Last week there was yet another “chasing our tails” debate about VBAC vs. repeat cesarean on yet another VBAC/ birth/ parenting message board on-line. You’ve seen them. They usually degenerate into:
“You are selfish for planning a VBAC!”
“Yeah? Well you are uninformed for planning a repeat cesarean!”
[Insert accusations of martyrdom for planning an unmedicated birth and countless other ugly things that no one would actually say to each other in real life.]
It’s truly boring to read. And sad. Why the need for insults and defensiveness?
I am not someone who enjoys “debating” and finds the “education by insult” method to be highly ineffective. I only came upon this exchange because it was on Facebook and someone tagged me as a resource. I’m usually putting my efforts into getting information to women who actually want it, not parachuting in to convince women of anything because people don’t generally respond well as we see here:
However, as I read the comments on this long, angry, and misinformed thread, I thought “No wonder we have a 92% repeat cesarean rate! The American College of Obstetricians and Gynecologists (ACOG) says most women are candidates for VBAC, most VBACs are successful, and women should be offered the option yet women remain woefully uninformed about their options. And then they go on-line with the ‘my doctor said VBAC was dangerous, risky, selfish, etc’ and other women read that and many believe it simply because a doctor said it.”
I felt compelled to respond. See, my goal is to bridge the gap between what major medical organizations recommend and what your average person believes and the best way to do that is to share the facts with the people who are actually spreading the myths. Will it change anything for the women who contributed to that thread? Perhaps, perhaps not. But if we all share this article whenever we see these ridiculous debates come virtual brawls, perhaps someone will click a link and realize that much of what they believe about post-cesarean birth options is incorrect. And that we should all release the judgement about other women’s birth choices. “It’s not my birth.”
It’s interesting the debate taking place here.
Strangely, there were no debates like this at the 2010 National Institutes of Health (NIH) VBAC Conference mostly because the room was filled with medical providers and researchers who knew the facts. (Well, them and a few non-medical professionals like me.) Here are two quotes from the conference:
There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky. – Mona Lydon-Rochelle PhD, MPH, MS, CNM
In terms of VBAC, ‘your risk is really, really quite low.’ – George Macones MD, MSCE
Both Drs. Macones and Lyndon-Rochelle are medical professionals and researchers. Now you may think, “Wait a sec. Everything I’ve heard from my family, friends, and medical provider is how risky VBAC is and how cesareans are the conservative, prudent, and safest choice. Why the discrepancy between the statements of these two prominent care provider researchers and the conventional wisdom prevalent in America?”
It’s all about the marketing of risk, non-medical factors that inhibit access to VBAC, and, as a result, women who often do not receive the whole truth when evaluating their post-cesarean birth options.
This isn’t about convincing anyone that VBAC is safer than repeat cesareans or vice versa. It’s about acknowledging that there really are risks and benefits to each mode of delivery and one can only make the best decision for herself by understanding these facts.
As ACOG says, two women can look at the same data and make two different decisions. It’s not that one woman is right and the other is wrong. But women are making the best decisions for themselves. So with that framework, why the need to be 1. defensive about the choice you made and 2. attack other women who made different choices?
What mainstream, respected medical organizations say
Guise (2010), the basis of the NIH VBAC Conference, performed a review of post-cesarean medical research to date and concluded,
While rare for both TOL [trial of labor] and ERCD [elective repeat cesarean delivery], maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCD. The rate of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly increased with TOL (4.7 1,000 versus 0.3 1,000 ERCD). Six percent of uterine ruptures were associated with perinatal death. Perinatal mortality was significantly increased for TOL at 1.3 per 1,000 versus 0.5 per 1,000 for ERCD…VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans… The majority of women who have TOL will have a VBAC, and they and their infants will be healthy. However, there is a minority of women who will suffer serious adverse consequences of both TOL and ERCD.
