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VBAC-ing in America

In Ina May Gaskin’s newest book, Birth Matters: A Midwife’s Manifesta, she describes why she believes that birth is a feminist issue.  While so many of us have permitted debates around abortion to take center stage when it comes to the politics of healthcare for women in the United States, the reality is that this focus on only one small aspect of healthcare for women and families has distracted us from an embarrassing fetal and maternal mortality rate in the United States.  Gaskin illuminates our complete failure to document maternal mortality and to evaluate cases of maternal mortality to improve standards of care that would actually make a difference.  She also shows that while birth has become more medicalized and we have started to use more technology, that our use of technology, surgery and testing have not actually resulted in safer births for mothers or babies.

Larry Cox supported this same sentiment in an Amnesty International article when he said, “Mothers die not because the United States can’t provide good care, but because it lacks the political will to make sure good care is available to all women.”  For the full Amnesty International Report follow this link.

While Gaskin’s safety for births at the Farm Midwifery Center from 1970 to 2010 are incredibly impressive (1.7% cesarean rate and a 96.8% rate of success with VBAC and maternal mortalit of 0 with neonatal mortality rate of 1.7 deaths per 1,000 births), the reality is that the total accepted for care over these forty-years (2,844) represents only a small percentage of what major hospitals will deliver in a year (here in Pittsburgh, Magee delivers over 10,000 per year).  In addition, we have to accept that many hospitals are working with high risk cases that would not have even considered a Farm birth. So many women become pregnant who already have significant health concerns and social challenges: drug and alcohol abuse, poor diet and nutrition, lifestyle stress, economic concerns, domestic violence, etc. that we have have to consider the fact that the general state of health for most adults in the United States is part of our failure.   No matter what, Gaskin makes incredibly strong arguments for care for women during pregnancy and post-delivery that provide evidence for success in the quality of care that she and the other midwives on the Farm have provided for such a long period of time.

One of the issues that we face in the United States, especially with the incredible rise in the cesarean rate, is how to support women who have had a cesarean with a previous birth and wish to try to have a vaginal delivery with subsequent births.  Making such a choice is referred to as a VBAC , which is short for “vaginal birth after cesarean.”  This is a subject that is relevant to me personally right now as I had a cesarean birth with my first child and am now 35-weeks pregnant with my second.

In my first birthing, I labored with the most excellent support and care of a group of midwives here in Pittsburgh at a hospital and am convinced that my cesarean was necessary and life saving.  It seems that my head-strong and passionate son was brow presenting.  In Ina May Gaskin’s Farm statistics, only 10 of 2,844 total births were brow presenting.  And, while she and her team managed to deliver five of them vaginally, the other 5 represent a considerable percentage of her cesarean deliveries.  The Farm’s c-section rate for breech presentations was less than 10%, but 50% for brow presentations.  Therefore, I am rather confident that it is highly unlikely that my second child will present in this same challenging way and that there is a chance, even if this is the case, that I could have a successful VBAC.

I know that there are many women who are not as fortunate as I am and they struggle with doubts and anger regarding their cesarean deliveries wondering if they were really necessary.  I also know that there are women who choose elective cesareans.  I am also sad to know that, while I am being fully supported by the midwife practice that I am in the care of, the physician that supports these midwives and my doula in my decision to attempt a VBAC, there are many women who wish this was an option who do not have the choice as their hospital does not permit it.  The big risk with VBAC, apparently, is the chance of uterine rupture.  While I agree that this is a rather scary outcome that should be considered, apparently, the risk of this is 1%.

What does this mean—this 1% risk?  Well, in my mind, it doesn’t mean very much.  The truth is that there are some inherent risks to birth (never mind the risks of just getting out of bed in the morning or the risks of refusing to get out of bed) that are much greater than this 1% risk.  So, basically, I’ve got bigger fish to fry. This year, each and every one of us in the United States has a 1 in 6500 chance of dying in an automobile accident.  Do I think about this each and every time I get into a car?  Absolutely not.  Calculated risk consideration seems appropriate here.  In addition, there are considerable risks with cesarean births that reflect the fact that, not only is it a birth, but it is major abdominal surgery.  For example, there is a 16% chance that a woman will require a blood transfusion and considerable risks to the mother’s internal organs.

One of the reasons why women did not feel that they wanted to have a trial of labor is that they were told that they would not be able to have an epidural for pain relief during their VBAC labor.  They were denied this option because physicians were under the (we now know false) impression that an epidural would mask the initial pain of a uterine rupture.  After years of research, we now know that a fetal monitor is more likely to show signs of distress before there is any pain.  Therefore, as long as mom’s uterine activity and fetal activity is being monitored during labor, there is no reason to suggest that she shouldn’t have an epidural if she wants one.  There is even some research that has suggested that women who had an epidural during their trial of labor had a 20% higher VBAC success rate.  While 20% is not significant enough to suggest an epidural (as many readers will know, this form of pain relief carries its own set of potential complications……), it does support women who both want a VBAC and want to at least have the option of an epidural for pain relief.

As a woman, it is hard to know sometimes how to even advocate on my own behalf, never mind how to start advocating for women in general, who face decisions regarding their birthing options.  I am so grateful for intelligent activists like Ina May Gaskin who not only bring these issues to light, but also offer realistic and reasonable action plans for improvement.  One thing that makes me very nervous is that, when a woman is denied options, she may be forced into making dangerous choices.  For example, a woman who is told that the only hospital in her area will not allow a trial of labor for VBAC may choose to have an unassisted home birth.  I am also concerned for women who, out of fear and anger, separate themselves from all medical professionals by lumping them together as “the enemy.”

