Posts Tagged ‘research’

NICHD Seeking Beta Testers for PregSource Data Collection Tool

November 24th, 2015 by avatar

Become a PregSource Beta TesterLamaze International frequently collaborates with stakeholders, researchers and other organizations who share an interest in maternal child health and improving maternity care for families both in the USA and internationally.  As part of this collaboration, Lamaze International would like to ask for your help in recruiting pregnant people, people who were pregnant in the past year or even those who are thinking of becoming pregnant to participate as beta testers before the PregSource data collection tool is launched to the public.

The objective of PregSource: Crowdsourcing to Understand Pregnancy (PregSource) is to better understand the range of physical and emotional experiences and alterations in behavior that women have during pregnancy and after giving birth, the impact of these experiences on women’s lives, and the perinatal challenges encountered by special sub-populations of women.

To advance these efforts, here is a some wording that you can use to invite class members, clients and patients to participate in the PregSource beta testing.  You are free to use this letter as is, or modify to suite your needs.  This would be a great news tidbit to include in your regular e-news, social media postings and share with your classes.

The information obtained from this study will be helpful in improving prenatal care for women.  Help Lamaze International and their research partners to successfully test this program.  Your effort is greatly appreciated.

Sample Letter

Lamaze International is partnering with Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), part of the National Institutes of Health, on a project called PregSource. PregSource is a crowdsourcing research effort that aims to improve understanding of the range of physical and emotional experiences that women have during pregnancy and after giving birth.

Because PregSource relies on crowdsourcing, we will be gathering information directly from pregnant women themselves, asking them to enter information about their pregnancies and the health of their babies into online questionnaires. Women who use PregSource can view how their responses compare to other PregSource participants, print or email reports to share with their health care team, and receive information from trusted sources on pregnancy-related issues.

PregSource is currently looking for beta testers to help ensure that the online platform is appropriate and that it is working correctly. If you or someone you know is pregnant, thinking about becoming pregnant, or were pregnant in the last year—we want YOU! Your assistance is critical to ensuring that PregSource can meet its goals. Please note that for the pregnant beta testers, we will need to verify some of the information using a copy of their medical records. We are committed to keeping all personal information secure and will destroy the medical record as soon as we have verified the information.

 If you are interested, please send your name, stage of pregnancy (or if already delivered) and email address to the NICHD at PregSource@nih.gov

We value your participation and your interest in helping us launch PregSource.

Childbirth Education, Lamaze International, Research, Research Opportunities , , ,

Series: Supporting Women When a VBAC Doesn’t Happen – Part One: A Unique Grief

November 5th, 2015 by avatar

By Pamela Vireday 

“Although the world is full of suffering, it is also full of the overcoming of it.”  –Helen Keller

CBAC part 1I am delighted to share with you a three part series that begins today, written by Pamela Vireday, who is an occasional contributor to Science & Sensibility.  In this series, Pamela examines the topic of women who experience a Cesarean Birth after a Cesarean. This is when families are planning for a vaginal birth after a prior cesarean, but the birth does not go as planned.  The experiences of women who have a CBAC are often negated and their emotional and physical well-being given short-shrift by both professionals and their social community of friends and family.  The research on this topic is slim and begs for exploration by qualified investigators.  Today, Pamela discusses the unique grief that CBAC women may experience.  Part two will examine the limited research available and part three will provide information on how to support CBAC women in the absence of published research.  We will also conclude the series with a useful resource list to share with the families you may work with  who find themselves in this situation.  You can also read a companion piece of Pamela’s own personal story, “Cesarean Birth after Cesarean, 18 Years Later” on her own website.- Sharon Muza, Community Manager, Science & Sensibility.

It is a hard truth that not all women who want a VBAC will have one.

In a typical high-intervention hospital setting, about 60-80% of women who attempt a VBAC will have one. (Grobman 2010) That’s a terrific, strong reason to support VBACs.

