Tuesday, April 30, 2013

Fight Back For VBAC: Protesting the Sorry State of VBACs Today

As we finish up Cesarean Awareness Month, let's not forget to also discuss the decline of VBACs (Vaginal Birth After Cesarean) in this country and around the world.  There is a new study out showing just how dismal the VBAC climate still is in many places.

The lack of access to VBACs is one significant reason that the cesarean rate is so high.  More than 90% of women who have a pregnancy after a cesarean will have more cesareans, even though most of these women could have a vaginal birth if they were allowed to try.

The problem is that they are rarely allowed to try anymore. Either there is an outright ban on VBACs at their hospitals, their care provider won't/can't attend VBACs, or their care provider subtly sabotages their care so they don't get a real trial of labor ("Sure, you can have a VBAC ─ but only if you go into labor by 40 weeks, the baby isn't too big," etc.).

So as we finish Cesarean Awareness Month, let's take a moment to examine the sorry state of VBACs today, how we got to where we are, and how we can Fight Back for VBAC.

A Brief History of VBACs in the U.S.

Many years ago, VBACs were practically unheard of in the United States. "Once a cesarean, always a cesarean" was the rule because most cesareans were done with an up-down classical incision that increased the chances of a uterine rupture during labor.

However, in time cesarean technique changed, and most OBs opted to use side-to-side, low transverse incisions instead.  This meant that the risk for uterine rupture, while not zero, was low.  Still, most U.S. care providers did not allow VBACs, even though VBACs were allowed in Europe.

Then in 1980, a conference was co-sponsored by the National Institute of Child Health and Human Development (NICHHD) and the National Center for Health Care Technology.  It concluded that VBAC was a reasonable option and could help decrease rising cesarean rates.

Slowly, research began to accumulate that VBACs were a reasonable choice.  Although some areas were slow to allow VBACs, the U.S. national VBAC rate began to rise significantly.  In 1980, the VBAC rate was 3.4%.  By 1996, the VBAC rate reached its peak at 28.3%.

As the 90s progressed, however, a highly-interventive obstetrics model that utilized a lot of induction and augmentation of labor was applied to VBACs too. These interventions increased the risk of uterine rupture and poor outcomes and made VBAC look more dangerous than previously thought. This was documented in McMahon 1996, which was criticized for its methodology but was unfortunately widely-publicized despite its flaws.

In addition, some insurance companies required a trial of labor, even when women didn't want one or were poor candidates for a VBAC.  Some labors were not adequately monitored, and dangerous drugs like misoprostol (Cytotec) were used to induce VBACs.  As a result, some highly publicized catastrophic outcomes and lawsuits began turning the tide of obstetric opinion against VBAC.

As you can see by the graph above, by the very end of the 90s there was a distinct downfall in the rate of VBACs, and after 2000 the rate really began dropping off.  It is less than 10% now. The graph stops in the mid-2000s; sadly, the rate is even more dismal now than the graph shows.  In some areas, the VBAC rate is absolutely awful; one study reported that Florida had a VBAC rate of only 1%.  

The reason for the steep 
drop-off in VBACs is that in 1999, the American Congress of Obstetricians and Gynecologists (ACOG, the trade union for OBs) issued new guidelines for attending VBACs, requiring doctors and anesthesiologists to be "immediately available" instead of "readily available" during a VBAC labor. 

This meant that OBs and anesthesiologists had to be IN the hospital the whole time a VBAC mother was in labor....."just in case." This meant OBs couldn't hold office hours to see other patients during this time, and hospitals had to pay anesthesiologists to be constantly on-site. "Immediately available" was financially and logistically impractical, so more doctors quit attending VBACs.

In particular, a lot of smaller hospitals instituted official VBAC bans because they could not meet the "immediately available" guidelines for 24/7 anesthesia and surgical coverage. This has had a particularly significant impact on states with lots of rural or small-city hospitals.

Other hospitals instituted "de facto" VBAC bans, where there were no official policies against VBAC but no doctors would attend one because of the requirement to be in hospital during a woman's whole labor.  In one study, 57% of women who were interested in VBAC reported that they had a repeat cesarean because their hospital or caregiver was unwilling to allow VBAC.

Furthermore, some insurance companies declined to insure doctors who attended VBACs, or made their malpractice insurance virtually unaffordable. As one report noted:
Insurers have also pressured hospitals and administrators to close VBAC services, and have been very effective. There are few other procedures in medicine whose availability is dictated by malpractice insurers, and none that are so widely needed.
The combination of all of these factors obliterated VBAC as a choice from basically half the hospitals in the country. 

The Change in Guidelines

Graphic from the 2010 NIH VBAC Consensus Conference 

The ONE-WORD change to "immediately" available in the ACOG guidelines was a virtual death knell for VBACs in the U.S.  Sadly, many other countries in the world followed the U.S. trend. It is quite difficult to get even a chance at a VBAC in many areas now.

Was this change in guideline based on good solid evidence? No. As ICAN's press release about VBAC bans notes:
The ACOG guidelines stipulate that a full surgical team be “immediately available” during a VBAC labor, though the stipulation is a “Level C” recommendation, which means it is based on the organization’s opinion rather than medical evidence.
Dr. Marsden Wagner, neonatologist and perinatal epidemiologist, criticized the change in guidelines in this way:
This recommendation, "VBAC should be in institutions equipped to respond to emergencies with physicians immediately available," has no data to support it--no studies showing improvements in maternal mortality or perinatal mortality related to the characteristics of institutions or availability of physicians.
In other words, the change in guideline wording that obliterated VBAC access for so many was based on NO REAL EVIDENCE.

This is not good science nor good public health policy.  It's birth politics, pure and simple, and at the price of women's reproductive autonomy.

A Different Standard for VBACs

"Immediately available" sounds good on paper ─ someone there at all times in case of the true emergency of uterine rupture ─ but it puts a level of demand on VBACs that no other birth has.

For every other birth, it's fine to have doctors on call nearby but not constantly on-site. Yet VBACs are treated differently.  It's this different standard that is the biggest barrier to VBAC availability.

Of course, it would be nice to have a surgical team standing by at all times in hospitals, ready to intervene in case of any emergency (not just obstetric; car accidents can happen at any time of the day or night) ─ but it's simply not practical or affordable to have 24/7 constant on-site coverage in most institutions. On-call nearby coverage is good enough for everything else. Why isn't it good enough for VBACs?

VBACs should not be held to a stricter standard just because they are VBACs. All births have potential risks. Yes, uterine rupture is an emergency and deserves to be taken very seriously.  However, emergencies can happen in ANY birth, including life-threatening emergencies like placental abruption, umbilical cord prolapse, and shoulder dystocia, which have about the same incidence as uterine rupture.

To say that it's not safe to do a VBAC without 24/7 coverage means that it's not safe to do ANY births at that hospital.

Nor is there proof that 24/7 coverage improves outcomes, as a number of sources have noted. And research shows that the decline in VBAC rates has not improved neonatal mortality or maternal mortality at all.

