The VBAC Controversy and Ca LMs
Part 1 ~ VBAC in California ~ Access-to-Care & Denial-of-Service Issues
Adapted and expanded upon from Jan Kemal’s VBAC article posted on the Science & Sensibility website
http://www.scienceandsensibility.org/?s=vbac
Introduction:
Cesarean section is the single most frequently performed major surgery in the world today. The CS rate in the US, which is among the highest in the world, is most frequently performed on the healthiest and most economically-advantaged women.
Once a country’s Cesarean section rate exceeds the optimal level of 5% to 15%, Cesarean delivery is not associated with improved maternal or neonatal outcomes in developed countries (such as the US) with an essentially healthy childbearing population.
The role of California licensed midwives (Ca LMs) in caring for pregnant women who previously had a Cesarean is controversial. However such a controversy cannot be addressed without providing context for the issue and a considerable amount of background information.
As two sides of the same coin, Cesarean delivery is the most expensive and statistically important maternity care issues of our time, while the lack of VBAC services is emblematic of bigger problems with an overly medicalized maternity care system that focuses on surgical delivery while failing to adequately support physiologic childbirth.
To understand VBAC issues it necessary to know the annual rate of Cesarean surgeries in the US, and the risks associated with a first or ‘primary’ C-section, including delayed and downstream complications, as well as the secondary and greater set of risks specific to repeat Cesareans. For the reasons outlined below, subsequent Cesarean surgery has an additional set of risks and downstream complications that do not apply to the original or primary C-section.
Another important topic is the functional access to non-surgical childbirth services, in this case Vaginal Birth After Cesarean or VBAC, in subsequent pregnancies for healthy women whose families want to avoid additional surgical risks and increased expense associated with elective or ‘repeat’ Cesareans.
Maternal-Infant Outcome Statistics for the US
Compared to countries with more cost-effective maternity care systems and far better maternal-infant outcomes, the US currently ranks 39th in maternal mortality and 50th in neonatal deaths. In spite these shocking numbers, maternity care for healthy childbearing women in the US is orders-of-magnitude more expensive and its focus on medicalized care often fails to meet the most basic needs of healthy childbearing families.
In 2002, 2006, and 2013, the highly-respected consumer advocacy group Childbirth Connection (formerly the Maternity Center Association of NYC) conducted formal surveys — Listening to Mothers — on the care received by maternity patients in the United States.
All three consumer surveys documented a universal pattern of medicalization (99%) in hospital labors and births that included the routine use of seven or more medical and surgical interventions. Seventy percent (70%) of new mothers reported at least one surgical intervention (episiotomy, vacuum, forceps or C-section). The women in these surveys were essentially healthy, with a normal pregnancy and a single fetus in a head-down position.
The resurgence of professional midwifery in the US is just one of many indicators of a growing frustration in many sectors with a medicalized and extremely expensive model of care that regularly turns the normal biology of spontaneous childbirth into a costly surgical procedure with serious risks. This includes intra-operative, immediate post-operative, delayed and downstream complications such as secondary infertility, placental abnormalities and stillbirth in a future pregnancy.
As judged by public health criteria, the US currently has the largest number of healthy, well-fed, well-educated, and adequately insured women of childbearing age in our nation’s history. We also have the most sophisticated and high-tech system of medical care of any country in the world.
Unfortunately, the confluence of these facts has not yet lived up to its obvious potential. One would expect the use of these advanced techniques and technologies to accurately identity, with laser-like accuracy, the small minority of childbearing women who actually benefit from these extraordinary medical and surgical interventions. This would then allow the obstetrical profession to use their considerable knowledge and skills to support and promote uncomplicated normal births for the healthy majority of childbearing women (over 70%) in a variety of low-tech and cost-effective settings.
Instead the most interventive and expensive form of childbirth in the history of the human species as been institutionalized in the US, with over 1.3 million women giving birth by Cesarean section each year. This is approximately equal to the number of students that graduate from college each year in the US.