If we are to inspire significant changes in healthcare policies that give ALL women equal access to quality healthcare, then we must be united.  Not only do we need to be united, but we also need to open to the multitudes of voices and ideas so that we do not alienate potential allies or refuse to understand our enemies.  As Sun-Tzi so clearly advised, “Keep your friends close, and your enemies closer.”

The greatest enemy of all is ignorance and its sister emotion, fear.  There is research that supports change and intelligent voices of activists like Ina May Gaskin that have provided us with a road map to something better, safer and more powerful.  We must stop allowing ourselves to be distracted by singular issues such as abortion or cesarean rates. These are just evidence of a far greater problem. We, the women who reflect more than half of the workforce of this country,  the women of the United States, will not allow substandard medical care to be the death of us.  This death is not just physical, it is spiritual as we allow our instincts, power and strength to be diminished by policies that deny us truly life-saving care.

I have compiled the most recent statements and research on VBAC in the United States here:

1. NIH Consensus Development Conference on
Vaginal Birth After Cesarean:
New Insights

PDF of final panel statement
Webcast of conference that is available free of charge.

The evidence report prepared for this conference through the Agency for Healthcare Research and Quality is available on the web

2. American College of Obstetricians and Gynecologists
Current Practice Guidelines for VBAC (#115, 8/2010)

3. An intelligent blog article that summarizes some of the main points of the new practice guidelines.

If you are local in Pittsburgh and looking for VBAC support, both midwifery groups here–at Magee Hospital and at the Midwife Center–can and will support you.  There is an active ICAN group (International Cesarean Awareness Network) here.  You can also meet women for excercise, community and support at prenatal yoga classes during your pregnancy.   I  offer classes through Matrika Prenatal.  Deena Blumenfeld of Shining Light Prenatal Education offers classes. Finding your own inner strength, learning to work with your fear and building a support network are only some of the benefits of prenatal yoga.  You can also find doula support for your birthing in Pittsburgh from doulas who are experienced specifically in VBAC through Hearts and Hands.

3 Comments Write a comment

  1. It’s not just the fetal / uterine monitors that show issues. ONE of the signs of uterine rupture is fetal distress. The other sign is abnormal pain. This pain can be felt through an epidural. If a mom is upping her dosage or is screaming in pain even with an epidural, something is amiss and needs to be addressed. Here is the NIH study http://www.ncbi.nlm.nih.gov/pubmed/20350643

    “There is even some research that has suggested that women who had an epidural during their trial of labor had a 20% higher VBAC success rate.” Please, please find this study or studies… I can’t for the life of me find the actual data.

    Also, please be careful about mixing personal opinions and facts. There’s quite a bit of that going on in this post. Your readers see your passion and strength, for sure. But they don’t necessarily see the line between facts and opinions here.

  2. Thank you for your response Deena. The problem that we all face is that there is no such thing as “fact,” even in science. Perhaps, it could be argued that especially in science there are no “facts.” This may also be the anthropologist in me speaking, but I think that, if we look at science over time, “the facts” are always shifting and changing. When my mom had me she was given an instruction sheet that said that she should have no more than two drinks and five cigarettes each day while pregnant. Now, women are told to completely avoid alcohol and tobacco products among many other things (soft cheese, lunch meats, caffeine restrictions, etc.). Our ideas about breastfeeding, definitions of what is advanced maternal age and birthing also continue to evolve. Each person can look at a set of data and have a completely different interpretation that is guided by their own personal experience, culture, ideas and perspective. Rayna Rapp has documented quite well the unique ways that individual women and families interpret genetic information shared with them after amniocentesis (see Testing Women, Testing the Fetus) and we know that the “truth” changes over time with each telling of a story (see Donald P. Spence, Narrative Truth and Historical Truth), but that doesn’t mean that anyone was telling lies. There is an abundance of research in Medical Anthropology (Clarke and Olesen 1999, Ginsburg and Rapp 1995, Oudshoorn 1994) that reflects the politics of reproduction and all of the incredible inequalities that women face on a global scale in terms of access to care, the type of care received, political economy of reproduction and more. What I feel most passionate about, and what I wanted most to communicate with this post, is that we only diminish our effectiveness when we focus on micro-issues rather than the source of problems. Whether or not epidurals make a VBAC 20% more successful or 20% safer or not almost seems beside the point [two sources for this percentage can be found in Table 10 in the original source evidence (http://www.ncbi.nlm.nih.gov/books/NBK44571/pdf/TOC.pdf) provided to the NIH committee: Bujold 2002 and Landon 2006 and can be found in the cited study publications #213, #214 and #80 in the referenced studies at the end of the report. ] The work that you do to support moms emotionally, physically and spiritually through prenatal yoga, postnatal yoga and childbirth education is so very important. Teaching women to trust their instincts, to choose their care provider carefully, to ask questions and to recognize that they have choices is a path to empowerment. We aren’t doctors and, speaking for myself, I’m not sure how to interpret a significant amount of the statistical data that is presented in the reports, so I can’t even begin to claim that I could read these medical journals and come away with a nuanced analysis. But, I do know that these reports support what I already know to be true: a woman with more information, more options and more support is safer than one who does not have these resources. The data and “facts” will continue to change, but the benefits of choice and empowerment are not likely to.

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