Before instituting such restrictive guidelines that potentially impacts the health of women so deeply, it is important to have research showing that 24/7 coverage makes a difference, that any improvements from such coverage would balance the women harmed from being forced into thousands of repeat surgeries in the smaller hospitals.  And that research is simply not there.

While it's ideal to have 24/7 coverage for all births because of the potential for emergencies, "readily available" is considered close enough coverage because 24/7 coverage on site is simply not practical or affordable for most hospitals.  

ACOG guidelines are only guidelines, not laws, but because they are considered "standard of care" in the community, few hospitals dare to defy them. If a hospital lets doctors be merely "on call" during a VBAC labor and something bad happens, they risk a huge malpractice award to the parents because they permitted the doctors to practice outside the standard of care from their parent organization.

Since only the very largest hospitals are able to do 24/7 coverage, VBAC was effectively wiped out in many places, all from the change of one little word.

Tweaking the Guidelines ─ Barely

ACOG's 2004 VBAC Guidelines continued to uphold this "immediately available" requirement, and VBAC access continued to drop drastically in the U.S.  Other countries followed suit, and soon a trial of labor was difficult to find in many parts of the world.

However, there were signs of push-back. The American Academy of Family Practice Physicians took on this "immediately available" requirement in their 2005 Trial of Labor After Cesarean (TOLAC) guidelines. It is uncommon for major medical organizations to come out and contradict each other like this, so the fact that the AAFP did so was a major reprimand to ACOG (emphasis mine):
TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes.... 
Current risk management policies across the United States restricting a TOL after a previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence...We could find no evidence to support a different level of care for TOLAC patients.
Basically, the AAFP is saying that the "immediately available" guidelines is really about protecting ACOG members in lawsuits, not improving outcomes in VBACs, and there is no evidence to support such a restrictive guideline.

In 2010, the National Institute of Health (NIH) held a VBAC Consensus Development Conference, examining the current state of VBAC in the U.S. and issuing some recommendations, including this one:
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. Given the low level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.
Many birth advocates hailed the results of this conference as the start of a pendulum swing back towards VBAC and thought that surely ACOG would change its guideline back to "readily available" soon afterwards. Sadly, this was not to be.

ACOG Changes Its Guidelines - A Little

As a result of publicity from this consensus conference and pressure from advocacy groups, ACOG did adjust its VBAC guidelines ─ but only a little bit.  It kept the recommendation for "immediately available" but created a little bit of flexibility by saying that while women should be counseled to go to a hospital with staff "immediately available" for emergency care, if they chose not to do so, they should be allowed to accept an increased risk of laboring elsewhere.

However, because most hospitals are still afraid of the liability of doing this when the guidelines still recommend "immediately available" surgical coverage, most hospitals have not changed their VBAC policies, despite the change in ACOG guidelines. 

As one commenter wrote:
By not making any changes in this recommendation, hospitals that cannot meet this requirement are not likely to begin offering medical care for VBAC. The NIH reported that the ACOG recommendation to have personnel “immediately available” as opposed to “readily available”, as recommended in all prior VBAC guidelines issued since the 1980s, has influenced about one-third of hospitals and one-half of physicians to no longer provide care for women who want a VBAC.
The difference between the 2004 guidelines and the 2010 guidelines is highlighted on the Birthing Beautiful Ideas blog (differences are highlighted in bold). The 2004 bulletin says:
Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.
The 2010 bulletin says:
A trial of labor after previous cesarean delivery should be undertaken at facilities capable of emergency deliveries. Because of the risks associated with TOLAC and that uterine rupture and other complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care. When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital’s resources and availability of obstetric, pediatric, anesthetic, and operating room staffs. Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.
The new ACOG guidelines do represent some progress. The organization acknowledged that its "immediately available" guideline had had a chilling effect on VBAC access, and it tried to add additional language to soften the impact of this recommendation. However, in the end, they elected not to change that key phrase, so their efforts are not likely to change the VBAC climate.  As Lamaze International noted:
Although a step in the right direction, troubling elements remain in the new guidelines for vaginal birth after cesarean delivery...
The revised guidelines acknowledge that requiring “immediately available” resources for an emergency cesarean have resulted in hospitals, insurers and the obstetric community issuing formal or informal bans of VBAC, effectively denying women access to care and choice in birth. While this was not the intention, the “immediately available” language remains in the new guidelines, which may continue to unfairly limit women’s access to VBAC.
The 2010 ACOG guidelines basically tell women to go to a large urban hospital with 24/7 coverage if they really want a VBAC, but this is simply not feasible for most families and won't change VBAC access.

Most people in rural areas or small cities simply can't afford to drop everything and move to The Big City for several weeks around a birth, and inducing VBAC labors for convenience introduces greater risk. Nor do most women want to drive several hours to The Big City while in spontaneous labor.....especially in uncertain weather seasons like wintertime.

Even women who live in big cities may not be able to choose hospitals with 24/7 coverage because of insurance issues, and not all large urban hospitals with 24/7 surgical coverage even allow VBAC. Furthermore, even in hospitals where 24/7 coverage is available and VBAC is allowed, providers vary widely in their support of a trial of labor.  So this ACOG recommendation to go to big hospitals does little to increase access to VBAC for most women.

Remember, more cesareans create more billable services, require less staffing (no hands-on labor support), make it easier to schedule personnel, and fills their hospital beds predictably. The sad truth is that hospitals make money from banning VBACs and increasing cesarean rates.

VBAC bans are not about what's best for moms and babies; it's about what's best for hospitals' bottom line, convenience, and liability concerns. And that's just wrong.

Guideline Changes Had Little Impact on VBAC Rates

The authors hoped that tweaking ACOG's guidelines would allow more flexibility and improve women's access to VBAC.  Certainly it was a step in the right direction, but one that many childbirth advocates felt didn't go far enough.  Maureen Corry of Childbirth Connection concluded:
Overall, it’s dubious that these guidelines will in fact open up access for women.
The American College of Nurse-Midwives (ACNM) agreed, stating:
ACOG's revised guidelines are unlikely to increase access to trial of labor and VBAC in the U.S
ICAN, the International Cesarean Awareness Network (and premiere VBAC advocate in the world)
More than a revision of the VBAC Practice Bulletin is required to reverse the over a decade long trend of increasing cesarean rates and decreasing VBAC rates.
Well, now we have data to show that the new guidelines have had little impact.  A new study, Barger 2013, shows that ACOG's tweak had almost no effect on improving VBAC access in California.  

The authors investigated whether TOLAC rates in California had increased after the 2010 VBAC Consensus Conference and the ACOG guideline change.  They found only minor effects at best.

Nearly half of California hospitals still do not allow a TOLAC, even with changed guidelines, and among many of those that do allow VBACs, the actual VBAC rate is still abysmally low. From the abstract:
Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change. CONCLUSIONS: Despite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44% of California hospitals do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer than 3% VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California.
Similarly, the Portland chapter of ICAN surveyed 52 hospitals in the state of Oregon in 2011 and found that a year after the guideline revision, VBAC bans had actually increased slightly.  In all, the incidence of VBAC in Oregon was less than 2%.

