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As most of you know by now, the National Institutes of Health (NIH) convened a Consensus Development Conference on VBAC (vaginal birth after cesarean) in Bethesda, MD, March 8-10, 2010. I felt privileged to represent CfM and be one of the voices for consumers, trying to keep the focus on what is best for women and babies rather than the concerns and pressures that hospitals experience.
It was clear that many of the presenters really understood the problem of VBAC bans, especially Rita Rubin who gave a powerful presentation of women’s stories. There was plenty of frustration, too, especially near the end when the panel ethicist refused to acknowledge a pregnant woman’s right to refuse surgery, even when she has appropriately weighed the risks to herself and her baby.
All in all, I think the conference really moved the VBAC conversation in the context of other problems in maternity care. It remains to be seen just how much medical practice – and culture – will change as a result of the panel recommendations.
This Grassroots Message includes CfM’s response to the NIH Consensus Report on VBAC. At the bottom, I’ve included links to the NIH conference documents, media coverage. Happy reading!
Citizens for Midwifery on the 2010 NIH Consensus Development Conference on VBAC
A little history provides context. The 1980 NIH Conference on VBAC pulled together the research that encouraged widespread access to VBAC. The critical recommendation then was “[i]n hospitals with appropriate facilities, services, and staff for prompt emergency cesarean birth, a proper selection of cases should permit a safe trial of labor and vaginal delivery for women who have had a previous low segment transverse cesarean birth.”
As a result, ACOG issued a series of guidelines on VBAC (in 1982, 1984, 1988, and 1994), the fourth statement saying that women with previous cesarean scar should be “encouraged” to attempt a trial of labor, with emergency support “readily available”. VBAC rates went up steadily throughout this period, peaking in 1996 at 23% of women laboring women with a prior cesarean scar.
We haven’t clearly traced what events led to the 1999 “ACOG #5” – their fifth set of guidelines on VBAC - where “encouraged” became “offered” and having emergency support “readily available” became “immediately available”. This change created obstacles for hospitals “offering” VBAC. Following this, a paper (Lydon-Rochelle M Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001;345:3-8) was published in 2001 in the prestigious New England Journal of Medicine. The results appeared to show that while risk of uterine rupture remained low, induction of labor in VBACs was associated with increased incidence of uterine rupture.
Overall, the quality of the research was flawed and the study was subsequently widely criticized. However, in the same issue, a strongly worded editorial by Dr. Michael Greene drew unwarranted conclusions that VBAC was dangerous - a conclusion not demonstrated in the study. This editorial became the focus of broad media attention. Hospital VBAC “bans” then escalated, and VBAC rates began to drop.
We now know, explicitly from this conference, that the risks and probabilities of success for VBACs have not changed since 1980. In short, Dr. Greene’s editorial incited a hysteria over uterine rupture that was out of proportion to the risks, and gave hospitals and the obstetric community permission to back away from VBAC altogether (even though that isn’t what “ACOG #5” says either). As a result, VBAC rates dropped precipitously to the present 10%.
What did the recent NIH Consensus Conference on VBAC get right?
The Conference panel’s final report states: “Given the available evidence, TOL [trial of labor] is a reasonable option for many pregnant women with a prior low transverse uterine incision.” This is a really important and positive conclusion that we can all use to “encourage” our local hospitals and obstetricians, along with their insurers, to change their policies.
To understand what follows this thesis statement, we need to look carefully at the range of verbs used: “must” and “urge” being the strongest, followed by “strongly recommend”, “recommend”, “should”, “should consider”, so on.
While the NIH Panel apparently feels the need to be “diplomatic” in its statement, Citizens for Midwifery (CfM) is in a position to speak more directly: over the last 11 years (since “ACOG #5”) obstetricians and hospitals collectively acted to restrict access to VBAC for a variety of reasons unrelated to the health and well-being of mothers and babies, and in doing so, caused untold harm. We now understand that where obstetricians and hospitals have restricted access to VBAC, they have done so without medical evidence for their actions and without disclosing to each and every patient what the evidence shows or the non-medical factors and conflicts of interest involved.
- The panel “urge[s] clinicians and other maternity care providers to use responses to the six questions, especially questions 3 and 4 [see the Final Report], to incorporate an evidence-based approach into the decisionmaking (sic) process” (emphasis ours), Questions 3 and 4 refer to the actual risks to mothers (question 3) and babies (question 4) and the levels of evidence that support that risk assessment.
- The panel goes on to “recommend the American College of Obstetricians and Gynnecologists and the American Society of Anesthesiologists to reassess [the “immediately available” guideline language] relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.” (emphasis ours)
This is a serious problem. We have to ask, what other interventions and practices are being urged on and performed unnecessarily on pregnant and laboring women without disclosure of such non-medical conflicts of interest? On what basis can any woman now trust an obstetrician or a hospital to have the health and well-being of her and her baby as the primary interest?
