NIH Post VBAC Conference Consensus Statement

March 12th, 2010

Following the 3 days of meetings and discussions between the National Institutes of Health’s Consensus Development Program, various obstetrical experts and birth advocates on the viability of vaginal birth after cesarean section (VBAC), the NIH has released a consensus statement highlighting the key points from the discussion,  where they believe subsequent research needs to focus and their recommendations to obstetricians about how to approach the subject of VBAC with their patients.

Here is a summary of the consensus statement.

  • The panel affirmed that a trial of labor (TOL) is a reasonable option for many women with a prior cesarean delivery.
  • Rigorous research shows that a trial of labor is successful in nearly 75 percent of cases, and maternal mortality is actually lower for women who have a trial of labor, regardless of whether they end up delivering vaginally or by cesarean, though those women who have an unsuccessful trial of labor and undergo a repeat cesarean delivery experience higher morbidity than those who have a successful VBAC.
  • Concerns have arisen because although VBAC does reduce morbidity in mothers, there is a slightly increased risk of morbidity and mortality to the fetus. The Panel is asking for more research to see if these disparities can be resolved and definitive risks determined for both mother and baby.
  • The panel is advocating for additional research to develop clear, evidence-based risk assessment tools to assist mothers and providers in the decision-making process from early pregnancy through delivery, accounting for individual risk factors, values, and preferences to see who is an appropriate candidate for TOL and VBAC and who is not.
  • The Panel strongly recommended that policymakers and providers collaborate in the development and implementation of appropriate strategies to address malpractice concerns that may keep providers from recommending VBAC, such as increases in malpractice premiums and threat of litigation in the event of untoward events.  These factors and others seem to be (along with other factors) exacerbating barriers to TOL  for women with a previous cesarean delivery.
  • The Pannel recommends that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess the requirements to have an obstetrician and anesthesiologist “immediately available” while any woman who is having a TOL is laboring.  This recommendation has created a significant barrier to TOL and VBAC for many hospitals who cite the cost of having an obstetrician and anesthesiologist constantly on call is prohibitive. They ask the societies to compare VBAC risk relative to other obstetrical complications of comparable risk, risk stratification, to see if it is truly necessary in light of limited physician and nursing resources.
  • The Panel recommends that Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. This will help the providers and patients better assess if a TOL really is a viable option for their situation.
  • They  recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate to develop integrated services that would reduce or even eliminate barriers to a trial of labor and subsequent VBAC.

The full NIH Consensus Statement is available Here.

Policy makers need to hear from us if we want to have choices in how we give birth to our children. I am in contact with many advocacy groups and will share your concerns. Please add your comments to the panel discussion in the comments section.  ~DTL

A VBAC is Safer on an Indian Reservation than in a Major US Hospital

March 10th, 2010

NIH Consensus Development Conference on Vaginal Birth After Cesarean Section

For the past 2 days, the National Institutes of Health has hosted a conference to develop a consensus statement on Vaginal Birth after Cesarean Section (VBAC). In the United States, nearly one in every three births is via cesarean section, a number that is more than double the 15% cesarean section rate recommended by the World Health Organization. The high number of cesarean sections in the United States comes in large part from repeat cesareans. The current NIH discussion is to determine whether or not a woman who has had a prior cesarean section should automatically have cesarean sections with subsequent pregnancies, whether or not VBAC’s are safe and in what situations should they be performed.

Proponents of VBAC argue that VBAC’s are safe in women who are at relatively low risk and when the procedure is performed by competent labor attendants (midwives) in a mother friendly environment. (For more on mother friendly childbirth, see MFCI.) Opponents say that VBAC’s pose unacceptable risks to both the mother and baby due to the risk of uterine rupture, hemorrhage, and potential death of both mother and baby. So who is right? Ironically, both sides because the success of VBAC rests in large part with where it is done and who attends that birth.

One with nature-The Indian Health Service

The March 6, 2010 New York Times published an article by columnist Denise Grady reporting on the successful birth rates at the Tuba City Regional Healthcare System in Tuba City, Arizona. This hospital is part of the Indian Health Service, A federally funded healthcare program that serves Native American Indians and Alaska Natives, and is run by the Navajo Nation. This small hospital which delivers about 500 infants annually has a 32% VBAC rate and an overall cesarean section rate of 13.5%, despite the fact that many Native American women develop gestational diabetes and hypertension during pregnancy which, if they were being cared for by the conventional US health care system, would make them more likely to have cesarean section deliveries.  How is such success possible?

Parameters that contribute to a low cesarean section rate overall and to high VBAC rates

To Fully understand the success of Tuba City and other hospitals like it, one must look at how the the overall system is structured. There are 5 specific things that Tuba City has in place that allows for their success.