In a 1996 the Medical Leadership Council, an association of more than 2,000 US hospitals, issued a report on cesarean delivery. The MLC concluded that the cesarean rate in US was:
“medicine’s equivalent of the federal budget deficit; long recognized as [an] abstract national problem, yet beyond any individual’s power, purview or interest to correct.”
Since those words were penned in 1996, the C-section rate shot up by 60% in all categories and ages of childbearing women – young as well as older mothers, those who are low-risk as well as women with health or pregnancy complications, with the economically-advantaged segment of the population having a higher rate of surgical delivery than is the average for the childbearing population as a whole.
A 2007 paper by the World Health Organization (reference below) compared worldwide CS rates with maternal and infant outcomes. It noted that higher CS rates do not confer additional health gains on new mothers or babies, but often increase maternal risks. This additional risks have negative personal implications for future pregnancies, as well as overburdening the country’s health services.
The paper noted that: “CS levels may respond primarily to economic determinants“, an observation that helps explain why the healthy and wealthy have more CS than the poor, who actually have a higher rate of pregnancy complications and other medical indications for Cesarean delivery.
“Rates of caesarean section: analysis of global, regional and national estimates” by Ana P. Betrán, et al Pediatric and Perinatal Epidemiology, vol 21, pp 98 – 113, 2007 W.H.O.
Cesarean rates & VBAC in the US ~ availability of VBAC in California
According to the most recent statistics from the Centers for Disease Control (CDC), more than a million (1,284,339 to be exact) cesareans were performed in the United States in 2013. The current Cesarean rate in the US is 33%. That’s one surgical delivery for every three births in the US, a number that applies to young healthy women of normal weight who have a single fetus in a head-down position, as well as older or heavier women whose singleton pregnancy or personal health status may be far than less ideal.
According to multiple studies, the explanation most often given for the drastically increased rate of Cesareans performed in the US over the last 40 years is increased maternal age, increased body weight of the childbearing population, and/or the use of artificial reproductive technologies (ART), etc. But the actual statistical record does not support these ideas.
With the exception of the very highest level of risk (under 1% of childbearing women), the increased rate of Cesarean delivery is relatively consistent across all categories of age and other health-related criteria. {ref: Eugene Declercq}, with one important distinction — the rich and famous are still statistically more likely to have Cesarean surgery than the poor and the ill.
Life after the first Cesarean
Irrespective of these demographics, each year hundreds of thousands of previous Cesarean mothers will find themselves pregnant again. Only a tiny fraction have a repeating medical condition that requires a repeat Cesarean, while the vast majority will face the issue of whether to schedule an elective repeat Cesarean or plan to go into labor normally, and if all goes well, have a normal spontaneous vaginal birth (VBAC) in a local hospital.
The National Institutes of Health (NIH) and the American College of Obstetricians and Gynecologists (ACOG) have both described vaginal birth after cesarean as a safe, reasonable, and appropriate option for most women.
In spite of recommendations based on solid statistical data, almost half (approximately 50%) of American hospitals ban VBAC – that is, disallow a normal vaginal birth in a laboring woman who previously had Cesarean. Instead hospital policies require these women to either submit to an unwanted repeat Cesarean. or leave their facility while in labor to either find a VBAC-friendly hospital or return home to give birth unattended.
Many individual obstetrical groups also refuse to attend a vaginal birth after a previous Cesarean. Together VBAC bans by hospitals and obstetrical groups help explain California’s extremely low VBAC rate of only 9%, which means 91% of previous Cesarean mothers in California are routinely being exposed to major abdominal surgery for all additional pregnancies.
Hospitals attribute policies banning VBAC to their concerns over possible lawsuits. Obstetricians often point to ACOG policies that require them to be physically present in the hospital the entire time that VBAC women are in labor, which is obviously inconvenient and time-consuming.
Doctors also site higher liability insurance premiums, since providing normal childbirth services to women who are having a VBAC would disqualify them from receiving the medical malpractice equivalent of a ‘good driver discount’. A reduction in the cost of liability insurance is offered by some med-mal insurance carriers to obstetricians who agree not to attend a planned vaginal birth for women with a previous Cesarean and those with a breech baby or twin pregnancy.