The underappreciated flip side of this statistic, however, is that about 20-40% of women who attempt a VBAC will have another cesarean instead, often after a long, hard labor. Yet little attention has been paid to these women and their families. How do they feel about their experience? How is their emotional journey different than after a primary cesarean or an elective repeat cesarean? What do these women need to integrate this experience into their lives?

Anecdotally, many women report that they did not feel supported after a VBAC attempt  (referred to as TOLAC – Trial of Labor after Cesarean) that ended in another cesarean. Some even felt judged or deserted by their care providers and friends. Research shows that the physical recovery is often harder, too. Yet little attention has been paid in the research to the needs of these women, and few resources exist that directly address their experiences.

Where is the support for women who have an undesired, unplanned second cesarean? Where is the acknowledgement of all the work they put in towards a VBAC, the hours of labor, the pain, the worry? Does all that preparation and work not count if one does not end up with a VBAC?

How can we in the birth field better support the women who do not have a VBAC? How can we help all mothers feel supported, regardless of outcome?


The first thing that we can do is to be mindful of our terminology.

Obstetric research typically uses the terms “Failed VBAC” or “Failed Trial of Labor After Cesarean” (Failed TOLAC). Many women feel that this terminology is judgmental and insensitive, adding to their emotional wounds at a time when they feel most vulnerable. Women who did not get a VBAC are not failures. The reality of birth is much grayer than a black-or-white, success-or-failure binary equation.

The term, “trial of labor cesarean,” is a better alternative than “failed VBAC.” However, it is cumbersome and perpetuates the mentality of being “on trial.”

Members of the International Cesarean Awareness Network (ICAN) created the more-neutral term “Cesarean Birth After Cesarean” (CBAC) as an alternative. It helps distinguish between a repeat cesarean that was gladly chosen and one that occurred when a mother planned and worked for a VBAC but didn’t get one.

Most of the time, CBAC refers to a woman who labored and then had a repeat cesarean. However, sometimes CBAC can also refer to an unwanted repeat cesarean performed before labor for legitimate medical reasons, because the mother was coerced or scared into a repeat cesarean, or because she was unable to find a supportive provider. The point is that an undesired cesarean is going to have a different emotional resonance than one which was wanted.

Some women prefer “CSAC” (Cesarean Surgery After Cesarean). We will use “CBAC” here because its meaning is intuitive and it is a logical companion term to “VBAC” but women should choose the term that feels right for their experience.

Women’s Stories

Women who have had CBACs often report that they did not receive adequate emotional support from birth professionals, friends, or family after the birth.

“When it comes to support, I had tons when PLANNING the VBAC but once it turned into a CBAC? Everyone disappeared. No one was willing to talk to me about it. No one really had information to GIVE me about a ‘failed VBAC.’ “Sarah Vincent

“I remember after my failed [VBAC] attempt how much I needed to share my story, talk about my disappointment and sadness, and process what went wrong. But it seemed as though nobody wanted to hear it. It was almost as if my CBAC might be contagious so I should refrain from talking much about it.” Teresa Stire

Personally, I had a CBAC after 5 hours pushing with no progress. My doula made me feel like I had given up too soon. She left soon after the cesarean and I never saw or heard from her again, despite the fact that she was supposed to do a postpartum visit. Her abandonment spoke volumes. Sadly, her judgment was only the first of many from the birth world.

CBAC mothers often feel their decisions are second-guessed like this. Well-meaning people will go through a CBAC mother’s birth story, looking for “wrong” decisions that caused the CBAC. Sometimes CBAC stories are used as cautionary tales to other hopeful VBAC mothers. Even when there are things a CBAC mother might have changed about her decisions, being held up as an example of “what not to do” is incredibly hurtful.

