March 11th, 2010
Once a Cesarean, Rarely a Choice
This week the National Institute of Health held a consensus conference on the topic of Vaginal Birth After Cesarean (VBAC.) The purpose of this conference was to present and explore the current available information about the risks and benefits of both a vaginal delivery, and a repeat cesarean delivery, whereby the panel may ultimately present a consensus statement on the safety, efficacy, and availability of VBAC.
With the current national cesarean rate of 31.8%, a VBAC rate of only 7.8%, and nearly 40% of US hospitals banning vaginal birth after cesarean, many women are finding they have no choice but to undergo major abdominal surgeries for the delivery of their children. However, many women, alongside providers and educators, have stood in opposition to this forced surgery as a fundamental violation of the mother’s right to choose what happens to her body and her baby. When the NIH announced the VBAC conference, many activists, mothers, and providers, felt this was an opportunity to beseech the researchers to look at the information available and see how the lack of choice has been harming mothers, their families, and even their providers. In a show of solidarity, birth activists from all over the world came to witness the conference, ask questions, and share the stories of the ways that forced cesareans have affected their lives or their practice.
Much to the surprise and delight of the concerned activists, the resonating tone throughout the NIH VBAC conference was that of maternal choice, patient autonomy, and informed consent or refusal. While in recent years the relatively small risks associated with VBAC labor have driven providers to restrict access to VBAC, the NIH speakers presented clear evidence that there are serious risks associated with repeat cesarean delivery as well. Dr. Howard Minkoff even pointed to the 2002 Smith study showing the risk to the baby in a VBAC labor is about the same as any other full term, normal vaginal delivery. Consistently, the speakers stated that VBAC is a reasonable option, elective repeat cesarean is not a risk-free delivery, and that ultimately, it is the mother’s choice which of those risks to accept. None of this is new information to anyone interested in maternal and fetal health, but these revelations in this type of forum validated the feelings of the many mothers and activists who have spent years pleading for supported access to VBAC.
Though most of the conference speakers focused on the statistical medical data on vaginal or cesarean birth, one speaker illustrated the more personal side of the story. USA Today reporter, Rita Rubin, brought the audience on an emotional journey as she presented stories of families across the country who have picketed, battled, or even birthed unassisted in the name of preventing an unwanted and unnecessary cesarean. Throughout the conference, speakers and audience members made the NIH panel aware that many mothers demand access to vaginal birth, and that the VBAC issue will remain a contentious topic until hospitals and providers start respecting, and honoring, the mother’s right to choose.
Unfortunately, the language about informed consent and patient autonomy did not make it into the final NIH consensus statement, and when panelists were pressed on the issue, they failed to recognize that pregnant women have the same right to choose thier course of care as any non-pregnant person. Says Susan Jenkins, legal counsel for The Big Push For Midwives,
“The panel refused to take a position on whether a pregnant woman has the same constitutional right to informed refusal as any other adult in the U.S. This is unconscionable and I wonder what this administration’s take is on an HHS panel questioning whether pregnant women are entitled to the full benefits of U.S. citizenship in regard to patient autonomy.”
Time will only tell if the more positive points made by NIH consensus will have an impact on VBAC access in this country. From a birth activist’s point of view, the statements made by many of the conference speakers were a huge leap in the right direction. However, our cesarean and VBAC rates will not be reversed overnight, and in the interim, scores of women are left without a choice but to either fight the system for their VBAC, or submit to a surgical birth. To these women and their families, this is really no choice at all.
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This article was written for, and cross-posted at RH Reality Check.
Click to Leave a Comment
I’m happy that the NIH took such a positive stand towards VBAC availability and women’s rights to refuse repeat cesarean delivery. I agree that the denial of a pregnant women’s ultimate right to refuse treatment as equal to a non-pregnant women is unfortunate, but not surprising given the political diversity of the NIH panel. I am hopeful that this new statement has an positive effect on VBAC availability in the next few years.
Nicholas Fogelson, MD´s last blog ..Academic OB/GYN Podcast Episode 16 – Grey Journal February 2010 
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I find the many ways that pregnant women’s autonomy and rights are denied to be unsettling and offensive. It can even be as basic as someone questioning your choice to eat a certain food, somehow when you become pregnant you’re not treated as an individual in the same way. It’s disappointing to hear that this attitude was present on the panel.
All the same, I am glad to hear that the tone was positive overall, and I hope that it is a step in the right direction for VBAC availability.
Amber´s last blog ..Bloggers are Real People
[Reply]
Had the privilege of taking a VBAC Facts class today and the speaker/teacher and the doctor were just back from the NIH Conference. It would have been a positive and enjoyable class no matter what – but the added positivity of them having just attended the NIH and hearing all of the good VBAC news, made it so much more empowering and enlightening for me.
[Reply]
@Michelle C – Jen (from VBAC Facts) was my roommate at the conference! And Dr. Fischbein stayed in the same hotel, and accompanied us to dinner one night. He’s a good hang. 
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