CIMS and The Media
Press Releases

The Coalition for Improving Maternity Services Applauds NIH Support for VBAC

Raleigh, NC (March 12th, 2010)—After more than a decade of discriminatory practices by hospitals, physicians, and malpractice insurance providers against women who choose to have a normal birth after a prior cesarean, the Coalition for Improving Maternity Services (CIMS) was extremely pleased that the National Institutes of Health (NIH) has finally issued an evidence-based report that supports women who want to labor for a VBAC (vaginal birth after a prior cesarean section).

After a review of the evidence-based outcomes in the medical literature, the NIH panel of experts concluded that VBAC is safer for women than a repeat cesarean section.  The NIH Consensus Development Conference: Vaginal Birth After Cesarean : New Insights, which took place from March 8-10 in Bethesda, Maryland, confirmed that a trial of labor is a safe and reasonable option to a repeat operation for many women with a prior cesarean delivery- knowledge that CIMS has been promoting for years.  The CIMS evidence-based consensus document, the Mother-Friendly Childbirth Initiative (MFCI), supports a woman’s right to make informed choices about what is best for her and her baby based on her individual values and beliefs.

Studies reviewed by the NIH reported that at least 60% and as many as 87% of women who labor for a VBAC have a healthy baby, with the highest rate in women who received the midwifery-model of care. Although the findings showed that maternal mortality is actually lower for women who labor after a prior cesarean whether they end up with a vaginal or a cesarean birth, more than 90% of U.S. women today have a repeat operation.  The report concluded that VBAC should be offered to all eligible low risk women with a previous cesarean section. More than one in four women had a VBAC in 1996 compared to 8 in 100 today.

In recent years the fear that a prior cesarean scar would separate during a VBAC (uterine rupture) has overshadowed all other potential complications that could occur for any woman giving birth. Although the NIH found that the overall rate of uterine rupture is low at 0.2 % in a woman with a prior vaginal birth attempting VBAC and up to 0.7% without one, in fact 8 percent of all uterine ruptures occur in women without a uterine cesarean scar and is usually associated with the induction of labor induction.

The NIH expressed concern about the barriers women face in accessing healthcare providers and hospitals who offer VBAC. Professional society guidelines for years had supported VBAC as a safe option for women.  However, in 1999 despite any scientific evidence, hospitals were warned not to provide care for women who wanted a VBAC unless they could make a cesarean “immediately available” in case of complications.  CIMS has questioned this discriminatory policy since currently the same guidelines are in place for women who have an induction or an epidural but hospitals and physicians have not chosen to block access to these two interventions.

“With the now widely known knowledge that the VBAC success rate is high, and that cesarean delivery puts women at increased risk for morbidity and mortality,” stated Dr. Tami Michele, an obstetrician/gynecologist and CIMS’ representative to the NIH Conference, “then physicians and hospitals who offer women no choice other than repeat cesareans would be sanctioning a surgical procedure with known potential for causing harm approximately 70 percent of the time.  This is an ethical contradiction to the physician’s oath of ‘first do no harm’.”

The NIH urged the American Congress of Obstetricians and Gynecologists (ACOG) and the American Society of Anesthesiologists (ASA) to reevaluate the previously stated requirements that surgical and anesthesia personnel be “immediately available” for VBAC laboring women in the rare case that a uterine rupture occurs.  This requirement has been the driving force behind hospitals banning women with previous c-section from having a trial of labor, and the NIH suggested that guidelines be revised to correlate with other obstetrical complications of comparable risk.

The risks and benefits differ for both trial of labor and elective repeat cesarean delivery, and the right to informed consent must be communicated by the care provider to the woman using evidence-based, shared decision-making.  It is not clear how many physicians engage expectant mothers in shared decision-making using evidence-based information, but many women have expressed that the risks of repeat cesarean section were withheld because there was no alternative when a hospital did not allow women to labor for a VBAC.

CIMS encourages childbearing women to find out more about the risks of cesarean section so they can make informed decisions about how they want to give birth.  CIMS recently published a fact sheet, “The Risks of Cesarean Section” and its companion resource for consumers “About The Risks of Cesarean Section: A Check List for Mothers To Read During Pregnancy.”  Both are available as a free download at www.motherfriendly.org.

 

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