Furthermore, the grief around a CBAC is different in some ways than that around a primary cesarean; women tend to feel more “broken” after a CBAC, as if their bodies had truly failed them, and many feel isolated and unsupported. Yet the birth community treats CBACs as if they are no different from primary cesareans. CBAC mothers have shared:

“I personally felt screwed by careproviders after my 1st CS, but after my 2nd I felt screwed by my body― I truly was broken.” Elaine Mills

“The isolation of CBAC is another aspect that may be relatively unknown. I felt very isolated ― from vaginal birth moms, from Elective Repeat Cesarean moms (ERCS) moms, and very much from VBAC moms. This has been very toxic for me.”   Rebecca H.

“Validating the…compounding nature of that loss (as opposed to a primary c/s) ― the nail in the coffin feeling ─ is so important.” Caroline Kelley

A CBAC is not experienced in the same way as a primary cesarean or an elective repeat cesarean. The grief resonates differently, even if the CBAC was prudent or necessary. Yet seldom is the unique nature of this loss acknowledged. How can we, as birth professionals, recognize these differences and support these women through this emotional journey? More on this in the Part Two of the series on Tuesday.


Grobman, W. A. (2010, August). Rates and prediction of successful vaginal birth after cesarean. In Seminars in perinatology (Vol. 34, No. 4, pp. 244-248). WB Saunders.

About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 20 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.


Cesarean Birth, Childbirth Education, Guest Posts, Series: Supporting Women When a VBAC Doesn't Happen, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , ,

Lamaze Parent Satisfaction Survey Will Benefit Families – Educators Play a Key Role in Increasing Response Rate

November 3rd, 2015 by avatar

VoteSurveyParticipation at in-person childbirth education classes has been on the decline in past years.  There has not been much research on the benefits of taking a childbirth class, and with the plethora of information available online, it is no surprise that enrollment may very well be on the decline.  At the same time, cesarean rates and obstetrical interventions have overall been increasing.  Maternal and neonatal morbidity and mortality rates have not been improving either.

In the 2013 Listening to Mothers  (LtM) III report, 59% of all first time mothers took childbirth classes, compared with 70% in the 2002 LtM I report.  In 2013, 17% of experienced mothers took classes, down from 19% in 2002 (Declercq, 2013, Declercq 2002).

Lamaze International, with its diverse and experienced team of Lamaze Certified Childbirth Educators, is in a unique position to collect data on the experiences of parents who take Lamaze childbirth classes and utilize Lamaze International resources.  The Lamaze staff and Board of Directors have developed and initiated a Parent Satisfaction Survey that can be filled out by families who have completed a Lamaze class.  The survey is meant to be completed after the birth of their baby, so that the information can be used to determine how their Lamaze class impacted their actual choices and experience.

The information being collected in this Parent Satisfaction Survey can play a key role in helping to:

Understand the impact of Lamaze classes

Data collected through these surveys can be used to understand the impact of Lamaze classes on families and birth outcomes and guide further research on this topic. Exploring this area of research can help Lamaze and other organizations to access funding to further develop and continue studying this important topic

Lobby for improved access

Information gained through these post-birth surveys  can be used to educate lawmakers on the outcomes of births when families participated in birth classes and encourage legislators to offer reimbursement and increased access for childbirth education classes across all socioeconomic and ethnic categories. Lamaze International plans to repeat their “Hill Day” campaign and lobby Congressmen/women in early spring of 2016 by visiting them in their D.C. offices and sharing information about maternal infant health and outcomes experienced by parents and infants during the childbearing year.

Improve information and educational materials

The results of the survey can help Lamaze International to be sure their message is on target and their educational materials are effective in sharing information on best practices, evidence based care and informed consent and refusal.  Lamaze can continue to develop curriculum and services that help families to “Push for Their Baby” during pregnancy, birth and postpartum.

Help LCCEs to deliver education

Every childbirth educator’s goal is to communicate important information to expectant families through engaging and effective activities.  Aggregated survey information can help Lamaze International provide information and direction to all the LCCEs so that they can assess how they can continue to provide valuable and useful information to the families participating in their Lamaze classes.