CfM wholeheartedly agrees, and only wishes that the NIH panel had written “urge” or “strongly recommend”. If individual OBs don’t feel that they have the expertise to support VBACs, they should hire midwives or refer clients to midwives or other maternity care providers who do have that expertise, as the NIH recommends, while making sure that such other options are supported in their local hospital. (Further support, through continuity of care, should be provided to those who opt for out-of-hospital birth that might require transport, in the same way that tertiary care facilities support primary care facilities within the regional health care hospital model. This recommendation empowers all parties to agitate for just such continuity of care.)
- The NIH panel “recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL [trial of labor]” (emphasis ours).
Where did the NIH panel straddle the line?
The panel wrote
- “Information, including risk assessment, should be shared with the woman at a level and pace that she can understand” (emphasis ours). “When both TOL [trial of labor] and ERCD [elective repeat cesarean delivery] are medically equivalent options, a shared decisionmaking (sic) process should be adopted, and whenever possible, the woman’s preference should be honored" (emphasis ours).
These recommendations tacitly admit that obstetricians have not been providing anything resembling an informed consent process for pregnant women regarding VBAC vs. ERCD. We would have liked to see much stronger language and direct reference to the right to informed refusal as well as informed consent, since US Patients Rights laws already require informed consent/informed refusal. The first point also relegates the issue of VBAC to "the woman's preference", a position that ignores a woman's right to refuse surgery and reduces the issue to one of "preference" which can easily be superceded by medical "advice".
- “[h]ealthcare organizations, physicians and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies.” (emphasis ours).
CfM believes that the NIH panel failed to acknowledge that the physician’s role in the decision making process is “shared” only to the extent that the physician shares information. He/she should share his/her risk assessment based on the actual and relative risks as documented by the research, and he/she is entitled to share his/her own opinion with the pregnant woman, but the ultimate decision belongs to the woman. If a physician lacks the expertise to support a trial of labor and vaginal birth, he/she should seek additional training, and not attend ANY births until able to do so.
The second point above tacitly admits that clinicians have not been publicly forthcoming with their TOL policy and VBAC rates, an enormous drawback for pregnant women. Although weaker than we would like, we are pleased that the Panel at least included this recommendation to disclose individual provider VBAC rates and policy. This is an essential ingredient of informed decision making, given that consumers have more access to the safety information about the car they might want to purchase than they do about the outcomes of their healthcare provider, and that choice of provider is the single best predictor of birth outcome. This recommendation empowers us, as consumers, to ask the lawmakers in each of the 50 states to require such disclosure.
CfM goes further in saying that informed consent should also include disclosure of all non-medical factors that influence their medical recommendations, such as convenience, scheduling and efficiency, malpractice insurance and lawsuit fears, and personal fear (disproportionate to the actual rate of occurrence) of the rare but catastrophic event. These are conflicts of interest that should be openly disclosed so that women can accurately interpret an obstetrician’s recommendations.
- The panel also stated “[p]olicymakers, providers and other stakeholders must collaborate in the development and implementation of appropriate strategies to mitigate the chilling effect of the medico-legal environment on access to care.” (emphasis ours).
We hope that consumers are appropriately considered to be stakeholders, and are included in any such collaboration.
Where did the recent NIH Consensus Conference on VBAC miss the mark?
Perhaps the greatest weakness of the NIH panel conclusion is in its final paragraph about the need for high-quality research. CfM agrees that more research is needed, but the paragraph is vague about what kind of research. Furthermore, it is CfM’s position that randomized controlled studies are inappropriate, unethical and impossible for VBACs. Instead, studies using voluntary selection of TOL and birth setting would provide useful new information in the area of natural, physiologically normal birth, which is seldom found within the hospital environment.
The NIH panel recommendations urge two courses of action that, if implemented, would go a long way toward improving the situation for women with prior cesareans. They state that their goal is to “support pregnant women with a prior transverse uterine incision to make informed decisions about TOL and ERCD”. To do that, they (1) urge evidence-based practice, and they (2) urge ACOG to reconsider “ACOG #5”. CfM agrees.
We would like to see the following actions.
- All hospitals and OBs should start supporting VBACs, not just “offering” and “encouraging”. CfM believes the Midwives Model of Care represents that support of physiologically normal birth.
- ACOG should rescind “ACOG #5” immediately. In doing so, insurance companies will no longer have a basis for dropping or threatening to drop malpractice insurance or raising insurance rates on practitioners and hospitals that offer VBAC, as those individuals and institutions will merely be responding to both the evidence and the guidelines. By rescinding “ACOG #5”, ACOG and its members would be taking a step toward rebuilding some trust and confidence of the women they serve.
- Informed consent must be based on an honest risk assessment, including information about provider outcomes, provider bias and conflicts of interest, as well as the research evidence, in order to support all women, not just VBACing women to have healthy births.
The NIH documents call all be reached from their press release, including the full report, the full evidence report, and recorded webcasts of the conference:
There has been a great deal of news coverage, including:
Many organizations are developing press releases and responses including ICAN and Lamaze International.
A running blog discussion from the conference can be found at
and several blog postings with ongoing discussion can be found here:
This article anticipated the NIH conference and very much supports CfM’s philosophy:
A fairly comprehensive list of articles on this conference is available at:
There’s even a petition: http://www.petitiononline.com/VBAC2010/petition.html