This is the sorry state of VBAC access today, and it is unlikely to improve anytime soon.

Restoring VBAC Access

So what is the solution?

Bottom line, ACOG needs to remove "immediately available" from their guidelines. A lack of 24/7 surgical and anesthesia staffing should not be a requirement to permit VBAC because VBAC should not be held to a different standard than all other births.

Thousands of women are, in essence, being forced into unnecessary surgery because of lack of access to VBAC.  Given the well-documented risks of multiple cesareans, this lack of access is harming women. This is unconscionable.

Doctors, hospitals and elected officials MUST start pressuring ACOG to revise their guidelines, and pressuring insurance companies to remove VBAC barriers in malpractice insurance. 

A professional trade union, hospital administrators, and insurance companies should not have the power to deny reproductive decision-making autonomy to women. This is a reproductive rights issue. As the editor of the journal Obstetrics & Gynecology stated:
Currently, hospitals, insurance companies, and plaintiff attorneys decide or strongly influence whether VBAC is an option. Instead, the patient should be allowed to make that choice after she has been informed of the facts and has been counseled by her physician thoroughly.
Experience shows that when care providers, administrators, and consumers work together, VBAC access can be improved, as some organizations have managed despite the medico-legal climate. This system is not perfect, but it's better than what exists in many areas.  And increasing access to VBAC can have significant effects in lowering the total cesarean rate.

We consumers have been pressuring ACOG for years to change the "immediately available" wording but have been only marginally successful. Too many ACOG members do not care about the chilling impact their guidelines have had on childbirth choices all over the country. However, if there is enough push-back from their own members and other professional colleagues, along with continued pressure from consumers, change can happen.

It's time for healthcare professionals to stop acquiescing with VBAC bans, to step up and make their voices heard.  They, too, must fight back for VBAC. 

The ACOG VBAC guideline wording will only change when the big guns in the medical and political community start pushing back and stop letting the insurance companies, paper-pushers, and lawyers dictate reproductive decision-making. Consumers must keep up the pressure and get more doctors, hospitals, and elected officials involved.

Finally, it's also important for consumers and healthcare professionals to continue to advocate for a lower primary cesarean rate.  As Dr. James R. Scott points out:
...attempts to increase the VBAC rate make little sense without addressing the reason for the problem in the first place. Reducing the number of primary cesareans deals with the problem where it originates. Unless measures are instituted to reverse the rapidly rising cesarean rate, catastrophic complications from placenta accreta and percreta associated with multiple repeat cesareans soon may be a greater problem than uterine rupture.

Want to take action? Link to this article on your blog or Facebook page. Find out if any of your local hospitals has a VBAC ban and if it does, push it to reverse its ban.  Pressure your doctor or midwife to speak up for VBAC and for lowering the primary cesarean rate. Click on this link for ways to start making your views known to your elected officials. Or get involved with your local ICAN chapter or other birth advocacy group.

Make some noise before cesareans are the norm and VBACs disappear altogether.


Discussions of the NIH conference, ACOG's VBAC guidelines, and VBAC rates
VBAC Access After Most Recent ACOG 2010 Policy Change

BMC Pregnancy Childbirth. 2013 Apr 3;13(1):83. [Epub ahead of print] A survey of access to trial of labor in California hospitals in 2012. Barger MK, Dunn JT, Bearman S, Delain M, Gates E. PMID: 23551909
...METHODS: Between November 2011 and June 2012, charge nurses at all civilian California birth hospitals were surveyed about hospitals' TOLAC availability and requirements for providers...RESULTS: All 243 birth hospitals that were contacted participated. In 2010, among the 56% TOLAC hospitals, the median VBAC rate among TOLAC hospitals was 10.8% (range 0-37.3%). The most cited reason for low VBAC rates was physician unwillingness to perform them, especially due to the requirement to be continually present during labor. TOLAC hospitals were more likely to be larger hospitals in urban communities with obstetrical residency training. However, there were six (11.3%) residency programs in non-TOLAC hospitals and 5 (13.5%) rural hospitals offering TOLAC. The majority of TOLAC hospitals had 24/7 anesthesia coverage and required the obstetrician to be continually present if a TOLAC patient was admitted; 17 (12.2%) allowed personnel to be 15-30 minutes away...In 2012, 139 hospitals (57.2%) offered TOLAC, 16.6% fewer than in 2007. Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change. CONCLUSIONS: Despite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44% of California hospitals do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer than 3% VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California.
BMC Pregnancy Childbirth. 2011 Oct 12;11:72. doi: 10.1186/1471-2393-11-72. Providers' perspectives on the vaginal birth after cesarean guidelines in Florida, United States: a qualitative study. Cox KJ. PMID: 21992871
BACKGROUND: Women's access to vaginal birth after cesarean (VBAC) in the United States has declined steadily since the mid-1990s, with a current rate of 8.2%. In the State of Florida, less than 1% of women with a previous cesarean deliver vaginally. This downturn is thought to be largely related to the American College of Obstetricians and Gynecologists (ACOG) VBAC guidelines, which mandate that a physician and anesthesiologist be "immediately available" during a trial of labor...Fear of liability was a central reason for obstetricians and midwives to avoid attending VBACs. Providers who continued to offer a trial of labor attempted to minimize their legal risks by being highly selective in choosing potential candidates. Definitions of "immediately available" varied widely among hospitals, and providers in solo or small practices often favored the convenience of a repeat cesarean delivery rather than having to remain in-house during a trial of labor. Midwives were often marginalized due to restrictive hospital policies and by their consulting physicians, even though women with previous cesareans were actively seeking their care. CONCLUSIONS: The current ACOG VBAC guidelines limit US obstetricians' and midwives' ability to provide care for women with a previous cesarean, particularly in community and rural hospitals. Although ACOG has proposed that women be allowed to accept "higher levels of risk" in order to be able to attempt a trial of labor in some settings, access to VBAC is unlikely to increase in Florida as long as systemic barriers and liability risks remain high. 
Decline in VBAC Access After 1999 ACOG Policy Change