Share the message with other stakeholders

Information gleaned from the survey will be shared with policymakers and key third-party organization stakeholders at upcoming roundtables that Lamaze representatives facilitate in and host.  It is important for health care providers, hospital administrators and maternal infant health organizations to recognize how effective Lamaze childbirth classes can be be in creating a safe and healthy birth for participating families.

Linda Harmon, Lamaze International’s Executive Director took a moment recently to answer some questions about the Parent Satisfaction Survey.

Sharon Muza:  There is not a lot of research available on the effectiveness of childbirth/Lamaze classes.  Do you feel this information could be used as the basis of that research?

 Linda Harmon: Lamaze has commissioned a White Paper which will present the evidence related to childbirth interventions overuse in the US hospital system, and the effects they can have on childbirth outcomes, and present the argument that evidence-based prenatal education is a critical avenue for women when making childbirth care decisions.  The parent satisfaction survey will support this research by providing data from the parents who have used Lamaze resources.

SM: How could the information gained from this survey be used to further reimbursement for families who take childbirth classes?

LH: Data gained from the Lamaze Parent Satisfaction Survey will be used to provide important insights about the impact of Lamaze childbirth education on the experiences and outcomes of pregnant women and their babies. These insights will provide valuable information to support discussions with healthcare insurers, hospitals and other strategic partners to advance Lamaze education.  Preliminary data from the Lamaze national parent satisfaction survey shows that women engaged with Lamaze have a cesarean rate of 20%. That’s about 13% less than the national cesarean rate of 33%.  If a 13% reduction in cesarean could be translated across the U.S., the potential cost savings would be nearly $4.7 billion annually.

SM: Lamaze International is an international leader in childbirth education and offers a great curriculum filled with best practice and evidence based information.  Have initial survey responses indicated that our classes have been a useful component for families welcoming a child?

LH: The preliminary data is very positive, but we need substantially more parent survey responses to  validate general trends. In the initial review of survey findings in March 2015,  we compared what women told us in the Lamaze survey with what women reported in the highly-respected national survey Listening to Mothers III: Pregnancy and Birth.  Early survey responses show that 94% of women taking Lamaze classes say that education provided by Lamaze improved their childbirth experience and 91% feel well informed about decisions in labor and birth.

You Can Help Advocate for Childbirth Education

Lamaze Certified Childbirth Educators play a key role in getting the word out to the families who participate in their classes.  Through information received from you, families can be directed to the survey and asked to participate.  During the online survey, participants are asked a handful of simple questions that seek to learn if childbirth education improved their birth experience.

Lamaze has put together many resources for LCCE educators to help you understand the importance of this survey.  These resources include:

  • An FAQ to help you become familiar with the survey and encourage you to participate.
  • How to introduce the survey in class – We have created sample messages and instructions for  encouraging your students to sign up for the survey
  • Promote the survey – We have developed a sample email you can send your class, introducing them to the survey, as well as sample Facebook, Twitter and blog posts.

Every family that participates in the survey will receive a coupon for a discount on a Lamaze toy.

Win a 2016 Lamaze International conference registration

If you encourage participation, you will be entered to win a complimentary Lamaze International 2016 Annual Conference registration. If your name is referenced as their childbirth educator in the survey, you will be entered in the drawing—and the more your name is referenced, the more entries you will have!  This is a real bonus reason to share the survey with parents, even beyond the benefits to research and programs. 

 Are you already encouraging your families to take the Parent Satisfaction Survey?  Share your experiences in the comments section.  If you have not yet begun to communicate information to your families about the survey, I hope that you will reconsider as you recognize the importance of your role in collecting this valuable data.


Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and Birth; Report of the Third National US Survey of Women’s Childbearing Experiences. New York, NY: Childbirth Connection.

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Risher, P. (2002). Listening to mothers: Report of the first national US survey of women’s childbearing experiences. New York.

