Unquestionably, the accessibility and safety of VBACs or vaginal birth after cesarean section has become an issue of controversy for pregnant women and birth activists. It’s an issue taken up by reproductive justice advocates who see the connection between choices in childbirth and the choice to continue with a pregnancy or not. Over the last decade VBACs have become increasingly less accessible with fewer clinicians and facilities willing to provide them, despite and with little regard for pregnant women’s desire to have a vaginal birth after a cesarean. The overwhelming reasons given focus on the safety of VBACs. Given the refusal of doctors and hospitals to allow low-risk pregnant women to experience what experts call a “trial of labor” over a planned c-section, it would stand to reason that maternal mortality and maternal health in the U.S. would be improving. This, however, is not the case. One out of every three babies in this country is born via c-section – far exceeding the World Health Organization’s recommendations that a country’s c-section rate remain between 5 and 10 percent. And maternal mortality rates in the U.S. have only been rising.
It’s why the National Institues of Health convened a 15 member panel of experts to address VBACs in the United States for a Consensus Development Conference – a conference which wrapped up today. The conference brought together an independent panel of experts including obstetricians, gynecologists and experts in maternal/fetal pain in order to create consensus on the safety and availability of VBACs.
Pouring over thousands of pages of evidence and peer-reviewed studies over the last few weeks, the all volunteer panel’s assessment of VBACs ultimately confirmed what birth activists and advocates of evidence-based maternal and newborn care have been saying:
“…that a trial of labor is a reasonable option for many women with a prior cesarean delivery. They [the panel] also urged that current VBAC guidelines be revisited, malpractice concerns be addressed, and additional research undertaken to better understand the medical and non-medical factors that influence decision making for women with previous cesarean deliveries.“
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On a briefing call for the press and in a press release, the panel’s chair, Dr. F. Gary Cunningham, chair of obstetrics and gynecology at the University of Texas Southwestern Medical Center confirmed the clarity of the panel’s findings saying,
“The VBAC rate has gone from 30% to 10% over the last fifteen years… [which] would seem to indicate that planned repeat cesarean delivery is preferable to a trial of labor. But the currently available evidence suggests a very different picture: a trial of labor is worth considering and may be preferable for many women…The use or employment of VBAC is certainly a safe alternative for the majority of women who have had one prior c-section.” [emphasis mine]
Dr. Cunningham and the NIH spokesperson did note that these findings are not attributable as NIH guidelines but rather should be looked at as conclusions “about where we stand and what we can do to provide better resources to women of whom we speak.”
The panel also recommended revisiting the guidelines put forth by the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists on ensuring the “immediate availability” of surgical and anesthesia personnel before allowing a trial of labor for a woman who has had a previous c-section. Two recent surveys of hospital administrators found that 30 percent of hospitals had stopped offering trial of labor or providing VBAC services because they could not meet this standard, creating a serious barrier to that option. According to a panel member,
“…we recommended these organizations reassess their requirement relative to other obestetrical issues. Bad outomes with VBACs aren’t very common – there may be only 10 catastrophic outcomes out of 100,000 births. We’ve seen an association but not necessarily a cause and effect.”
But perhaps the most controversial part of the conference came when a panel member asserted that pregnant women may not have full rights to informed consent when it came to undergoing surgical procedures (ie cesarean sections).
Birth activists from The Feminist Breeder to Courtoom Mama to The Big Push for Midwives tweeted their outrage. Tweets from those in attendance or those following the conference reflected the frustration with the statement:
“evidently pregnant women can have preferences, but not rights. Let’s take it to court!”
“…Panelist just said it is not a settled matter of ethics or law that women make their own choices. Huh?”
“It is not a settled matter of ethics or law that informed refusal applies to pregnant patients.”
“It’s 2010, people, and the people we trust to catch our babies aren’t sure we have constitutional rights?”
Susan Jenkins with The Big Push for Midwives pressed the panelists during the press briefing afterwards asking them to confirm that, in fact,
“…The panel is unwilling to affirm the ethical necessity of recognizing that a woman has an absolute right to informed refusal of a surgical procedure that may cause harm to her?”
To which the panelists resonded that
“..the claim that the right to refuse is a controversial claim is not at all so in law or medical ethics. That controversy is way beyond the scope of this panel. However, we did emphasize the need for an evidence based, unbiased approach to the informed consent process to make sure women are informed about surgeries so that they may make their own decisions for themselves. So there is a strong emphasis on informed consent in our conclusions.”
However, the draft statement, Jenkins noted, indicated that the panel’s position was that “only where it’s considered ‘medically reasonable’ would women have the right to refuse and there is no definition of medically reasonable.”
The panelists said that it was the physicians’ job in such cases to “help women make a decision that reflects her values.”
To which Jenkins responded, “What if her values are to say no at the end of all of that?”
The final draft of the panel’s statement is scheduled to be published this evening. If the NIH VBAC panel aims to take a strong stand that for the health and safety of pregnant women and their fetuses VBACs must become increasingly accessible, ensuring language that states that women have the opportunity to make the final decisions about their health is critical.