In the United States a growing number of healthy expectant mothers who wish to plan a VBAC are finding it increasingly difficult to locate a careprovider and hospital willing to provide them medical care. Preliminary data from the National Center for Health Statistics indicate that in 2003 only 10.6% of women with a prior cesarean had a VBAC.

Left with no other option than to submit to a medically unnecessary cesarean section many women are choosing to have a VBAC at home or at a free standing birth center. A recently published 10-year study of 1,453 US women who planned to have a VBAC in a birth center found that 87% did have a vaginal delivery, but the health risks for some women were high.

You can download the study from the November 2004 issue of Obstetrics & Gynecology, and read the responses to the study from national organizations and medical experts.

First Research on Out-of-Hospital VBAC Published in the Green Journal

Perkiomenville, PA. Fifteen years ago vaginal birth after cesarean section (VBAC) was viewed as an important tool to reduce the high rate of cesarean sections in the United States. The number of VBACs rose from 3% in 1980 to 20% in 1990.

Before and during this period, a small but persistent population of women desiring to avoid a second surgical birth was opting for a home birth often with unlicensed care providers. An opinion issued by the American College of Obstetricians & Gynecologists in 1988 supported a trial of labor for VBAC, reversing the opinion of once a cesarean always a cesarean. In the late 1980's women seeking a VBAC increasingly approached birth centers for care. At that time, although there were anecdotal reports from consumer organizations on the success of VBAC in home birth, there was no hard evidence on the outcomes for women attempting a VBAC in any out-of-hospital setting. In considering the needs of women seeking an alternative to the hospital setting for VBAC, the National Association of Childbearing Centers conducted a 10-year study of VBAC in birth centers to obtain data to formulate an evidence-based opinion on this practice.

"Results of the National Study of Vaginal Birth After Cesarean in Birth Centers" is published in Obstetrics & Gynecology (November 2004). Although 87% of women laboring at the birth center in this study had successful vaginal births this study confirms that having a cesarean-scarred uterus increases the risk of serious complications before and during labor and birth.. One of the most important messages coming out of this study is that there is no way for a woman who has had a c-section, to fully avoid the increased risks that come from having had a prior cesarean section. Her reproductive potential carries a scar for life, and that scar increases her risk for serious complications in subsequent pregnancies. Because of this increased risk, a trial of labor for VBAC should not be attempted in any out-of-hospital birth setting. This recommendation is made even more strongly for women seeking a VBAC with the greater risks of more than one prior cesarean delivery or pregnancy of 42 weeks or more.

The increased risks associated with pregnancy involving a uterus scarred by a cesarean section cannot be completely avoided in a subsequent pregnancy even if the woman elects to have all future births by elective repeat cesareans. Therefore it is important that physicians, midwives and pregnant women make every effort to avoid that first cesarean birth. The incidence of first cesareans is lower for births in birth centers and for hospital births attended by midwives or the services of a doula. Birth centers and in-hospital midwifery and doula services should be promoted as means to reduce the rate of primary cesarean sections. Hospitals that have around-the-clock obstetric and anesthesia services and thus can deal with sudden obstetric complications should provide availability to VBAC services, and promote midwife/obstetrician team care and use of doulas to increase the VBAC success rate and decrease the risk of adverse outcomes associated with VBAC.

The National Association of Childbearing Centers is the nation's most comprehensive resource on birth centers. A non-profit membership organization founded by the Childbirth Connection under a grant from the John A. Hartford Foundation of New York, NACC is dedicated to developing quality holistic services for childbearing families that promote self-reliance and confidence in birth and parenting. NACC publishes materials on birth centers, sets national standards for birth center operation, and promotes state regulations for licensure and national accreditation by the Commission for the Accreditation of Birth Centers. More information about NACC can be found at www.BirthCenters.org.

For background information on VBAC and birth centers, please Click here.

Avoiding First C-Section Should Be Priority, New Research Indicates

For Immediate Release
November 11, 2004

Contact: Tim Clarke
(240) 485-1821
tclarke@acnm.org
American College of Nurse-Midwives

Silver Spring, MD - Women seeking a vaginal birth after cesarean (VBAC) have an increased risk of complications that require hospital management and will benefit from in-hospital care provided by midwife/obstetrician teams, according to new research published in the November issue of Obstetrics & Gynecology. The researchers also cited a previous study of 29,046 women which found that women with a previous cesarean section had higher rates of several maternal and neonatal complications than other women and this increase in complications persisted whether or not they had a repeat cesarean section.

