Support Breastfeeding

CIMS, Breastfeeding Is Priceless. A Coalition for Improving Maternity Services Fact Sheet

Sylvie Donna, A Look at the Research: The Link Between Epidural Analgesia and Breastfeeding.


TRIAL OF LABOR, A New Film About Four Mothers and Their Determination To Give Birth Naturally After A Prior Cesarean

22 Jul

Two fathers, Robert Humphreys, an independent, award winning film maker and Dr. Elliot Berlin, a Chiropractor specializing in alternative prenatal care, set out to make a documentary film about the VBAC Ban in U.S. hospitals and its impact on the physical and psychological health of women who want to birth naturally after a prior cesarean. TRIAL OF LABOR, a documentary initially conceived as an educational film about the medicalization of birth in the U.S. and the pros and cons of VBAC and repeat cesarean, evolved into a powerful and inspiring personal journey of four mothers who had a prior cesarean and who were determined to find caregivers who would support their choice for a VBAC. The children of both Humphreys and Berlin were born at home. As men and fathers, they witnessed how powerful and validating birth can be.

With a healthy pregnancy, and a low horizontal scar on the uterus, women who go into labor on their own at term have about a 70% to 75% chance that they will have a safe VBAC. Avoiding a routine repeat cesarean protects women from complications of major abdominal surgery as well as potential complications in a subsequent pregnancy.

However, current controversial ACOG guidelines (Practice Bulletin #115) requiring that trial of labor (TOLAC) should take place in hospitals where resources for emergency cesarean are “immediately available” make it very difficult for expectant mothers to find VBAC supportive careproviders.

The National Institutes of Health (NIH) found that this “immediately available” recommendation was based on consensus and expert opinion rather than strong support from high-quality evidence.  The NIH also found that this recommendation had influenced about one-third of hospitals and one-half of physicians to no longer provide care for women who want a VBAC.

Told from the mothers’ own point of view, TRIAL OF LABOR is a sensitive and insightful look at four strong and courageous mothers who challenge an irrational and un-affirming medical care system to escape from a routine repeat operation-initially, the only option they thought they had.

Their journey to VBAC forces them to look back at their unexpected and unwanted cesarean birth. Face conflicting emotions about their ability to give birth and examine carefully the benefits and downside of both a natural birth and another operation.

“It was the most surreal Kafkaesk experience,” said one mother about her cesarean. “When I reflect about it,” says another, “I get visibly angry. That I didn’t inform myself enough.”

The mothers’ decision to give birth vaginally, where and with whom , did not come easy. “It’s very difficult to step away from the medical establishment,” expressed one expectant mother and yet,  chose to have a VBAC at home, her last resort, despite the lack of published evidence about its safety. Each mother decided for herself how she can best give birth this time.

The U.S. saw an increase in VBACs from the 1980s through the mid 1990s, but the VBAC rates have consistently declined since. One in four women had a VBAC in 1996 compared to 1 in 100 today.

Filmmaker, Robert Humphreys said, “Women have the power and wisdom to give birth. They have been doing it for thousands of years. We men need to step back and respect their strength and ability to give birth on their own.“

The producers of TRIAL OF LABOR have received an encouraging response to their request for  funding to complete the film and meet their post-production costs. They also plan to produce DVDs of the film. Humphreys and Berlin have launched a Kickstarter campaign to raise the funds and are asking the birthing community and the public at large to view the trailer and spread the news about this important and much needed film.

To view the trailer and find out more about the film visit, TRIAL OF LABOR.

How Do Mothers Make Choices About VBAC or Repeat Cesarean?

7 Jun

Yasmine L. Konheim-Kalkstein, Ph.D. is Assistant Professor of Psychology at Mount Saint Mary College, in Newburgh, New York. As a mother who had a prior cesarean, she is one of the very few women in the United States who are given a choice to plan a VBAC or schedule a routine repeat cesarean. Less than 10 percent of U.S. women with a prior cesarean have a VBAC.

Dr. Konheim-Kalkstein is conducting a research study to better understand how women in the U.S. make a decision about planning a VBAC or having a repeat cesarean.

She writes:

I am, probably as a result of my own experience, conducting research on psychological factors that influence women’s decisions to try for a VBAC or choose a repeat c-section.

I have researched decision-making in the past, but it was during my second pregnancy, while being faced with the decision to plan a VBAC or choose a repeat operation, and hearing other women’s choices (often very different) that I became interested in the question of what influences women’s decision-making in childbirth. 

As a pilot study, I’m gathering data from women who had to make this decision. It’s an online anonymous survey that takes less than 10 minutes. I hope this study will help maternity care professionals learn how best to support women in their decisions. Women who take the survey have the opportunity to be drawn to win a $25. gift card.

Specifically, our project examines the psychological influences that lead women to plan a VBAC or schedule a repeat cesarean section. When we make any decision, we are often influenced by the knowledge available to us, the way risks are presented to us, our prior experiences, stories we may have heard, and of course, our own personality. This project broadly explores these influences, in order to better understand the components that influence the decision-making. 

Of course, there is no right or wrong choice in the case of a VBAC vs. a scheduled c-section. Our survey seeks only to collect data, not to influence decisions. We are not medically trained; we are interested in the psychology of decision-making. We hope our study will contribute to research that will ultimately benefit women, as well as those involved in supporting women in their healthcare decisions.

I am happy to share my own personal story, but only after women take the survey as I don’t want to bias them one way or another. 

To take the survey, go to .

For additional information about this project, you can contact Dr. Konheim-Kalkstein


Childbirth Connection, VBAC or Repeat Cesarean

American College of Nurse-Midwives, What You Need to Know About VBAC and Repeat Cesarean

Northern New England Perinatal Quality Improvement Network, Birth Choices After Cesarean (Patient Education)

American Academy of Family Physicians: Trial of Labor After Cesarean, Shared Patient-Physician Decision-Making Tool

Power To Push Campaign, British Columbia, Vaginal Birth After Cesarean

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