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Some thoughts on practice guidelines and VBAC as a “vital option”

March 3rd, 2010 by avatar

VBACNext week, scientists, policy experts, and advocates will come together for the National Institutes of Health Consensus Development Conference on Vaginal Birth after Cesarean (VBAC). A panel will spend three days reviewing the evidence and hearing public testimony. On Wednesday they’ll announce their findings in a press telebriefing.

The NIH isn’t calling their findings “practice guidelines,” but they’re very likely to be taken as such. I’ll admit: the concept of guidelines, at least as they are developed and used in the United States, is a little troubling to me. On the one hand, guidelines can represent, as the Institute of Medicine suggests, “a move away from unexamined reliance on professional judgment toward more structured support and accountability for such judgment.” But what about their limitations?

Guidelines are seen by the public and by health professionals as objective and scientific, but:

Experts often look at the same body of evidence and come up with different conclusions.

  • Chauhan and colleagues have demonstrated significant variation across national guidelines in management of shoulder dystocia and intrauterine growth restriction. In other words, the American Congress of Obstetricians and Gynecologists (ACOG) doesn’t agree with its counterparts in other countries about how these conditions should be diagnosed and treated.
  • A study in the current issue of Birth compared VBAC guidelines from six countries and found little agreement not just on practice and management issues, but on the data itself: they found a four-fold variation in the reported upper-end risk of uterine rupture, as well as significant variation in the reported likelihood of vaginal birth in a VBAC labor.
  • In 2008, ACOG reversed its position on the safety of expectant management of prelabor rupture of membranes, without citing any new evidence at all (and despite the publication of new evidence that, if anything, strengthens the argument for expectant management.)

Often, experts aren’t even looking at the same body of evidence.

  • In the comparative study of national VBAC guidelines, 22 individual references were cited for uterine rupture, none of which appeared in all six guidelines. Only two studies were cited in three of the national guidelines and an additional 5 studies were cited in two national guidelines.
  • In the shoulder dystocia review only half of eligible references were cited in both of the national guidelines the researchers analyzed.
  • In the review of intrauterine growth restriction, only 12% of references were cited in both national guidelines.
  • Guideline authors rarely if ever include a rationale for why they included the studies they included and excluded others.

The evidence they are looking at is often limited or flawed.

Even when guidelines are evidence-based, they’re often ignored.

  • When ACOG issued new guidelines about fetal heart rate monitoring in labor last year, blogs and Twitter went nuts with the news that they had finally admitted that intermittent auscultation is safe and effective, and that continuous electronic fetal monitoring doesn’t live up to its many promises.  I pointed out at Our Bodies, Our Blog that ACOG hadn’t changed a single word of its guidelines with respect to intermittent auscultation and the limitations of EFM; it’s just that their recommendations had been ignored. (No surprise: they’re still being ignored.)

And then there’s the not-so-small issue that guidelines suggest that a “one size fits all” approach will translate into the best care for everyone, which anyone who takes care of patients or has been a patient recognizes is flat-out false. We all have different reasons for making the health choices we do. An individual’s informed consent or refusal can and should trump guidelines, but in practice, guidelines dictate practice and policy for all women. Case in point: the last time ACOG issued VBAC guidelines, hospitals and care providers began banning vaginal birth outright in women with prior cesarean surgery. The VBAC rate in this country plummeted virtually overnight.

The International Cesarean Awareness Network is hosting a blog carnival on the theme, “Why is VBAC a Vital Option?” I suspect we’re going to hear a huge range of responses, along with some stories of the astounding lengths some women have gone to in order to ensure that VBAC remained a viable option for them. Not every woman goes to these lengths – plenty of women are perfectly happy to have repeat cesareans and would make that choice even if VBAC was offered and supported – but these stories underscore the fact that blanket guidelines will not apply to every woman everywhere.

Despite all of this, I’m actually rather optimistic about the NIH VBAC Conference. In my mind, the situation around VBAC has gotten so bad in this country that a fresh look at the issues and the evidence can only help matters. Plus, the meeting comes on the heels of major recommendations for maternity care reform and the conference findings are likely to echo and lend credence to many of these. Judith Rooks shares six more reasons we should be optimistic about the upcoming meeting. And last but not least, there is a huge consumer contingent planning to have their voices heard at this conference either in person or by webcast, and many of them are connected via social networks to a far greater number of consumers. You can hear me and Lamaze President-Elect Debra Bingham on The Feminist Breeder’s Blog Talk Radio Show on Monday, recapping Day One of the proceedings.

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Let Your Voice Be Heard at the #VBAC NIH Consensus Development Conference

January 4th, 2010 by avatar

VBAC_WebImage

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.

text-box-2The 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.

cesarean 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!

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