These findings, taken in concert with other studies that detail the short- and long-term risks of cesarean section, make it even more imperative that no woman receive a cesarean section without a medical indication, said the American College of Nurse-Midwives (ACNM). ACNM supports VBAC for women who are appropriately selected, counseled and managed and is increasingly alarmed that fewer hospitals are offering women this option. Recent reports that some professional liability companies are refusing to cover physicians who offer this option are also disturbing.

"Research such as this reinforces the importance of avoiding primary cesarean sections unless there is a medical necessity," said Katherine Camacho Carr, CNM, PhD, president of the College. Dr. Carr practices at Highline Midwifery and Women's Health in Seattle, Washington.

"Cesarean section is major surgery and women must be thoroughly informed about the long-term implications of this method of delivery," Dr. Carr continued. "It is not surprising to find that collaborative management between midwives and physicians significantly improves the chances that a woman will have a vaginal birth or a successful VBAC. Midwives are experts in the management of labor that leads to a vaginal birth and we place a high value on working collaboratively with our physician colleagues."

Health care must be guided by evidence-based outcomes, ACNM said. The debate over VBAC and elective cesarean section appears to be being driven by fear over litigation, a lack of understanding about current research and a false sense of security about the risks of surgery. Women need unbiased, individualized information concerning their birth options. Health care professionals must choose candidates for VBAC carefully, monitor these women appropriately while providing an environment that is conducive to a vaginal birth, and must be prepared to intervene quickly if problems develop.

For more information about preventing primary cesarean section, please visit www.midwife.org and www.matenitywise.org.

For more information, please contact Tim Clarke, Jr., ACNM Communications Manager at (240) 485-1821 or via email at tclarke@acnm.org.

With roots dating to 1929, the American College of Nurse-Midwives is the oldest women's health care association in the U.S. ACNM's mission is to promote the health and well-being of women and infants within their families and communities through the development and support of the profession of midwifery as practiced by certified nurse-midwives and certified midwives. Midwives believe every individual has the right to safe, satisfying health care with respect for human dignity and cultural variations. More information about ACNM can be found at www.midwife.org.

8403 Colesville Road, Ste. 1550, Silver Spring, MD 20910-6374 · Phone: (240) 485-1800 · Fax: (240) 485-1818 · www.midwife.org.

The American College of Obstetricians and Gynecologists sent out this statement on October 29, 2004

Researchers Advise Against Attempting VBACs in Birth Centers

ACOG NEWS RELEASE
ACOG Office of Communications
communications@acog.org

Washington, DC -- Women and birth centers are strongly advised against attempting VBACs (vaginal birth after cesarean) in birth centers because the health risks are too great, according to the results of a new national study published in the November issue of Obstetrics & Gynecology. While researchers found that women attempting VBAC in a birth center who were at least 42 weeks of gestation or who have had more than one previous cesarean delivery had the worst outcomes, they advise all women against attempting a VBAC anywhere but in a hospital.

During the 1980s, the number of birth centers across the US increased. These nonhospital facilities were designed to provide maternity care to women at low risk of obstetrical complications. At the same time that these birth centers were increasing, studies suggested that VBACs were safe for some women. The national VBAC rate rose from 3% in 1980 to 20% in 1990 as more women attempted to avoid subsequent cesareans.

Researchers from several US institutions, supported by the National Association of Childbearing Centers Foundation, prospectively studied the birth outcome data from 1,453 pregnant women who had at least one previous cesarean and who attempted to deliver via VBAC at one of 41 US birth centers. The study covered a 10-year period, from 1990 to 2000. Ninety-three percent of these women had only had one previous cesarean delivery and 46% had also had a previous vaginal birth.

While 87% of all women who labored in a birth center delivered vaginally, only 76% of all the women actually delivered in the birth center-the rest delivered at a hospital after being transferred due to complications. Women with more than one cesarean delivery were significantly more likely to have a uterine rupture when attempting VBAC in a birth center. Gestational age of at least 42 weeks also raised the risk for a negative outcome.