This is a complex topic which cannot be sufficiently covered in a Facebook thread. Some doctors are absolutely misinformed about the actual risks and benefits of VBAC vs. repeat cesarean. Other doctors may try to influence a woman to have a repeat cesarean due to factors that have nothing to do with an individual woman’s medical history. The NIH addressed barriers to VBAC during their Final VBAC Statement when they said:
We are concerned about the barriers that women face in gaining access to clinicians and facilities that are able and willing to offer trial of labor…. We recommend that hospitals, maternity care providers, health care and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor.
The NIH isn’t recommending more women have access to VBAC because they are a crunchy, granola organization who concerns themselves with birth experiences. They are looking at the data.
Here are some great resources:
- ACOG’s VBAC Guidelines
- ACOG’s VBAC Handout
- National Institutes of Health VBAC Final Statement, videos of the conference presentations, etc:
- Cesarean Task Force Power to Push Handout
But what are women actually told about their post-cesarean birth options?
I’m really curious. If your OB recommends repeat cesareans across the board or “doesn’t do VBAC,” did they actually share with you any of the resources above? Because the mainstream, respected organizations of ACOG and the NIH use words like…
.. to describe VBAC. Did any of your doctors use these terms?
To be clear, if you want an elective repeat cesarean, it doesn’t make a difference to me. But if you are “choosing” it based on a misrepresentation of the facts, that makes me really frustrated because every woman is entitled to accurate information and no one should be coerced into a medical decision.
How many of your OBs actually counseled you on the risks and benefits of VBAC vs. repeat cesarean? Or did you just hear the risks of VBAC?
How many of you were informed of the increasing risks that come with each cesarean?
The risks of placenta accreta [which has a maternal mortality of 7% and hysterectomy risk of 71%], cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral injury [damage to the ureters – the tubes that connect the kidneys to the bladder in which urine flows – is one of the most serious complications of gynecologic surgery], and ileus [disruption of the normal propulsive gastrointestinal motor activity which can lead to bowel (intestinal) obstructions], the need for postoperative ventilation [this means mom can’t breathe on her own after the surgery], intensive care unit admission [mom is having major complications], hysterectomy, and blood transfusion requiring 4 or more units [mom hemorrhaged], and the duration of operative time [primarily due to adhesions] and hospital stay significantly increased with increasing number of cesarean deliveries (Silver, 2006).
How many of you were informed that placental abnormalities (such as previa, accreta, increta, and percreta) make future pregnancies more dangerous for you and baby regardless if you plan a VBAC or another cesarean? And each cesarean increases the risk to you and your future children (Silver 2006)? Read more about placental abnormalities.
How many of you were informed that your risk of placenta accreta after two cesareans (0.57%) is similar to your risk of uterine rupture in your first VBAC (0.4% in a non-induced/augmented TOLAC after one prior low transverse cesarean) (Silver, 2006; Landon, 2004)? So essentially, you are just exchanging the risk of uterine rupture for the risk of accreta?
Did they tell you that placenta accreta has a maternal mortality rate of up to 7% and an over 70% hysterectomy rate? Read more from ACOG’s Committee Opinion on Accreta.
How many of you were informed that your risk of uterine rupture after one low transverse cesarean is similar to the risk of placental abruption, cord prolapse, or shoulder dystocia during your first pregnancy? And yet, did anyone offer you a cesarean during your first pregnancy to avoid these uncommon, though very serious, complications? Were you warned at every prenatal about the risk of cord prolapse and urged to reconsider your desire to have a vaginal birth? You likely weren’t, yet the risk of uterine rupture is marketed very differently to moms pregnant after a cesarean and it’s effective too because women are terrified of uterine rupture while the risks and realities of placenta accreta remain foreign to them. (Read more here.)
Did they inform you that the risk of infant death within 28 days of delivery in a VBAC is similar to a first time mom (Smith, 2002)?
When informed consent isn’t
The point is, when care providers use words like dangerous, risky, and selfish, or say things like “if you were my daughter/wife, I wouldn’t recommend a VBAC,” they have already made the decision for you. What woman is going to question her OB unless she already knew these facts? Unless she understood the bigger picture and realized that she was receiving misinformation?