Semin Perinatol. 2010 Aug;34(4):237-43. doi: 10.1053/j.semperi.2010.03.002. Trends and patterns of vaginal birth after cesarean availability in the United States. Gregory KD, Fridman M, Korst L. PMID: 20654773
A review of the literature and analysis of the National Inpatient Sample Database was performed to describe the trends in vaginal birth after cesarean availability in the United States and the factors associated with changing use. Vaginal birth after cesarean increased after the first National Institutes of Health Consensus Conference on Cesarean Childbirth in 1981. It increased from 3% to a maximum rate of 28.3% in 1996. Despite studies reporting stable success rates of approximately 70% and low complication rates (<1%), concerns about patient safety and physician liability have led to more restrictive policies and a decrease in vaginal birth after cesarean use. The current rate is approximately 8.5%, and decreased rates have been noted for all age and ethnic groups. There is decreased use of vaginal birth after cesarean as the result of concerns about patient safety and physician liability, which has resulted in decreased availability.
Clin Perinatol. 2011 Jun;38(2):179-92. doi: 10.1016/j.clp.2011.03.007. Recent trends and patterns in cesarean and vaginal birth after cesarean (VBAC) deliveries in the United States. MacDorman M, Declercq E, Menacker F. PMID: 21645788
Cesarean delivery is the most common major surgical procedure for women in the United States, with 1.4 million surgeries annually. In 2008, nearly one-third (32.3%) of US births were by cesarean delivery. Cesarean delivery rates have increased rapidly in the United States in recent years because of an increasing primary cesarean delivery rate and a declining vaginal birth after cesarean (VBAC) rate. In 2007, the VBAC rate was 8.3% in a 22-state reporting area. The US VBAC rate was lowest among 14 industrialized countries; 3 countries had VBAC rates greater than 50%.
Matern Child Health J. 2005 Jun;9(2):181-8. The UTAH VBAC Study. Gochnour G, Ratcliffe S, Stone MB. PMID: 15965624
BACKGROUND: ...We examined the effect this new guideline [kmom: 1999 "immediately available" wording] would have on physician's VBAC/TOL practices in Utah...METHODS: In spring 2001, we surveyed by mail all physicians practicing obstetrics in Utah... RESULTS:...Forty-five percent of all physicians reported a decline in VBAC practices in the preceding 12 months. Urban physicians' use of VBAC/TOL decreased the least, followed by rural and suburban. Eighty-seven percent of physicians had C/S "immediately" available during TOL: urban physicians 100%, suburban 88%, and rural physicians 76%...CONCLUSION: Physicians use of VBAC/TOL has changed. TOL is offered less by obstetrical providers in Utah and more repeat C/S are performed since 1999 when ACOG updated this policy guideline. This decline has been more noticeable in suburban and rural hospitals and is consistent with recent national trends. Many rural physicians are unable to comply with ACOG Practice Guideline number 5 recommendations.
J Matern Fetal Neonatal Med. 2004 Jul;16(1):37-43. Vaginal birth after Cesarean rates are declining rapidly in the rural state of Maine. Pinette MG, Kahn J, Gross KL, Wax JR, Blackstone J, Cartin A.  PMID:
...STUDY DESIGN: We examined birth certificate and hospital data in the State of Maine from 1998 to 2001...RESULTS: VBAC rates declined by over 50% from 30.1 to 13.1%. The total Cesarean rate climbed from 19.4 to 24.0%. The most commonly reported reason for decrease in VBAC varied depending on whether a practitioner's hospital met ACOG guidelines. CONCLUSION: A marked decline in VBAC occurred after the change in ACOG vaginal birth after Cesarean policy. Multiple factors have contributed to this decline, including patients refusing VBAC after counseling and inability of institutions to meet ACOG guidelines.
Birth. 2007 Dec;34(4):316-22. Changing policies on vaginal birth after cesarean: impact on access. Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ. PMID: 18021147
...METHODS: Every hospital in Colorado, Montana, Oregon, and Wisconsin was contacted by telephone at least once during the period 2003 to 2005... RESULTS:...Almost one-third, 68 of 222 (30.6%), of responding delivery hospitals that previously offered VBAC services had stopped doing so; seven hospitals had never allowed VBAC. Of the hospitals that still allowed VBAC, 68 percent had changed their VBAC policies since 1999, with the most frequent changes requiring the in-house presence of surgery (53%) and anesthesia (44%) personnel when women desiring VBAC presented in labor...CONCLUSIONS: In the years following advocacy of the 1999 policy, the availability of VBAC services significantly decreased, especially among smaller or more isolated hospitals.
Keeping VBAC Accessible

Clin Obstet Gynecol. 2012 Dec;55(4):1021-5. doi: 10.1097/GRF.0b013e3182618921. Why VBAC in Northern New England is still viable: the Northern New England perinatal quality improvement network. Lauria MR, Flanagan V, Capeless E. PMID: 23090472
Under the strong leadership of Maternal-Fetal Medicine specialists and the support of the tertiary care centers serving the region, Northern New England (NNE) initiated a collaborative project to improve the availability and safety of trial of labor aftercesarean delivery. The project involved over 250 individuals from over 30 organizations and resulted in a strong regional guideline that has been implemented by institutions across the nation. The availability of trial of labor after cesarean in NNE has increased. The work led to the creation of the NNE Perinatal Quality Improvement Network, whose work has improved regional outcomes.
VBAC Conferences and Documents

National Institutes of Health. Cesarean childbirth. NIH publication no. 82-2067. Washington (DC): Government Printing Office, 1981.

NIH Consens State Sci Statements. 2010 Mar 10;27(3):1-42. NIH Consensus Development Conference Draft Statement on Vaginal Birth After Cesarean: New Insights. Bangdiwala SI, Brown SS, Cunningham FG, Dean TM, Frederiksen M, Hogue CJ, King TL, Lukacz ES, McCullough LB, Nicholson W,Petit NF, Probstfield JL, Viguera AC, Wong CA, Zimmet SC. PMID: 20228855
...CONCLUSIONS: (1) Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision...When both TOL and ERCD are medically equivalent options, a shared decision-making process should be adopted and, whenever possible, the woman's preference should be honored. (3) We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for "immediately available surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources...We 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. (4) We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers. Policymakers, 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....

Monday, April 22, 2013

VBAC After Prior VBAC: Decreased Risks, Not Increased Risks

Just in time for Cesarean Awareness Month, another *headdesk* moment from My OB Said What?!?.

This one is about whether a woman who has already had VBACs should continue to have more VBACs or whether she needs to sign up for more cesareans because having too many VBACs becomes "too dangerous."
"I will not go over this with you and you are being argumentative! More than a few VBACs will be unsafe because the scar stretches and can become unstable. I don't care how many safe VBACs you've had and about any of the other testing you've had in the past, this is dangerous!" --OB to mother trying to VBAC again
Sometimes I can't believe the stupid things that come out of some providers' mouths. With all the research out there disproving the foolish myths that circulate, I can't believe that this is even a question, yet every once in a while we still hear this one in VBAC groups. Sigh.

So let's go over what the research actually says:
  • Prior vaginal births actually decrease your risk for rupture (de Lau 2011, Zelop 2000)
  • Prior VBACs particularly decrease your risk for uterine rupture (Mercer 2008, Shimonovitz 2000)
  • Each successive VBAC does not get more risky  (Mercer 2008)
  • Each successive cesarean does get more risky (Silver 2006)
  • Grand multiparity (5 or more pregnancies) is not a contraindication to a trial of labor (Kugler 2008) 
  • Women with a history of VBAC have a very high success rate in subsequent trials of labor (Mercer 2008, Gyamfi 2004)
Of course, in the interest of accuracy, I would point out that once you've had a cesarean, the risk of uterine rupture is never zero or negligible, even with multiple prior VBACs.  However, the risk is decreased compared to a woman who has never had a VBAC.  And the risk of multiple repeat cesareans is certainly significant.