Babies, Cesarean Birth, Childbirth Education, Lamaze International, Lamaze News, New Research , , , , , ,

Time for ACOG and ASA to Change Their Guidelines! Eating and Drinking in Labor Should Not Be Restricted

October 27th, 2015 by avatar

“…The problem for anesthesiologists is that our practice guidelines on obstetric anesthesia are strongly worded, and state that women can not eat during labor. We can’t ethically design a large enough study to answer this question, so we will have to wait for expert opinion to change.” – Paloma Toledo, MD

Screenshot 2015-10-26 17.04.39Social media was all abuzz yesterday about information coming out of the American Society of Anesthesiologists (ASA) conference currently being held in San Diego, CA. Headlines everywhere screamed “Eating During Labor May Not Be So Bad, Study Suggests,” “Light Meal During Labor May Be Safe for Most Women,” and “Eating During Labor Is Actually Fine For Most Women.”  People chortled over the good news and bumped virtual fists over the internet celebrating this information.

The ASA released a press release highlighting a poster being presented at the ASA conference by two Memorial University medical students, Christopher Harty and Erin Sprout. Memorial University is located in St. Johns, Newfoundland, Canada. When a professional conference is being held, several press releases are published every day to advise both professionals and the public about news and information related to the conference. This was one of many released yesterday.

The student researchers suggested in their poster presentation that it may be time for a policy change. Their research indicated that, according to the ASA database, there has only been one case of aspiration during labor and delivery in the period between 2005 and 2013. That aspiration situation occurred in a woman with several other obstetrical complications. “…aspiration today is almost nonexistent, especially in healthy patients,” the researchers stated. The research was extensive – examining 385 studies published since 1990. Much of the research available supported the findings in the poster presentation/study.

The current policy of the ASA on oral intake in labor is that laboring women should avoid solid food in labor. You can read the ASA’s most current guidelines, published in 2007: Practice Guidelines for Obstetric Anesthesia An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia.  The American College of Nurse Midwives recommends “that women at low risk for pulmonary aspiration be permitted self-determined intake according to guidelines established by the practice setting.” They also conclude “drinking and eating during labor can provide women with the energy they need and should not be routinely restricted.”  American College of Obstetricians and Gynecologists recommends no solid food for laboring women and refers to the ASA guidelines.

I connected with Paloma Toledo, MD, an obstetrical anesthesiologist who is attending the ASA conference in San Diego to ask her what her thoughts were on this new research. “General anesthesia is becoming increasingly rare, so fewer women are at risk for aspiration, since most women will have neuraxial anesthesia for unplanned cesarean deliveries. The question is, is eating in labor unsafe? They do allow a light meal in the UK, studies have shown that eating does not adversely affect labor outcomes, and in the CEMACE data, despite allowing women to eat in the UK, there have not been deaths related to aspiration. I think a lot of women want to move away from the medicalized childbirth and have a more natural experience. Women want to eat, and I believe the midwife community has been encouraging eating in labor. The problem for anesthesiologists is that our practice guidelines on obstetric anesthesia are strongly worded, and state that women can not eat during labor. We can’t ethically design a large enough study to answer this question, so we will have to wait for expert opinion to change.”

Lamaze International released an infographic in July, 2014 covering this very topic. “No Food, No Drink During Labor? No Way!” and I covered this in a Science & Sensibility post sharing more details.  You can find all the useful infographics available for downloading, sharing and printing here.  Additionally, the fourth Healthy Birth Practice speaks to avoiding routine interventions that are not medically necessary, and it has long been clear that restricting food and drink in labor is certainly an intervention that should not be imposed.

It is important for birth professionals to recognize what the American Society for Anesthesiologists’ press release is and what it is not. We must not overstate the information that they have shared. Please be aware that this is not a policy change.

Hopefully, this will be a call to action by the ASA to examine the contemporary research and determine that that their existing guidelines are outdated and do not serve laboring and birthing people well, nor reflect current research.