While there were no maternal deaths, overall there were five stillbirths and two newborn deaths among women attempting VBAC. There also were six uterine ruptures among women attempting VBAC.

Data showed that 24% of all women who attempted VBAC at a birth center were transferred to a hospital before they gave birth due to medical problems such as failure of labor to progress, fetal conditions, and maternal complications. Of the 24%, 23 women were transferred immediately to hospitals and 324 were transferred at some point during a trial of labor.

Forty-two women (3.8%) who successfully delivered their baby via VBAC in a birth center were transferred to a hospital after delivery, approximately half due to maternal problems and half for newborn problems. The most common reason for maternal transfer was for repair of lacerations. Respiratory problems were the most common reasons for neonatal transfers.

According to the researchers, women with a previous cesarean delivery are at an increased risk for complications during subsequent births compared with women who have not had a cesarean. Women attempting a VBAC, therefore, cannot be considered low risk and are best cared for in a hospital setting to deal with potential complications. The researchers encourage more hospitals to offer VBACs so that women who wish to avoid another cesarean have a safe place to deliver. They also emphasize that their study underscores the importance of implementing policies and strategies to avoid unnecessary primary cesareans in the first place.

Contact: Bruce Flamm, MD, University of California, Irvine, at bruceflamm@aol.com or 909-353-4412.

# # #

Studies published in Obstetrics & Gynecology, the peer-reviewed scientific journal of The American College of Obstetricians and Gynecologists (ACOG), do not necessarily reflect the policies or opinions of ACOG. ACOG is the national medical organization representing over 47,000 members who provide health care for women.

Article Provides Results of National Study of Vaginal Births After Cesareans in Birth Centers

November 5, 2004
National Center for Education in Maternal and Child Health

On the basis of these findings, we advise both birth centers and women with prior cesarean deliveries against attempting VBACs [vaginal births after cesareans] in any nonhospital setting," state the authors of an article published in the November 2004 issue of Obstetrics & Gynecology. In 1990, the Standards Committee of the National Association of Childbearing Centers recommended that VBACs could be offered in birth centers under certain conditions. After reported increases in the number of uterine ruptures during VBACs attempted in birth centers, in 1999 the American College of Obstetricians and Gynecologists issued a new set of guidelines recommending that VBACs should be attempted "only in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care." This report presents the findings of the National Association of Childbearing Centers' study of VBACs in birth centers and evidence-based recommendations regrding the advisability of performing trials of labor after cesarean delivery in birth centers.

Data were collected for 1,453 women who presented at participating birth centers for an attempted VBAC between 1990 and 2000.

The authors found that:

• Eighty percent of the women had a vaginal delivery.


• Having had a previous vaginal delivery was associated with an increased chance of successful vaginal delivery in the current trial of labor (94.4%, vs. 80.9% for women with no previous vaginal delivery).


• Nearly one-fourth (347) of the women were transferred to a hospital before delivery. Thirty-seven of these transfers were coded as emergencies.


• Of the 1,106 women who delivered in the birth centers, 42 (3.8%) were transferred to a hospital after delivery, approximately half for maternal indications and half for neonatal indications.


• There were 6 uterine ruptures, 7 perinatal deaths, 1 hysterectomy, and 15 liveborn infants with 5-minute Apgar scores <7.


• Women with more than one previous cesarean delivery were significantly more likely than women with only one previous cesarean delivery to have a uterine rupture.


• The occurrence of serious adverse outcomes, particularly perinatal death, was increased among women who delivered at 42 or more weeks of gestation.

The authors conclude that "because out-of-hospital birth is not a safe choice for women with prior cesarean deliveries, hospitals should provide the option of care by a midwife/obstetrician team for women seeking VBAC within the hospital setting."

Lieberman E, Ernst EK, Rooks JP. 2004. Results of the National Study of Vaginal Birth After Cesarean in Birth Centers. Obstetrics & Gynecology 104(5):933-942.

Originally published in MCHAlert © 2004 National Center for Education in Maternal and Child Health and Georgetown University. Reprinted with permission.