Given that the risk for rupture goes down somewhat with successive VBACs, given that women with a prior VBAC have a very high success rate in subsequent VBAC attempts, given that grand multiparity is not a contraindication to VBACs, and given that there are strong risks with multiple repeat cesareans, why would doctors limit how many VBACs a woman is "allowed" to have?

Mercer and colleagues stated as much in the conclusion of their study, saying (emphasis mine):
Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy. There is no reason to place a limit on the number of VBACs a woman can have.
That research was published in 2008.  It's long past time for the entire obstetric community to get the memo on this.


Mercer BM, Gilbert S, Landon MB. et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol. 2008 Feb;111(2):285-291.  PMID:  18238964   You can read the entire study here.
OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs. METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery. RESULTS:  Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52%(P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter. CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.
Arch Gynecol Obstet. 2011 Nov;284(5):1053-8. Epub 2011 Aug 31. Risk of uterine rupture in women undergoing trial of labour with a history of both a caesarean section and a vaginal delivery. de Lau H, Gremmels H, Schuitemaker NW, Kwee A. PMID: 21879334
PURPOSE: To determine the risk of uterine rupture for women undergoing trial of labour (TOL) with both a prior caesarean section (CS) and a vaginal delivery. METHODS: A systematic literature search was performed using keywords for CS and uterine rupture. The results were critically appraised and the data from relevant and valid articles were extracted. Odds ratios were calculated and a pooled estimate was determined using the Mantel-Haenszel method. RESULTS: Five studies were used for final analysis. Three studies showed a significant risk reduction for women with both a previous CS and a prior vaginal delivery (PVD) compared to women with a previous CS only, and two studies showed a trend towards risk reduction. The absolute risk of uterine rupture with a prior vaginal delivery varied from 0.17 to 0.46%. The overall odds ratio for PVD was 0.39 (95% CI 0.29-0.52, P < 0.00001). CONCLUSION: Women with a history of both a CS and vaginal delivery are at decreased risk of uterine rupture when undergoing TOL compared with women who have only had a CS.
Obstet Gynecol. 2004 Oct;104(4):715-9. Increased success of trial of labor after previous vaginal birth after cesarean. Gyamfi C, Juhasz G, Gyamfi P, Stone JL.  PMID: 15458891
OBJECTIVE: To estimate whether a history of a previous successful vaginal birth after cesarean delivery (VBAC) has an effect on a subsequent VBAC attempt...RESULTS: Of the 336 patients with a history of one or more previous successful VBAC attempts, 94.6% had a subsequent successful VBAC, whereas 70.5% of the remaining 880 patients were successful (P <.001). For those patients with one or more previous successful normal spontaneous vaginal deliveries, 87.8% had a successful VBAC, whereas 75.6% were successful without this history (P =.001)...Patients with a history of previous VBAC were 7 times more likely to have a subsequent VBAC success (odds ratio 7.40, 95% confidence interval 4.51-12.16; P <.001)...CONCLUSION: A history of a previous successful VBAC increases the likelihood for success with future attempts....
Isr Med Assoc J 2000 Jul;2(7):526-8. Successful first vaginal birth after cesarean section: a predictor of reduced risk for uterine rupture in subsequent deliveries. Shimonovitz S, Botosneano A, Hochner-Celnikier D.  PMID: 10979328
BACKGROUND: Uterine rupture is a catastrophic obstetric complication, most often associated with a preexisting cesarean section scar. Although a vaginal birth after a cesarean is considered safe in modern obstetrics, it is not known whether repeated VBACs increase the risk of rupture, or whether the first VBAC proves the strength and durability of the scar, predicting further successful and less risky vaginal deliveries. OBJECTIVES: To evaluate the effect of repeated vaginal deliveries on the risk of uterine rupture in women who have previously delivered by cesarean section. METHODS: In this retrospective study, 26 VBAC deliveries complicated by uterine rupture were matched for age, parity, and gravidity with 66 controls who achieved VBAC without rupture. The histories, demography, pregnancy, labor and delivery records, as well as neonatal outcome were compared. RESULTS: We found that the risk of rupture decreases dramatically in subsequent VBACs. Of the 40 cases of uterine rupture recorded during the 18 year study period, 26 occurred during VBAC deliveries. Of these, 21 were complicated first VBACs. We also found that the use of prostaglandin-estradiol, instrumental deliveries, and oxytocin had been used significantly more often during deliveries complicated with rupture than in VBAC controls. CONCLUSIONS: Once a woman has achieved VBAC the risk of rupture falls dramatically. The use of oxytocin, PGE2 and instrumental deliveries are additional risk factors for rupture, therefore caution should be exerted regarding their application in the presence of a uterine scar, particularly in the first vaginal birth after cesarean.
Am J Obstet Gynecol. 2000 Nov;183(5):1184-6. Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor. Zelop CM, Shipp TD, Repke JT, Cohen A, Lieberman E.  PMID: 11084564
OBJECTIVE: We examined the effect of prior vaginal delivery on the risk of uterine rupture in pregnant women undergoing a trial of labor after prior cesarean delivery. STUDY DESIGN: The medical records of all pregnant women with a history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed...RESULTS: Of 3783 women with 1 prior scar, 1021 (27.0%) also had > or =1 prior vaginal delivery. During a subsequent trial of labor, the rate of uterine rupture was 1.1% among pregnant women without prior vaginal delivery and 0.2% among pregnant women with prior vaginal delivery (P =.01). Logistic regression analysis controlling for duration of labor, induction, birth weight, maternal age, year of birth, epidural analgesia, and oxytocin augmentation indicated that, among women with a single scar, those with a prior vaginal delivery had a risk of uterine rupture that was one fifth that of women without a previous vaginal delivery (odds ratio, 0.2; 95% confidence interval, 0.04-0.8)...CONCLUSION: Among women with 1 prior cesarean delivery undergoing a subsequent trial of labor, those with a prior vaginal delivery were at substantially lower risk of uterine rupture than women without a previous vaginal delivery.
Archives of Gynecology and Obstetrics. 2008 Apr;277(4):339-44. The safety of a trial of labor after cesarean section in a grandmultiparous population. Kugler E, Shoham-Vardi I, Burstien E, Mazor M, Hershkovitz R.  PMID: 17957377 
BACKGROUND: The rate of vaginal birth after a cesarean (VBAC) delivery in the multiparous population has decreased largely in recent years because of maternal and neonatal complications. The clinical management of grand multiparous (GMP) women (>5 births) with a prior cesarean delivery is even less clear. The purpose of the present study was to assess the risks of maternal and neonatal complications associated with VBAC compared to that of repeated elective cesarean section (CS) in the GMP population. METHODS: A retrospective study of 1,102 GMP women with a singleton gestation and a prior single CS was conducted. Data were retrieved from the database of the Department of Obstetrics and Gynecology at the Soroka University Medical Center, Beer Sheva, Israel. Maternal and neonatal outcomes were compared between women who underwent a successful VBAC attempt, women who had failed in a trial of labor and women who had an elective repeated CS. RESULTS: Six hundred and nineteen women (56%) underwent a successful VBAC, 155 (14%) underwent a trail of labor and 328 (30%) had an elective repeated CS. Women who had a successful VBAC required less blood transfusion, and had less puerperal fever diseases (P < 0.001). Induction or augmentation of labor was associated with failure of VBAC (P < 0.001). No significant differences in neonatal complications were observed between the groups. No significant difference in uterine dehiscence, uterine rupture, amnionitis, postpartum hemorrhage, hysterectomy, puerperal fever and thromboembolic diseases was observed between the groups. CONCLUSIONS: A successful VBAC in the GMP population was not associated with a higher risk of maternal complications in comparison with a repeated elective CS.
Obstet Gynecol. 2006 Jun;107(6):1226-32. Maternal morbidity associated with multiple repeat cesarean deliveries. Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y,Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai B, Langer O, Thorp JM, Ramin SM, Mercer BM; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. PMID: 16738145
...METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

