Tag Archives: VBAC

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.

A Mother Writes, “I Do Not Want a Repeat Cesarean.”

20 Mar

A mother from North Carolina wrote to ask what she can do to get hospitals in her community to provide care for VBAC.

” I just found your site, and I know you must be really busy, but I wanted to drop a line to tell you why your site will be very important to me. I live in a small town, and the local hospital will not allow VBAC’s. I just had my first baby 6 months ago, and after laboring 26 hours (13.5 of which were at the hospital) they then realized that my baby was breech and ushered me into a cesarean. The only options they gave me at that time were to undergo general anesthesia and be put to sleep, or have a spinal block and my husband could be in the OR with me.

I was mortified at the lack of information I had received and the fact that it took so long for them to realize that my baby was breech. When I was getting ready to leave the hospital the nurse proceeded to tell me that next time it will be easier since I will be able to schedule my cesarean because the hospital will not support VBAC.

I was shocked! I do not plan to have any more children for a couple years, but I do not want to wait until I am pregnant to try to fight this system. I do not want a repeat cesarean and I want other women to have the option to VBAC at this hospital. Every other hospital is over an hour away from this town and of the 3 hospitals that are within that approximate hour drive, there is only 1 that will allow a VBAC. That would mean that I would likely have to have all my prenatal care with a provider that is that far from me.

While it would be worth it for me to drive that far, it is not fair that a group of providers and the hospital will not give women a fighting chance. Nor do they educate them on the dangers of repeat cesareans. Instead they scare them into thinking that they can only have cesareans. Thank you for creating a web page to help educate women.”

Crystal

It is not unusual for hospital staff to discover in labor that a woman is carrying a breech. Had the breech been diagnosed during the last weeks of pregnancy, Crystal would have had the option of having an external version or finding a careprovider skilled in breech vaginal birth.

When it comes to hospitals refusing care for women who want to plan a VBAC, current ACOG guidelines for VBAC state that facilities must at least inform women of the availability of emergency care in case of complications from a VBAC and refer women to hospitals and providers that do support VBAC. ACOG also recommends that hospitals do change their policies and find ways to safely support healthy women who want to avoid a medically unnecessary cesarean.

Having said that, sometimes the only way a hospital will change its VBAC policy is in response to pressure from birth advocates in the community. Women with a previous cesarean who plan to become pregnant should canvas the hospitals in their community to find out about available care for VBAC and birth centers will often support women who want a VBAC.

Although ACOG supports VBAC, often physicians and hospitals don’t provide care for VBAC because their malpractice insurance coverage is increased by thousands of dollars for liability insurance coverage for VBAC .  Information about lack of VBAC liability coverage is not usually provided to the public. Many physicians who support VBAC loose business because the hospital at which they have privileges has a no-VBAC policy.

In Northwest Arkansas a grassroots birth advocacy group was successful in getting the hospital in their community to change policy and accept to provide care for women who want a VBAC.

Beth Day and Genet Jones of BirthNetwork of Northwest Arkansas describe how birth advocates made it possible for women to avoid an unnecessary repeat cesarean section.  Beth Day writes,

“Last month in Rogers, Arkansas  three local hospitals  overturned their ban on VBAC.  Our work with one hospital in particular has been a beautiful blend of work, relationship building, and timing.  I  have lived in the area and have attended births at this one hospital as a doula for the past 5 years.  As a result of my work there, I developed a good working relationship with one of the physicians who was not only the only doctor who would allow women to labor and birth in water, but was among the few who championed VBAC.

Then, two years ago, Genet and I were working with our local chapter of ICAN, staging protests at each of the area hospitals that banned VBAC.  The protests themselves were not directly successful.  In fact the hospitals really dug in their heels and stood in solidarity defending the bans.  But perhaps we planted the seed for a swift reversal of the bans once the new ACOG guidelines were published.

This summer, I was contacted by one hospital  They asked me to outline the benefits of supporting mothers who wanted to plan a VBAC.  I jumped on the opportunity and wrote a long email which basically outlined the reasons why they not only should allow VBAC, but why they should seize this moment to attract a niche market of natural birthers by becoming the only “mother-friendly” hospital in the area.

This email was circulated and they invited us to come and present our case for “mother-friendly” maternity care to the CEO, the head of obstetrics, the chief nursing officer of the hospital.  Genet and I prepared a power-point presentation which explained why it made good business-sense to become “mother-friendly” and went together to make the presentation.  We received excellent feedback after the presentation.

The hospital did indeed reverse the ban (along with two other hospitals who simply made the move without our input) and I believe that they are in the process of getting approval to retrofit one of the LDR (labor-delivery-recovery) rooms with a permanent labor tub.  We also hope to work with their nursing staff to encourage them to receive “mother-friendly nurse” recognition.

We are so thankful for the help we received from CIMS and BirthNetwork National in giving us the framework for the information we presented to this hospital.  Without the institutional support of both, I’m afraid we would have looked just like a couple of home birth nuts.  But because we had the CIMS and BirthNetwork connections and information, we were able to put forth a convincing argument for changing the way hospitals do business.”

For additional information about changing VBAC bans in your community see ICAN’s Advocacy webpage.

A California Non-Profit Helps Mothers Reduce Their Odds for Cesarean By Helping To Pay For Doulas, Midwives, and Birth Center Births

2 Dec

As with many other communities in the United States, in South Orange County, California expectant mothers have unlimited access to high intervention hospital options for childbirth, including an elective cesarean section, but restricted access to a midwifery model of care in or out of the hospital. However, the Community Alliance for Birth Options (CABO), a non-profit group dedicated to helping families access non-interventive care believes that all expectant mothers should have access to birth options that meet their needs. CABO awards women, with financial hardships or lack of insurance coverage, scholarships to help pay for non-interventive maternity care services of their choice. Research shows that by giving birth with a midwife, having a doula, and giving birth at home or in a birth center women are much less likely to be exposed to the harms of routine medical interventions and less likely to have a cesarean.

In May 2008 the only hospital-based nurse-midwifery service in the community was disbanded when the OB services at South Coast Medical Center closed its doors. However, through donations and by sponsoring annual fundraisers and silent auctions CABO has found a way to provide families with the financial support they need to pay for a doula, choose a certified nurse-midwife as a primary care provider, or give birth in a birth center. Often, health insurance coverage does not include reimbursement for these services.

On December 10, 2010 CABO will hold its Holiday Evening Fundraiser at the Coto De Caza Golf & Racquet Club. Last May CABO awarded three scholarships of up to $3500. All awards are kept confidential.

CABO also provides outreach and education on alternative and complementary maternity services for women. The non-profit’s goals include advocating for evidence-based care, educating the community about the safety of low-interventive birth options, promoting collaborative practice of nurse-midwives and physicians, and advocating for change in the current health care system.

CABO and other birth activist groups who support the midwifery model of care are actively pushing back the medical establishement and insurance companies who control access to and reimbursement for midwifery care, birth centers, doulas, VBAC, and home births.

Watch a video about Beach Cities Midwifery, one option available to families in South Orange County.

http://www.youtube.com/watch?v=At65_ekEZM0

Resources For Non-Interventive Care

American Association of Birth Centers

BirthNetwork National

Citizens For Midwifery

Dona International

Mothers Naturally

My Midwife

The Big Push for Midwives

Where’s My Midwife?

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