Childbirth educators and others can continue to share what the evidence says about the safety and benefit of oral nutrition during labor and encourage families to request best practice from their healthcare providers and if that is not possible, to consider changing to a provider who can support evidence based care.


American College of Nurse-Midwives, (2008). Providing Oral Nutrition to Women in Labor.Journal of Midwifery & Women’s Health53(3), 276-283.

American Society of Anesthesiologists Task Force on Obstetric Anesthesia. (2007). Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia.Anesthesiology106(4), 843.

Committee on Obstetric Practice. (2009). ACOG Committee Opinion No. 441: Oral intake during labor. Obstetrics and gynecology114(3), 714.

Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003930. DOI: 10.1002/14651858.CD003930.pub3.

Childbirth Education, Do No Harm, Evidence Based Medicine, Healthy Birth Practices, Lamaze International, Medical Interventions, Research , , , , , , , ,

Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making – Interview with Study Author Melissa Cheyney, PhD, CPM, LDM

September 15th, 2015 by avatar


“Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making” came out on August 26th as an e-pub ahead of print in the journal Birth: Issues in Perinatal Care. It provides a much-needed analysis of VBACs in the home setting in the United States. To help the birth professional community better communicate the findings with students, clients and others considering home birth after cesarean (HBAC), Jeanette McCulloch of BirthSwell interviewed Melissa “Missy” Cheyney, PhD, CPM, LDM, one of the paper’s authors. The abstract of the paper, lead-authored by Kim Cox, CNM, PhD and co-authored by Marit Bovbjerg PhD, MS and Lawrence M. Leeman MD, MPH, can be found in an online-only version here. Additional insights specifically for midwives can be found at the MANA blog. – Sharon Muza, Community Manager, Science & Sensibility

Jeanette McCulloch: Tell me about the new study looking at outcomes for families planning a trial of labor after cesarean (TOLAC) at home.

Melissa Cheyney: This study is significant because it is the largest study to date on outcomes for women and babies who attempt a TOLAC at home in the United States. We were able to create two subsamples from the MANA Stats 2.0 data set: 12,092 multiparous women without a prior cesarean and 1,052 women with a prior cesarean. This enabled us to compare outcomes for women who went into labor intending to deliver at home and had a previously scarred uterus with those who did not. Our goal was to provide whatever information we could (given our sample size) about the potential risks and benefits of attempting a VBAC at home.

JMc: The actual number of people who are planning TOLACs is relatively small. Why did you think this research was important?

MC: We know that as long as the primary cesarean section rate in the US remains above 20% (it’s currently 21.5%), and as long as many women continue to desire more than one baby, families will be faced with important decisions about what to do in subsequent deliveries. Because there are well-known risks to repeat cesareans as well as to a trial of labor after cesarean, we wanted to make sure that we could provide women who are considering a VBAC (and especially a VBAC outside of the hospital) with as much information as possible to support shared decision making.

JMc: What were the top findings of the study?

MC: First off, we found relatively high success rates. Overall, women with a prior cesarean had a VBAC success rate of 87%. Most of these were HBACs. While some women who who transferred to the hospital during labor went on to have a VBAC in the hospital, most had cesareans for “failure to progress.” Women who had also had a previous vaginal birth had a success rate of 90.2%, and those who had a previous VBAC had an even higher rate of success at 95.6%. These rates are among the highest reported in the literature across places of delivery and provider types.

We also found that women who had a previous cesarean were more likely to need to transfer care to the hospital in the intrapartum period than were women without a previous cesarean. So the transfer rate for women who were attempting a VBAC at home was 21.7% compared to 8.5% for multiparous women who did not have a previously scarred uterus.

We also found that, for those women who transferred, the most common reason that they transferred was a slow, non-progressive labor and not a uterine rupture or anything emergent. We also were able to calculate a combined intrapartum and neonatal mortality rate in the group that had a prior cesarean, and that was 4.75 out of 1000 compared with a rate of 1.24 out of 1000 in multiparous women without a history of cesarean. This is a highly statistically significant difference, and means that we know there is some elevated risk for women who’ve had a prior cesarean relative to a woman who’s already had a baby and who has no scarring of the uterus.

