Tag Archives: increasing vbac

New Jersey Poised to Increase Access to VBAC

6 Jan

New Jersey has one of the highest cesarean rates in the country. According to U.S. Preliminary data for 2012 New Jersey has the third highest cesarean rate in the nation,  38.7% preceded by Florida (38.1%) and Louisiana (40.2%). In the last two decades repeat cesarean births without labor more than doubled in New Jersey, from 40% to 85%. According to the New Jersey Department of Health currently one in four cesareans are routine repeat operations without serious risk indications. The New Jersey VBAC Task Force wants to change that.

Task Force members agree that VBAC should be available to all low-risk women who choose to labor after a prior cesarean and increasing access to VBAC would improve obstetric care. New Jersey hospital VBAC rates vary widely, from 31.0% at Monmouth Medical Center to 0% for Memorial Hospital and Southern Ocean Medical Center in 2011. The Task Force suggested establishing a network of regional VBAC referral centers who can meet safety requirements for VBAC. The Task Force is a multidisciplinary collaborative group which includes the New Jersey Hospital Association, health insurance payers and malpractice insurers.  20111225_Jess_6619_2000

Hospitals often deny VBAC care by referring to the costly and realistically unattainable ACOG guidelines which recommend a surgical team and anesthesia be “immediately available” when women labor for a VBAC. Having had a prior cesarean adds a level of risk to the subsequent laboring process, however, the risks of laboring for a VBAC are the same as for women giving birth for the first time, yet women giving birth for the first time are not denied medical care, nor are they told that they are at risk because the hospital cannot guarantee that a surgical team and anesthesia will be “immediately” available in case they would need a cesarean section.

The New Jersey VBAC Task Force concluded that ACOG’s definition of “immediate access” has never been defined by ACOG or any other authority and the legal liability of this ambiguous recommendation is “not conducive to frank discussion with patients, resulting in obscure and often misleading counseling.”

Providing safe medical care for women in New Jersey who want to plan a VBAC is not an impossible task. After more than one year of deliberations, the Task Force concluded that many of New Jersey’s hospitals already have the resources that can meet the safety standards recommended to support mothers who want to plan a VBAC. The Hospital Capacity and Regional Accessibility Subcommittee reasoned that being able to provide advanced neonatal care was just as critical for responding to complications that may develop during labor for a VBAC.

New Jersey licenses 20 hospitals as intensive perinatal centers or intermediate/regional perinatal centers. These hospitals are required to have full-time on-site coverage by neonatal and pediatric specialists and consulting arrangements with anesthesiology. Responding to a Task Force survey, 14 of 20  intensive care perinatal centers  reported having 24-hour in-house obstetric coverage for cesarean, availability of anesthesia and operating room teams, and 60% of the intermediate and basic perinatal centers reported 24-hour on-site coverage and the rest the availability of an off-site obstetrician within 30 minutes once the need for a cesarean was established.

Also in response to the Task Force survey, 7 of the intensive perinatal care centers and 6 of the intermediate care centers were in favor of becoming a regional VBAC referral center.

To successfully increase access to VBAC the Task Force made several recommendations:

  • Re-evaluate the risks of laboring for a VBAC by comparing low-risk women with a prior cesarean with New Jersey’s benchmark population, low-risk multiparous women without a previous cesarean for a more realistic evaluation of potential maternal and neonatal complications.
  • Develop a VBAC education program to educate expectant parents about the benefits and risks of laboring after a prior cesarean.
  • Educate providers and hospitals about the benefits and risks of VBAC, adequate staffing and resources, labor progress patterns for VBAC , guidelines for augmentation of labor, signs and symptoms of uterine rupture or dehiscence and practice drills for appropriate response for a uterine rupture.
  • Educate in-hospital staff about VBAC including, risk management, nursing, anesthesiology, neonatology, lab and blood banks to have a more coordinated response in case of complications.
  • Providers should try to shift the focus of their conversation with their patients from “defensive communication and liability strategies toward true shared decision making.”

Tom Westover, MD of Cooper University Hospital in New Jersey and a member of the New Jersey VBAC Task Force will address health professionals and birth advocates about increasing access to VBAC on March 26 at the New Jersey BirthNetwork Symposium at Rutgers University Inn & Conference Center, Supporting NJ’s Birth Plan: Taking the Next Step and Implementing Evidence-Based, Mother-Friendly Maternity Practices in New Jersey.

 Resources

Northern New England Perinatal Quality Improvement Network,  VBAC Project

Childbirth Connection, Maternity Care and Liability: Pressing Problems, Substantive Solutions

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.

California Reseachers Call For Fewer Cesareans and More VBACs

30 Jan

In a recently published White Paper by the California Maternal Quality Care Collaborative researchers in California confirmed that the high number of cesarean sections performed in the United States and in California put mothers and babies at increased risks and add significantly to healthcare costs with little evidence of health benefits.