Thursday, April 11, 2013

High Induction Rates and High Cesarean Rates in Women of Size

In honor of Cesarean Awareness Month, let's dissect yet another blame-the-fat-mother study.

In this study, the authors looked at the rate of complications and interventions by class of "obesity." As they expected, they found that the rate of complications rose as the mother's BMI rose.  They also found that the rate of interventions like inductions and c-sections rose as the mother's BMI rose, and emphasized the importance of weight loss to prevent these.


These studies always blame the fat woman and emphasize weight loss to prevent cesareans etc., instead of also examining how their own biases and practices (a high induction rate in obese women and a low surgical threshold) are negatively impacting outcomes in women of size.  

In this study, induction rates increased from 25.3% in "normal" BMI women to 42.9% in class III obesity women.  

Where's the questioning of the necessity of most of these inductions?  

Sure, inductions to some extent are going to be increased because there is more blood sugar and blood pressure issues in obese women, and it's true that these tend to rise as BMI rises. So by all means, go ahead and emphasize the importance of good nutrition and regular exercise as a possible way to decrease the number of obese women with complications. No one objects to that, as long as the emphasis is on reasonable expectations and not extreme measures.

But nearly half of the obese women in this study "needing" to be induced?  I don't think so.  Many of these inductions are NOT due to medical indications like high blood pressure or uncontrolled blood sugar.  Many are because docs are nervous about a big baby and decide to induce early (even though that increases the cesarean rate substantially and does not reduce shoulder dystocia), or because they think that pregnant fat women will never go into labor on their own.  Bzzzt on both counts!

Researchers always assume in studies that every induction in an obese woman is a necessary induction.  Some indeed are, but many are NOT.  Yet most researchers steadfastly refuse to connect the dots between the insanely high induction rate in fat women and the obscenely high cesarean rate in this group.  Augh!

Researchers, if you really want to start lowering the cesarean rate in women of size, start examining the insanely high induction rate of these women, and start putting those inductions under the microscope to see which ones are truly justified and which ones are not.  

Cutting back on the rate of questionable inductions in "obese" women has tremendous potential for lowering the cesarean rate in this group, and, given the high failure rate of most diets, is much more achievable than pressuring all fat women to lose weight before pregnancy.  


J Obstet Gynaecol Can. 2013 Mar;35(3):224-33. The impact of increasing obesity class on obstetrical outcomes. El-Chaar D, Finkelstein SA, Tu X, Fell DB, Gaudet L, Sylvain J, Tawagi G, Wen SW, Walker M.  PMID: 23470110
Objective: Nationally, rates of obesity continue to rise, resulting in increased health concerns for women of reproductive age. Identifying the impact of maternal obesity on obstetrical outcomes is important to enhance patient care. 
Methods: We conducted a retrospective cohort study of 6674 women who delivered a singleton infant at ≥ 20 weeks' gestation between December 1, 2007, and March 31, 2010, at The Ottawa Hospital. Maternal pre-pregnancy BMI was used to classify women into normal, overweight, and obese (class I/II/III) categories according to WHO classifications. Obstetrical outcomes among obese women were compared with those of women with normal BMI. Multivariable regression models were used to determine adjusted odds ratios and 95% confidence intervals. 
Results: Compared with women with normal BMI, obese women had significantly higher rates of preeclampsia, gestational hypertension, and gestational diabetes, and these rates increased with increasing BMI (trend-test P < 0.001). There was a significant increase in rates of induction of labour in the obesity categories, from 25.3% in women with normal BMI to 42.9% in women with class III morbid obesity (aOR 1.67; 95% CI 1.43 to 1.93). Rates of primary Caesarean section rose with increasing BMI and were highest in women with class III morbid obesity (36.2% vs. 22.1% in women with normal BMI) (aOR 1.46; 95% CI 1.23 to 1.73). 
Conclusion: Increasing BMI is associated with increasing rates of preeclampsia, gestational hypertension, and gestational diabetes. There is a significant increase in rates of induction of labour with increasing obesity class, and a significantly increased Caesarean section rate with higher BMI. Obstetrical care providers should counsel obese patients about the risks they face and the importance of weight loss before pregnancy.

Monday, April 1, 2013

Cesarean Rates: Debunking the Mother-Blaming

It's April, Cesarean Awareness Month, so I'll be blogging about several cesarean-related topics this month.

Let's start off with an interesting video from Eugene DeClercq about the rise in cesarean rates. The video was done about data through 2009, so it doesn't have the most recent information in it, but it still has some valuable observations and commentary.

First, look at the cesarean rate graphs above.  Notice the c-section rate in 1970 vs. 2010.  Huge increase.  This is not all bad, as some babies and mothers are undoubtedly saved by cesareans. However, a too-high rate exposes mothers and babies to significant risks, presenting more risks than benefits.  So what we need is to find the right balance.

It's important to notice that the increase in cesareans hasn't been steady. It exploded in the late 70s and early 80s, dipped in the late 80s and early-to-mid 90s when there was pressure to reduce rates, and then steeply increased again until just recently when it leveled off a bit for the first time in years.  This fluctuating rate is important when examining the usual mother-blaming excuses for why the cesarean rate has risen over the years.

DeClercq debunks the usual excuses given by many in the maternity care community for why the cesarean rate has risen so much, including:
  • Women are too old
  • Women are having more twins
  • Babies are getting bigger
  • Women are requesting more cesareans
DeClercq addresses and debunks each of these.

For example, he notes that the trend towards older mothers slowed greatly a while ago, as did the trend towards more twins.....yet the cesarean rate continued to rise strongly afterwards. It wouldn't have done so if these factors were really what was pushing the rise in cesareans.