JMc: You had some interesting findings that suggest that not all TOLACs have the same outcomes. Tell us about that.

MC: We also performed some sub-group analyses where we compared women who were having a trial of labor after cesarean with other groups. We compared them to first-time mothers and to women who had a previous vaginal birth and a cesarean and were now attempting a VBAC after a cesarean. We were able to get pretty nuanced findings about relative risk within the TOLAC group.

In other words, we found that there is variation in risk within the TOLAC subsamples. So, just to say that VBAC is dangerous or that TOLAC at home has a high success rate doesn’t really give the full picture. You can break down this group, look at it much more closely, and get a better sense of how to talk with clients about the risks of TOLAC at home under their specific circumstances. Just as success rates vary by obstetric history, so do risks associated with VBAC. Our study is certainly the first study to do that for a large sample of planned HBACs

JMc: What advice do you give to families that may be considering HBAC in your practice?



MC: I say that it’s important to look at success rates, but that it is also important to think about the likelihood of an intrapartum transfer, distance from the hospital, and a variety of other factors that are unique to each person. I actually think that looking at the cases that did not have good outcomes can be very informative. They help us to see who might be a reasonable candidate for an HBAC and who might not be. For example, in our dataset there were five deaths overall—three during labor or in what we call the intrapartum period, one that was early neonatal (or the first 7 days of life), and one that was late neonatal (out to 28 days after birth). Those all occurred in the TOLAC group, yielding death rates of 2.85 for intrapartum, .95 for early neonatal, and .95 for late neonatal. So for the combined intrapartum and neonatal mortality rate, the total is 4.75 out of 1000.

When we look at these cases more closely, we see that two of the cases were very likely uterine ruptures, based on the heart tone patterns that the midwife was able to distinguish at home. The three other ones were deaths that were totally unrelated to the TOLAC status of the mother. One involved known risk factors related to giving birth to a twin, the second one was a surprise breech with an entrapped head, and the third one was a cord prolapse. So three of the five deaths likely had nothing to do with the fact that the mother had had a previous cesarean.

JMc: It’s surprising to see mothers with this kind of risk profile delivering at home. Can you help us understand why you think a mother, for instance, one that is attempting a twin VBAC birth at home, might choose that?

MC: In these kinds of cases, you have to ask this: if you have someone who has a cesarean for her first birth and she gets pregnant subsequently, what happens to her if she has twins in her second pregnancy? Who is going to offer her a TOLAC? What if she happens to be breech at term in the pregnancy following an unplanned and often unwanted cesarean? These women, who have a compounding of risk, have no chance, very likely, of finding a provider in the hospital who’s going to support these births. So, it might seem odd that out of only 1000 VBACs, you’d have this scenario. But it does make sense, if you think about the fact that these women might be the most likely to be excluded from a trial of labor in the hospital. This actually kind of fits with something else we found.

Regions of the US that have low rates of VBAC access in the hospital, the southeast, for example, have a higher percentage of the total births contributed to MANA Stats that are VBACs. When you look on the west coast, in states like Oregon, Washington, and California, where VBACs are more readily available in the hospital, even though there are more contributors and more data coming from the west coast, the total proportion of births that are VBACs is significantly lower in our data set. We take that to mean that when women have the option to try VBAC in the hospital, there is less pressure to attend those women at home. In a state where you have very limited access to hospital VBAC, those midwives are more commonly approached by women who are feeling forced to explore the option of a home birth for a VBAC because they can’t acquire one in their local hospital. That is both concerning and a reminder that even though we often discuss the US maternity care system as less well integrated than, say, the Netherlands, nonetheless, the various models and options for birthing care in this country do impact each other. We should all be working together to make birth safer for all women.

