NIH Vaginal Birth After Cesarean Panel: Do Pregnant Women Have Full Decision Making Power?


Unquestionably, the accessibility and safety of VBACs or vaginal birth after cesarean section has become an issue of controversy for pregnant women and birth activists. It’s an issue taken up by reproductive justice advocates who see the connection between choices in childbirth and the choice to continue with a pregnancy or not. Over the last decade VBACs have become increasingly less accessible with fewer clinicians and facilities willing to provide them, despite and with little regard for pregnant women’s desire to have a vaginal birth after a cesarean.  The overwhelming reasons given focus on the safety of VBACs. Given the refusal of doctors and hospitals to allow low-risk pregnant women to experience what experts call a “trial of labor” over a planned c-section, it would stand to reason that maternal mortality and maternal health in the U.S. would be improving. This, however, is not the case. One out of every three babies in this country is born via c-section  – far exceeding the World Health Organization’s recommendations that a country’s c-section rate remain between 5 and 10 percent. And maternal mortality rates in the U.S. have only been rising.

It’s why the National Institues of Health convened a 15 member panel of experts to address VBACs in the United States for a Consensus Development Conference – a conference which wrapped up today. The conference brought together an independent panel of experts including obstetricians, gynecologists and experts in maternal/fetal pain in order to create consensus on the safety and availability of VBACs.

Pouring over thousands of pages of evidence and peer-reviewed studies over the last few weeks, the all volunteer panel’s assessment of VBACs ultimately confirmed what birth activists and advocates of evidence-based maternal and newborn care have been saying:

“…that a trial of labor is a reasonable option for many women with a prior cesarean delivery. They [the panel] also urged that current VBAC guidelines be revisited, malpractice concerns be addressed, and additional research undertaken to better understand the medical and non-medical factors that influence decision making for women with previous cesarean deliveries.

On a briefing call for the press and in a press release, the panel’s chair, Dr. F. Gary Cunningham, chair of obstetrics and gynecology at the University of Texas Southwestern Medical Center confirmed the clarity of the panel’s findings saying,

“The VBAC rate has gone from 30% to 10% over the last fifteen years… [which] would seem to indicate that planned repeat cesarean delivery is preferable to a trial of labor. But the currently available evidence suggests a very different picture: a trial of labor is worth considering and may be preferable for many women…The use or employment of VBAC is certainly a safe alternative for the majority of women who have had one prior c-section.” [emphasis mine]

Dr. Cunningham and the NIH spokesperson did note that these findings are not attributable as NIH guidelines but rather should be looked at as conclusions “about where we stand and what we can do to provide better resources to women of whom we speak.”

The panel also recommended revisiting the guidelines put forth by the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists on ensuring the “immediate availability” of surgical and anesthesia personnel before allowing a trial of labor for a woman who has had a previous c-section. Two recent surveys of hospital administrators found that 30 percent of hospitals had stopped offering trial of labor or providing VBAC services because they could not meet this standard, creating a serious barrier to that option. According to a panel member,

“…we recommended these organizations reassess their requirement relative to other obestetrical issues. Bad outomes with VBACs aren’t very common – there may be only 10 catastrophic outcomes out of 100,000 births. We’ve seen an association but not necessarily a cause and effect.”

But perhaps the most controversial part of the conference came when a panel member asserted that pregnant women may not have full rights to informed consent when it came to undergoing surgical procedures (ie cesarean sections).

Birth activists from The Feminist Breeder to Courtoom Mama to The Big Push for Midwives tweeted their outrage. Tweets from those in attendance or those following the conference reflected the frustration with the statement:

“evidently pregnant women can have preferences, but not rights. Let’s take it to court!”

and

“…Panelist just said it is not a settled matter of ethics or law that women make their own choices. Huh?”

“It is not a settled matter of ethics or law that informed refusal applies to pregnant patients.”

“It’s 2010, people, and the people we trust to catch our babies aren’t sure we have constitutional rights?”