1. Midwives attend most of the vaginal deliveries.

Midwives are more likely to “wait it out” if a woman is having a long labor and the baby isn’t in distress than to recommend a cesarean section. Midwives never induce labor, a process known to increase the likelihood of a cesarean section becoming necessary. Midwives are trained to assist women during childbirth process rather than to try to control it.

There is additional incentive amongst Native Americans to avoid cesarean sections. Many Native American couples wish to have more than 2 children and are educated about the dangers of repeat cesarean sections. Additionally, Native Americans believe that incisions are a threat to the spirit of the person being cut, so surgery is something to be avoided as much as possible.

2. Any and all family members are present and welcome.

In Tuba City as well as within any Navajo community, a laboring woman is never left alone. Not only will her partner be present, most likely her mother, grandmother, aunts, cousins and any other female relatives or family members. The laboring mother is constantly massaged and offered sips of water and small bits of food. With all of this support and her own prior exposure to labor and childbirth, the laboring mother has no fear whatsoever of her own labor and delivery.

3. Easier Adherence to ACOG VBAC Guidelines

The American College of Obstetricians and Gynecologists hs issued guidelines for VBAC’s. An obstetrician and anesthesiologist should be present or very quickly accessible while a woman who has had a previous cesarean section is laboring in the event that she requires and emergent cesarean section.

While many community hospitals have been unable to meet this criteria citing cost prohibition of maintaining professional staff on call at all times, hospitals on Indian reservations have had no such problem. The Tuba City Hospital is located within the property of the Navajo Indian reservation. Many of the physicians who work at the hospital either live on the reservation or within minutes of the hospital. Many doctors who are on call may actually go home while a midwife attends a birth because if they are needed, they can be at the bedside within minutes.

4. No Threat of Malpractice litigation

The Tuba City Hospital and its doctors are federally insured against malpractice because it is a federally funded facility. Hence the obstetricians are not as concerned about being sued if complications arise or about increases to or complete cancellation of their malpractice premiums.

5. No threat of wealth

The professionals that staff the hospitals in the Indian Health Services are paid flat salaries; $190,000 to $285,000 annually for the physicians and $80,000 to $120,000 for midwives. Since the staff is not paid per procedure, there is no incentive to do more and potentially unnecessary procedures.

“Conventional” Wisdom

In conventional western medicine, childbirth is a procedure to be managed and controlled. In most US hospitals, laboring women are not allowed to move freely because they are hooked up to fetal monitors. They labor in bed and primarily on their backs-the least comfortable position in which to labor.

A woman is not allowed to have anyone she pleases at her side and many times is alone during her labor process when the doctor or nurse needs to “check her progress.”While many women hire doulas, many US hospitals still try to and successfully block their presence in the labor and delivery rooms.

Many more interventions are involved; from intravenous fluid administration, to epidural anesthesia, to labor induction with oxytocin, an episiotomy (a surgical incison in the perineum to allow passage of the baby without tearing. Not usually needed but frequently done “just in case.”), to forceps and/or vacuum extraction of the baby to cesarean section. The natural process of  labor and delivery is now seldom allowed to “play itself out.”

Why is there such a disparity between the two methods?

In this era of Health care reform and in the midst of this contentious debate, the Navajo nation is a blatant example of less being more. The United States spends more money than most industrialized nations for health care and yet we have some of the sickest, most obese citizens in the world. We also have some of the highest maternal and infant mortality rates in the industrialized world. We are in no way, shape or form getting what we are paying for.

If the United States truly wants to lower cesarean section rates to be more in line with WHO recommendations, if it wants to  improve VBAC rates and if the US truly wants to improve  maternal, fetal and infant mortality, we have to change how we do things.

  • Births should be attended to by the most qualified attendants-midwives.
  • In uncomplicated situations, labor and delivery should be allowed to progress naturally at their own times.
  • Women should be allowed to move freely during labor and to have anyone they need present. Cultural and religious traditions should be respected.
  • Treatments and interventions should be administered on a case by case basis and not as standards of care. Interventions should be kept to a minimum and not be performed as a defense against litigation.
  • Monetary incentive should not be given to providers for more interventions, yet providers should be assured of adequate compensation for their skills.

Most physicians in our current health care system would balk at these recommendations because these would represent sweeping changes in the way they are trained, how they practice medicine and most especially in the way that they are paid. However we Americans, especially we women, have to ask ourselves how much longer are we going to put up with and pay into a system that clearly does not have our best health at its core?

It will be interesting to see what the NIH consensus comes up with. Quite frankly I am not all that encouraged that much is going to change, but the fact that there was even the discussion means that we are moving, ever so slowly, in a more positive direction.