JMc: How do you think these findings should influence families that are considering a trial of labor after cesarean at home? What advice do you have for them?

MC: I think these findings have ramifications for everyone who’s considering a home birth, not just women who are considering a home birth after a cesarean, because one of the most interesting things that we’ve found is that that risk within our sample varies considerably by obstetric history and parity. What I mean by that is that a woman who does not have a previously scarred uterus, and she’s already had a baby vaginally, her risk is incredibly low. It is difficult to find a negative outcome in that group.

The next safest group to be delivering at home is actually women who have had a cesarean, but have also had a vaginal birth. They are less risky than first time mothers as a group. Then the highest risk, along the VBAC status and parity continuum, is a woman who has never had a vaginal birth, but has had a cesarean.

So, the range of risk goes from the lowest risk: a multiparous woman (multip); to a multip with a cesarean and a previous vaginal birth; to a nulliparous woman: and then to a woman who has never had a vaginal birth but has had a previous cesarean. Both deaths from suspected uterine rupture occurred in this later group. Each mother had had only one prior cesarean. That’s a really important thing to keep in mind, and I think that’s where our policy implications lie as well. States that want to restrict all HBACs need to be looking much more closely at the research, especially if some of this work is replicable with larger samples, because there is a nuancing of risk within subgroup. It may not make sense, for example, to allow nulliparous births at home but restrict all VBAC mothers with any prior cesarean history, regardless of the fact that they may have had a previous vaginal birth or a prior VBAC. These women who live within an appropriate distance to a hospital, have well documented placenta positions and adequate time between births may actually be lower risk than a first time mother.

JMc: What advice do you have for policy makers who might be considering HBAC regulations in their state?

MC: Over the course of my career, I’ve seen the data on home and birth center safety, patient selection, ethics, the benefits of normal physiologic birth — so multiple components of midwifery care and birth outside of the hospital — grow so quickly. I recommend setting the scope of practice for midwives in rule (sometimes called regulations or administrative laws) rather than statute. In many states, it is very difficult to get a statute changed, whereas it is often much easier to open your rules or regulations over a period of every few years, for example, to examine new research and make sure that you are writing rules/regulations that support evidence-based practice for midwives. It is an exciting time to be working on some of these questions. Data from registries like MANA Stats and the American Association of Birth Centers’ Perinatal Data Registry should enable us to engage in critical, ongoing quality assurance and quality improvement at national, state and individual practice levels. I think we need to find ways of regulating home birth that stay open, flexible and responsive to the data, to the needs of the families we serve, and to the guidance of medical ethicists who are equipped to help us sort through difficult questions related to choice, individual autonomy and relative risk.

About Melissa Cheyney and Jeanette McCulloch

Melissa Cheyney head shot 2015Melissa Cheyney, PhD CPM LDM is Associate Professor of Clinical Medical Anthropology at Oregon State University (OSU) with additional appointments in Public Health and Women’s Studies. She is also a Certified Professional Midwife in active practice, and the Chair of the Division of Research for the Midwives Alliance of North America where she directs the MANA Statistics Project. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press) along with several, peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-led birth at home. Dr. Cheyney is an award-winning teacher and was recently given Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the MANA Statistics Project. She is the mother of a daughter born at home on International Day of the Midwife in 2009.

Jeanette McCulloch head shot 2015Jeanette McCulloch, BA, IBCLC has been combining strategic communications and women’s health advocacy for more than 20 years.  Jeanette is a co-founder of BirthSwell, helping birth and breastfeeding organizations, professionals, and advocates use digital tools and social media strategy to improve infant and maternal health. She provides strategic communications consulting for state, national, and international birth and breastfeeding organizations. A board member of Citizens for Midwifery, she is passionate about consumers being actively involved in health care policy.


Babies, Cesarean Birth, Guest Posts, Home Birth, informed Consent, Maternity Care, Midwifery, New Research, Newborns, Research, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , ,

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