And in fact, babies are NOT getting bigger.  However, our management of big babies has changed.  As Henci Goer and CNM Amy Romano note in their book, "Optimal Care in Childbirth":
Cesarean rates have increased in all weight categories, the incidence of macrosomia declined from 1990 to 2000, and cesarean rates with macrosomia have soared: U.K. physicians delivered only 3% of babies weighing 4000 g or more via cesarean in 1958, while U.S. obstetricians today may perform cesareans on as many as half the women with babies of this size.  
And most women are NOT requesting elective cesareans.  While there are some women who do want elective primary cesareans, the number of these women is quite small, probably less than 1%.  So this factor can't be blamed for the rising cesarean rate either.

DeClercq also addresses the common defensive reply from some OBs that "There is nothing wrong with a high cesarean rate," because they feel a cesarean is the best way to guarantee a good outcome.  Turns out it's not.  Non-indicated cesareans increases risks for both mothers and babies. What a shock.

DeClercq is a professor at Boston University School of Public Health, and has an MBA and a PhD.  He's not afraid to speak his truths, whatever the audience.  You have to love his Baaawstan accent, but he has a great way of being able to communicate complicated concepts in simple and understandable ways.  I'm a big fan.

I saw him speak at an ICAN conference a few years ago.  I was quite impressed by him. He's a data wonk, but a layperson's data wonk as well as a data wonk's data wonk (if you know what I mean). I like that he can communicate effectively both with the statisticians/medicos and with the general public ─ without dumbing things down.

An Unquestioning Eye Towards Obesity?

That doesn't mean we agree about everything. In that lecture at our ICAN conference, he pointed out the problems with blaming women for the rise in cesarean rates, and debunked everything but obesity.

He noted that many doctors are blaming increasing cesarean rates on the "obesity epidemic." When he looked at the data, he found that high-BMI women do have high cesarean rates and have for a while. So he basically said there might be some truth to obesity being tied to a rise in cesarean rates. Augh!

Yet Goer and Romano point out in their book that, like the trends in older mothers and twin births, the rise in maternal weight leveled off a while ago, yet the cesarean rate kept on rising:
The relationship between maternal weight and cesarean rate cannot be ascertained directly, but the proportion of high-weight women increased from 1991 to 1996 while cesarean rates were falling and held steady from 1999 to 2004 when cesarean rates were once again on the rise.  
This casts doubt on the idea that obesity is to blame for the rise in cesarean rates.

I'd also point out that while it's true that high-BMI women have a high cesarean rate now, he didn't go back far enough into the past.  If you go back far enough, high-BMI women didn't have cesarean rates anywhere nearly as high as now, and often had very similar cesarean rates to average-BMI women.

I think that debunks the idea that obesity itself causes a high cesarean rate, and suggests instead that the highly-interventive way obese pregnancies/labors are now being handled, with more intervention and a lower surgical threshold, has more to do with higher cesarean rates in obese women.

In other words, it's how the management of obese women has changed that has impacted the cesarean rate, rather than obesity itself, and perhaps a more realistic solution than universal weight loss is to change the way those pregnancies are managed instead.  That will help lower the cesarean rate in this group.

In other words, yes, the cesarean rate in fat women is high.....but it probably doesn't have to be that way.  If we change the over-interventive way we manage pregnancy and labor in obese women, then that will lower the c-section rate in them, and in turn may have a modest influence on the overall cesarean rate.

I've written about this many times before on this blog and elsewhere.  Rather than repeat the information here again, I've included links to articles I've written about the idea that obesity causes cesareans and an increase in fat mothers automatically necessitates a high cesarean rate:
  • Supersized Women and Cesareans: A Tale of Two Cities - blog post comparing two recent research studies with similar populations (BMI of 50 and up) but one had twice the cesarean rate of the other. If obesity were an intractable "cause" of cesareans, their cesarean rates should have been similar, but one was much higher, nearly twice the rate of the other. Obviously, management is relevant too
  • News Flash: Labor Managed Differently in High-BMI Women! - blog post discussing a recent study that found that the labors of high-BMI women had more interventions, were intervened in earlier, and had a lower threshold for surgery.  When interventions were controlled for, the difference in cesarean rate was far smaller.  In other words, it's not just about women's obesity, it's also about the way our labors are over-intervened in and the fear level among some providers
  • The Fat Vagina Theory: "Soft Tissue Dystocia" - blog post debunking one of the most common reasons given for a higher cesarean rate in obese women, Soft Tissue Dystocia (adipose tissue crowding the vagina and not letting a baby pass)
  • Ghettoizing Fat Pregnant Women - blog post decrying the new trend to limit fat women's choices in birthplace, care provider, and birth options, solely by BMI
  • Scapegoating Fat Women Once Again - blog post debunking yet another media press release blaming fat women for the rise in cesarean rates and calling for a more nuanced (and less mother-blaming) approach
  • Women of Size and Cesarean Sections: Tips for Avoiding Unnecessary Surgery - article for the Our Bodies, Ourselves website, with practical ways that women of size can lower their risk for a cesarean and increase their chances of a VBAC
  • Avoiding Surgery: Lowering the Cesarean Rate in Big Moms - article I wrote for a healthcare consumers e-zine about lowering your risk for a cesarean
Finally, for care providers reading this blog, I'd suggest reading the series I wrote on the Science and Sensibility blog last year. While acknowledging the potential risks of obesity and pregnancy, it also suggests rethinking the paradigm with which most care providers approach obese pregnant women.
Science and Sensibility: Rethinking the Obesity Paradigm: An Insider's View
Declercq is right that cesarean rates are elevated in high-BMI women, but they don't have to be.  It's not a causal relationship. And it's not what drove the rise in cesarean rates in recent years.  I wish he would acknowledge that, and the fact that cesarean rates in this group can be reduced.

If the desired end is improved outcomes for women of size and their babies, then we need to consider all possible management options for them, not just the highly-interventive management style currently used for them, and individualize our approach based on the actual needs of the woman.  

Yes, some obese women will have complications and require more interventive care, but many will not, and we do considerable harm (via very high cesarean rates, risky inductions, and more iatrogenic premature births) when we force highly-interventive management on all obese women, as the trend towards "bariatric obstetrics" does.

Save the high-intervention management for those cases that truly need it; utilize the low-tech tools that work well to lower cesarean rates in other groups (fewer early inductions, more quality labor support, more attention to fetal position and fetal re-positioning techniques, more patience in labor, fewer automatic repeat cesareans, etc.). In that way we can likely bring down the cesarean rate in women of size too.

Care providers (and public health advocates) must stop shrugging their shoulders and writing off women of size as a lost cause in the cesarean department.  A high cesarean rate is NOT endemic to obesity if we change our management of it, our fear of it, and our nearly-automatic reach for the scalpel when a fat pregnant women walks into the hospital.
Final Thoughts

Many care providers have excused the rising cesarean rate by blaming mothers.  According to them, women are too old, too fat, gain too much weight in pregnancy, have huge babies, have too many multiple births, or are requesting all these cesareans.

