Why were good science and best interests of mothers and babies thwarted in the evidence report and conference process? Major resources were allocated to address the priority question of the safety of increasing casual and fully elective use of cesarean section in comparison with planned vaginal birth. Women, providers, policy makers and others would all benefit from high-quality guidance from the federal government on these matters. Unfortunately, the process and products are instead contributing to confusion and controversy.

The inside story of what happened remains to be told. Here are some important questions:

* Why was the focus exclusively on mothers’ demand for cesarean while failing to address provider and other health system pressures, such as liability fears and convenient scheduling and staffing?
* Why was the “maternal request” frame retained in the face of no evidence report data whatsoever about incidence or trends in the U.S. and about effects in any context?
* Why did the final panel statement fail to reference actual data on “cesarean delivery on maternal request” as defined by NIH, available from Listening to Mothers, a national U.S. survey of women who gave birth in 2005, which was conducted by the leading survey research firm Harris Interactive and was reported in two presentations at the NIH conference, while the panel statement provided much detail about other evidence described as “proxy,” “weak,” and of “little confidence”?
* Why were biases in the entire process consistently in the direction of favoring cesarean delivery and discrediting vaginal birth, beginning with focused searching for just a few of the possible outcomes?
* Why did responses to the third key question fail to identify any of the many well-established effect modifiers that promote safe, spontaneous vaginal birth and favorably alter the risk profile for mothers and babies in the present pregnancy and over the long term?
* In planning, carrying out and reporting on the evidence report and conference, why were such valuable and important perspectives as family medicine, midwifery, nursing and consumer advocacy entirely excluded or given extremely marginal roles?

I think we have to be proactive to make sure the same mistakes aren’t made this time around.

As for the non-safety factors, key question #5 is “What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean?” I’ll be covering it here shortly and certainly hope you’ll chime in. I think we’re going to find lots of answers to that question among readers.

The image above is one that I use in virtually all of my lectures on VBAC. It clearly shows that the CS rate rises (significantly) as VBAC rates decline. Given the epidemiological trends in rates of VBAC, CS rates and trials of labor, it would be interesting to see if there is (as I suspect) correlating data in rising maternal complications with rising cesarean deliveries. The data is clear that for an individual patient there are significant risks with each subsequent CS delivery (placenta previa, placenta accreta, etc); however I would be interested to see if we now have epidemiological (population based) increases in adverse maternal outcomes in the last 10 years.

As we have previously discussed here and elsewhere, the refusal to offer the option of a VBAC is problematic from an obstetric, ethical, and business perspective. If you say that a procedure has a 97% chance of NOT being complicated and then offer that same procedure 0% of the time; I don’t think that it can be justified as a medically sound judgment.

Perhaps there should also be further discussion regarding the factors that influence avoidance of VBAC besides safety (which I don’t think is justifiable as I’ve outlined above).

Experience of physicians, financial incentives, fear of malpractice and misconceptions about the procedure need to be addressed in order to turn the tide toward options that benefit patients.

Thanks again for facilitating the conversation…