Let Your Voice Be Heard at the #VBAC NIH Consensus Development Conference
I arrived home from my holiday vacation to a stack of mail that included an invitation from the National Institutes of Health to attend the Consensus Development Conference on Vaginal Birth after Cesarean this March. The conference is free and open to the public and will be broadcast by live webcast. Invited experts will present findings from a systematic review of the scientific evidence, consider several key questions, accept public comment, and ultimately prepare a consensus statement.
The 2006 so-called “Cesarean Delivery on Maternal Request” (CDMR) NIH Conference was deeply flawed and yet legitimized the tiny number of truly elective primary cesareans on the basis of maternal autonomy. NIH Consensus Conferences can influence policy and practice, so as advocates for safe and healthy birth choices and for patients’ rights to informed consent and refusal, it is in our interest to see that the upcoming VBAC conference brings together the best possible evidence on all birth choices for women with prior cesareans.
Here at Science & Sensibility, we will be offering our thoughts on sources of data for each of the conference’s key questions, focusing on sources that are likely to be missed, ignored, or undervalued by the panel.
The first question…
What are the rates and patterns of utilization of trial of labor after prior cesarean, vaginal birth after cesarean, and repeat cesarean delivery in the United States?
The panel will certainly look to CDC data for this question, and will see the all-to-familiar curve.
I would suggest the following additional sources:
The Listening to Mothers II Survey, a nationally representative survey of women who gave birth in U.S. hospitals in 2005. The researchers found:
Among those women who had had a cesarean in the past, 11% had a vaginal birth after cesarean for the most recent birth, while 89% had a repeat cesarean. Of women with a previous cesarean, 45% were interested in the option of a VBAC, but most of these women (57%) were denied that option. The most common reasons for the denial of the VBAC were unwillingness of their caregiver (45%) or the hospital (23%), followed by a medical reason unrelated to the prior cesarean (20%).
The Database of Hospital VBAC Bans produced by volunteers from the International Cesarean Awareness Network. The Database lists all hospitals with official policies banning VBAC as well as those with “de facto bans,” in that the hospital allows VBAC but none of the providers practicing there offer the option to their patients. According to a press release about the database, the number of hospitals banning VBAC has increased 174% since 2004.
Evidence that hospitals are relying on court-ordered cesareans to enforce VBAC-bans, resulting in high-profile cases, such as that of Joy Szabo who traveled hundreds of miles to another hospital to avoid the court ordered repeat cesarean and Laura Pemberton, who planned a home birth in an unsuccessful attempt to avoid one.
If you have other data sources you think are important for the VBAC Conference, with respect to the question of utilization patterns, please leave them in the comments!
Amy, Thank you for highlighting the spectrum of information that should be covered at this conference in order to come up with the evidence based policy directives in this important area. I am planning on attending the conference and would really like to meet you there if you plan to attend…
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…
Thanks for your thoughts. I hope to go to the meeting. If not, I will definitely attend the webcast. I’ll certainly let you know if I do plan to attend.
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.
I just registered – I’m totally going. Haven’t broken the news to the husband yet though! I just wrote an entire proposal for my Truman scholarship directed at Kathleen Sebelius, specifically on this topic (http://thefeministbreeder.com/the-case-for-reducing-the-cesarean-rate/) – so I’m DYING to see what is said about it here.
I hope I am not the only one reading positive vibes from that mailing. The fact that their general info flyer includes the point that non-medical factors may be influencing VBAC decisions makes me very hopeful that a positive and balanced statement will come from this meeting (and I’d like to just strike out that word, as we all know these non-medical factors do influence these decisions). I wish I could go, and look forward to their statement post-meeting.
Thanks for the post and the information it brings. I didn’t get that flyer but might be interested in going or doing the webcast. I’ll check out the link.
@Labor Nurse, CNM
I certainly don’t want to sound pessimistic. In fact, I’m quite optimistic that this meeting will be part of a pendulum shift back toward ensuring safe VBAC access. But I also recognize that meetings like this often undervalue or ignore the consumer voice and fail to incorporate all of the relevant evidence. After the Maternal-Request Cesarean Delivery meeting at the NIH, Childbirth Connection issued a response that raised many methodological issues and highlighted irregularities and apparent biases in the process. They wrote:
I think we have to be proactive to make sure the same mistakes aren’t made this time around.
Amy, thanks for pointing that out. “Maternal request” is interesting, in my opinion- such as the “elective repeat” cesarean. As we know, many “elective repeats” aren’t truly elective on the woman’s part…and “maternal request”, in my opinion, seems to be a way to make everything “ok” with not doing VBAC if the woman is “requesting” a c-section.
How do I attend the web seminar? Thanks, Nancy Thompson