No, these factors are not entirely irrelevant, but by and large they are NOT responsible for the tremendous rise in cesarean rates in recent years.  As Goer and Romano note:
U.S. cesarean rates have increased sharply at every maternal age, in every ethnic group, and for every demographic or medical risk factor.
This is not a matter of a rising tide of high-risk mothers driving up the cesarean rate, but rather a deep and increasing trend towards more intervention (and a lower surgical threshold) in ALL groups.

By blaming mothers, caregivers avoid taking responsibility for their own actions which have pushed up the cesarean rate. 

The induction and "pushed birth" epidemic, the over-intervention in normal labors, the lack of support for vaginal breech birth, the virtual abandonment of VBAC, the loss of skills in manually turning poorly-positioned babies, the lack of patience during labor, the increasingly narrow definition of "normal," and the lowering of surgical thresholds have all been caregiver-driven reasons for the rise in the cesarean rate.

Eugene DeClerq has been one of the leading voices pointing out the flaws in blaming mothers for the rising cesarean rate, and bravo to him for doing so.  We need MORE respected voices speaking up and pushing back against the mother-blaming culture of many maternity care providers.

Unfortunately, the one finger-pointing he doesn't seem to question is obesity.  I wish he would apply the same questioning eye to the historical data on cesareans in obese women that he does to other possible "causes."  I'm tired of obesity-blaming getting a free ride (no questions asked!) from even the best public health advocates.

However, I'm pleased to report that a few researchers and childbirth advocates (like Goer and Romano) are beginning to push back on this issue.  Let's hope this is the start of a new trend.

Even though Eugene and I don't see completely eye-to-eye about this one issue, I still find much to admire in his writings and his research analysis.  He has a lot of valuable things to say about cesarean rates and birth in general, he says it in a very understandable way, and we need to listen carefully to it.

Now if we can only get him to dig a little deeper on the obesity question....


Pediatrics. 2003 May;111(5 Pt 2):1181-5. Contribution of excess weight gain during pregnancy and macrosomia to the cesarean delivery rate, 1990-2000. Rhodes JC, Schoendorf KC, Parker JD.  PMID: 12728135
OBJECTIVE: After declining for many years, cesarean delivery rates recently increased. To explore whether this increase is associated with excess weight gain during pregnancy, resulting in macrosomic infants who require cesarean delivery, we examined trends in excess weight gain, macrosomia, and cesarean delivery...CONCLUSIONS: Excess weight gain and macrosomia do not seem to be the primary factors that contribute to the recent increase in cesarean delivery because cesarean delivery rates have increased in all weight gain categories and macrosomia rates have decreased steadily from 1990-2000. Nonetheless, women who gain excess weight account for a growing proportion of cesarean deliveries because their relative numbers have grown.
Am J Public Health. 2006 May;96(5):867-72. Epub 2006 Mar 29. Maternal risk profiles and the primary cesarean rate in the United States, 1991-2002. Declercq E, Menacker F, Macdorman M. PMID: 16571712
OBJECTIVES: We examined factors contributing to shifts in primary cesarean rates in the United States between 1991 and 2002. METHODS: US national birth certificate data were used to assess changes in primary cesarean rates stratified according to maternal age, parity, and race/ethnicity. Trends in the occurrence of medical risk factors or complications of labor or delivery listed on birth certificates and the corresponding primary cesarean rates for such conditions were examined. RESULTS: More than half (53%) of the recent increase in overall cesarean rates resulted from rising primary cesarean rates. There was a steady decrease in the primary cesarean rate from 1991 to 1996, followed by a rapid increase from 1996 to 2002. In 2002, more than one fourth of first-time mothers delivered their infants via cesarean. Changing primary cesarean rates were not related to general shifts in mothers' medical risk profiles. However, rates for virtually every condition listed on birth certificates shifted in the same pattern as with the overall rates. CONCLUSIONS: Our results showed that shifts in primary cesarean rates during the study period were not related to shifts in maternal risk profiles.
J Matern Fetal Neonatal Med. 2013 Apr;26(6):547-51. doi: 10.3109/14767058.2012.745506. Epub 2012 Nov 28. Cesarean delivery in obese women: a comprehensive review. Wispelwey BP, Sheiner E.  PMID: 23130683
BACKGROUND: Obesity (BMI ≥30) is a significant independent risk factor for many gestational complications, including cesarean delivery (CD). While CD rates are increasing in women of every BMI, the trend is more pronounced as maternal weight increases. OBJECTIVE: This review seeks to describe the risk modulators that explain the high prevalence of CD in obese women, as well as to discuss the excess complications of the procedure in this group of parturients. In assessing the rationale for the procedure and weighing this against the excess risks involved, a clearer indication of when to perform CD in obese women might be developed. RESULTS: A thorough review of the literature indicates that a decreased cervical dilation rate, an increased induction rate, the presence of comorbid conditions, concern about shoulder dystocia, and weight gain in excess of recommendations during pregnancy all may contribute to the high rate of CD in obese women. Obese women are at increased risk of CD-related complications including anesthetic complications, wound complications, venous thromboembolism (VTE), and failure of vaginal birth after CD. CONCLUSIONS: Given the excess risks associated with CD in obese women, and that some of the rationale for the procedure (e.g. slower labor, concern about shoulder dystocia) may not be justified based on current evidence, a reassessment of the threshold at which obese women are recommended for CD is necessary.
J Obstet Gynaecol Can. 2011 May;33(5):443-8. Higher caesarean section rates in women with higher body mass index: are we managing labour differently? Abenhaim HA, Benjamin A. PMID: 21639963
BACKGROUND: Higher body mass index has been associated with an increased risk of Caesarean section. The effect of differences in labour management on this association has not yet been evaluated. METHODS: We conducted a cohort study using data from the McGill Obstetrics and Neonatal Database for deliveries taking place during a 10-year period. Women's BMI at delivery was categorized as normal (20 to 24.9), overweight (25 to 29.9), obese (30 to 39.9), or morbidly obese (≥ 40). We evaluated the effect of the management of labour on the need for Caesarean section using unconditional logistic regression models. RESULTS: Data were available for 11 922 women, of whom 2289 women had normal weight, 5663 were overweight, 3730 were obese, and 240 were morbidly obese. After adjustment for known confounding variables, increased BMI category was associated with an overall increase in the use of oxytocin and in the use of epidural analgesia, and with a decrease in use of forceps and vacuum extraction among second stage deliveries. Higher BMI was also found to be associated with earlier decisions to perform a Caesarean section in the second stage of labour. When adjusted for these differences in the management of labour, the increasing rate of Caesarean section observed with increasing BMI category was markedly attenuated (P < 0.001). CONCLUSION: Women with an increased BMI are managed differently in labour than women of normal weight. This difference in management in part explains the increased rate of Caesarean section observed with higher BMI.