The report also confirmed that there are psychological costs that are often overlooked. Postpartum anxiety, depression,  and post-traumatic stress disorder (PTSD). Cesareans affect maternal-infant attachment and breastfeeding as well.  The cesarean rate in California and the United States increased by 50 percent between 1998 and 2008. It rose from 22 percent to 33 percent in ten years. Researchers found no data to document any population-level benefit to mothers or newborns associated with the  increased rate of cesareans.

The authors state, “Today providers seem to see no ‘downside’ to a high cesarean rate; and women seem increasingly accepting of the prospect of a cesarean.”

California healthcare payers pay hospital charges of $24,700 for a cesarean compared to $14,500 for a vaginal birth. The authors state physicians, healthcare payers, employers who pay for childbirth costs, and public health officials are not aware of the “disconnect” between the amount of dollars spent and the health outcomes in U.S. maternity care.

The authors of  Cesarean Deliveries, Outcomes, and Opportunity for Change in California: Towards a Public Agenda for Maternity Care Safety and Quality found that the increasing cesarean rates can be attributed to two main reasons: cesareans performed on mothers having their first baby and the dramatic decline in VBACs.

The number of cesarean performed during labor vary widely and reflect individual physician discretion rather than clear medical indications.  In fact researchers found that 90 percent of the variation in cesarean rates during labor is due to only two indications: failure to progress and non-reassuring fetal heart tones (fetal distress).  The number of cesareans performed for these two indications vary widely and depend on the physicians’ individual response to these two conditions.  Attitudes of physicians and nurses on the labor and delivery unit also play a part.

The White Paper showed that overall, hospital cesarean rates in California varied from 18 percent to over 50 percent of all births. Hospital cesarean rates for low-risk mothers giving birth for the first time varied from 9 percent to 51 percent. More recent data showed that in 2009 hospital cesarean rates in California varied from 16 percent at Sutter Davis Hospital in Davis to 68 percent at Los Angeles Community Hospital.

The Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States, states, “Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes. There are no data that higher rates improve any outcomes, yet the CS rates continue to rise.” 

The argument has often been made that hospitals with high cesarean rates have a higher proportion of high-risk births and that rising cesarean rates are due to “maternal request.” This report clearly shows that there is no foundation to these arguments.

With regard to the decline of  VBACs, researchers say it will take persistent pressure from childbearing women and advocates for evidence-based practice in childbirth, public reporting of  hospitals who support VBAC and increased awareness by childbearing women about the safety and benefits of VBAC. Citing a national survey  of women’s experience of childbirth, the authors found that reality-based television shows on childbirth and many websites send an incorrect message that cesareans are easy, pain-free, and risk-free. Most women have very little knowledge of  common hospital procedures and their impact on the normal progress of labor.

Based on interviews of California careproviders, the report found that VBAC is also “not popular” with physicians due to the longer time commitment needed for a vaginal birth and their perception of increased liability.

“Whatever the motivation for today’s more ‘defensive’ approach to delivery,” the authors state, ” it is not resulting in better outcomes for babies or their mothers.”

The White Paper is an extensive and insightful study of the rising cesarean rate in California, the health risks of surgical birth, the medical factors driving the trend, and the socio-cultural factors that keep cesarean rates high. It also dispells several myths about cesarean section.

The report includes a valuable, multi-faceted response to reducing cesareans. Strategies include, quality improvement measures, examining hospital practices that lead to cesareans, public reporting of hospital cesarean and VBAC rates, payment reform, and an education campaign to increase awareness about the short- and long-term health risks of cesareans for mothers and babies.

The authors make a  strong recommendation to use several facility-appropriate approaches at the same time since many of  “these interventions interact positively with and reinforce each other, making the whole greater than the sum of its parts.”

The White Paper is a collaborative report by researchers from the California Maternal Quality Care Collaborative, the Pacific Business Group on Health, and the California Perinatal Quality Care Collaborative.

 

Resources

To find out more about reducing the odds for “failure to progress,” during labor, see

Six Lamaze Healthy Birth Practices

To see how Contra Costa Regional Medical Center in California made changes to support women who want to plan a VBAC, see the video

The Birth After Cesarean Improvement Project

To find out more about what some hospitals are doing to reduce cesareans, see

Michigan Health & Hospital Association Keystone Center- Obstetrics

Sutter Health, California,

West Virginia Perinatal Partnership- First Baby Clinical Initiative

For a list of support groups for mothers who experience psychological stress after a cesarean see,

Support Groups 

To find out more about hospital intervention rates and what mothers think of their careproviders, see

The Birth Survey

New Study Reveals Non-Clinical Factors Have Significant Impact on VBAC

29 Jul

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.


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