This is how we got to a place where, per the American College of OBGYNs, most women are VBAC candidates and most VBACs are successful and yet, do you know the American VBAC rate? It is 8.2%. Yes. So, 92% of women with a prior cesarean have a repeat cesarean. And a lot of this is due to of VBAC bans. And another huge chunk is because when people are confused about their options, they are ripe picking for manipulation.
Most women don’t know about ACOG and the NIH. Most don’t know where to get good information and so they rely on their OB. Which we should be able to do!
But, there are OBs who, for a variety of non-medical reasons, do not support VBAC. Rather than boring you with their non-medical reasons (like cesarean deliveries are quicker than vaginal, they can ensure that they will attend the birth – not their partner – which means they will get paid for that birth, they can enjoy a better work/life balance because they aren’t called at 2am to deliver your baby, etc, etc, etc) they just tell you that it’s dangerous.
Or that your medical insurance doesn’t cover VBAC.
Or that VBAC is illegal.
Or that most VBACs fail.
Or that 10% of moms and babies die during a VBAC.
Or that no research exists about VBAC because all women have repeat cesareans.
Or that cesareans have no complications other than those associated with surgery.
Or some other lie that will result in just enough fear for you to schedule a cesarean.
[SIDE NOTE: When I talk about OBs who lie, I really don’t need the person piping up with the “not all OBs are bad” reply. I know many wonderful, ethical doctors, but I think we can all agree that when any care provider uses lies in the course of their interaction with patients, we can safely say that these care providers are not one of the good ones. Agreed? Ok, let’s move on…]
Since we trust our OBs, we believe them, and we don’t ask about VBAC guidelines! Shoot, most moms don’t know that there are VBAC guidelines! And so, we sign up for our cesareans, and subscribe to the idea that VBAC is dangerous and then share that lie online with whoever we can. And this contributes to the conventional wisdom that VBAC is a reckless decision that only selfish women make… and the cycle continues.
So if Facebook isn’t a good source of information, where should I go?
Please, look at what ACOG says. Look at the NIH. Look at the evidence. Both VBAC and repeat cesarean have real risks and real benefits. Only you can make this decision when you actually know the facts. Perhaps you do know the facts and made an informed decision to have a cesarean – GREAT! But many of the statements in this thread are not factual and that is disconcerting considering the level of passion displayed about who is “right” and who is “wrong.”
I’ve already done the legwork. I teach a 6 hour class entitled “The Truth About VBAC: History, Politics, & Stats.” I’m a Continuing Education Provider for the California Board of Registered Nursing. I’m not some crazy VBAC advocate who thinks everyone should have a VBAC. I am simply someone who believes everyone is entitled to the facts and I’m so tired of the lies that women are fed from who should be trusted medical professionals.
For what it’s worth, ACOG says expecting a big baby, going overdue, having twins, or having an unknown or low vertical scar should not prohibit a woman from planning a VBAC. ACOG also does not recommend a specific time frame from cesarean to subsequent pregnancy/delivery nor do they recommend a specific suture type.
And of course this entire post is referring to scheduled, elective cesareans, not surgeries that occur due to a complication. When we talk about medically indicated cesareans, those are performed due to complete placenta previa, transverse lie, infection, preeclampsia/ eclampsia, fetal demise, etc.
Or if you just don’t want a vaginal birth and would prefer a cesarean. That’s your choice too!
But choosing an elective cesarean based on the facts is very different than scheduling one because your OB claims your risk of uterine rupture is 60% after one low transverse cesarean. Because that is just not true. If we could just get to a place where women could feel free to make the best decision for themselves based on the evidence and didn’t feel so darn defensive about that decision, we would make a huge step forward. Please, join me in a world where we check our judgment at the door and just work to share good information and realize that not everyone makes the same decision. And that’s ok.
For more information on the sources cited, please review my bibliography.