Susan Jenkins with The Big Push for Midwives pressed the panelists during the press briefing afterwards asking them to confirm that, in fact, 

“…The panel is unwilling to affirm the ethical necessity of recognizing that a woman has an absolute right to informed refusal of a surgical procedure that may cause harm to her?”

To which the panelists resonded that

“..the claim that the right to refuse is a controversial claim is not at all so in law or medical ethics. That controversy is way beyond the scope of this panel. However, we did emphasize the need for an evidence based, unbiased approach to the informed consent process to make sure women are informed about surgeries so that they may make their own decisions for themselves. So there is a strong emphasis on informed consent in our conclusions.”

However, the draft statement, Jenkins noted, indicated that the panel’s position was that “only where it’s considered ‘medically reasonable’ would women have the right to refuse and there is no definition of medically reasonable.”

The panelists said that it was the physicians’ job in such cases to “help women make a decision that reflects her values.”

To which Jenkins responded, “What if her values are to say no at the end of all of that?”

The final draft of the panel’s statement is scheduled to be published this evening. If the NIH VBAC panel aims to take a strong stand that for the health and safety of pregnant women and their fetuses VBACs must become increasingly accessible, ensuring language that states that women have the opportunity to make the final decisions about their health is critical.

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  • shanonmom

    I should preface all of my comments with the following:

    I’m pro-life. I’m a conservative Christian.

    And today, I stood there and heard an argument which I will never ever stop being angry at. I, as my child’s mother, can have my rights superseded by an obstetrician who is stepping in and presuming a role as my child’s guardian AS IF HE HAD MORE OF A STAKE IN THAT CHILD’S BIRTH THAN I DO.

    There will never be an obstetrician on this planet that has more of a compelling interest in my birth and my child than I do. They do not have the right and if they think that what happens to me during pregnancy is a question for ACOG’s ethics rather than myself and my husband, then they deserve all of the firestorm they will get for usurping the rights of myself and other women.

    Though, it must be said, I’m not anti-obstetrician or medical practitioner! I am against the fact that ACOG has put themselves into this role of “protection” rather than cooperation and is using it to force …get that? FORCE women into surgery without medical indication. It’s time we stopped them by playing a spade for a spade and making them state whether or not they support and do VBAC or they don’t. There is no middle ground any longer.

    Shannon Mitchell

    Birthaction.org

  • cpcwatcher

    I appreciate your solidarity on this, ShanonMom.  But I do wish our sisters who identify as “pro-life” would see the connection between the choice-in-VBAC issue and the choice-in-abortion issue.  I’m a doula as well as repro-justice activist, so it’s just something that’s nearly always on my mind! 

  • mandamama

    I’m in the same boat as Shanonmom.  Not to debate the issue (unless it’s friendly :)…just to explain/clarify the position….. for us pro-lifers, the issue of how to best bring a baby INTO this world is not the same as taking a baby OUT of this world.  For us, (and what we believe the science clearly says now), life begins at conception…a human life.  And all humans have equal rights to life, inalienable rights..inherent rights to life (“life, liberty, and the pursuit of….”)  …..first and foremost.   And since that is a life, it is murder to take it.  Not a “choice” just as murdering the mayor isn’t a “choice” i have in this world.  There are civil laws set up to protect us from murder (even though we “ought” to know NOT to, we still have to have laws)….(again, not debating HERE, just explaining why/what we believe…thus how it’s possible us pro-lifers can also believe it’s a mother’s right to birth how she wants to)…so……that is not the same as a mother trying to birth her child into this world the healthiest and safest way.  It’s not the same as her WANTING to bring that child into this world…. her goal and desire is a “healthy” live child…..but it’s her decision how to reach that goal.  Does that make any sense? (i don’t mean, do you agree w/ what i am saying? but did i state my position clearly enough?)

  • prochoiceferret

    her goal and desire is a “healthy” live child…..but it’s her decision how to reach that goal. Does that make any sense?

    Yes. You can’t force her to give birth in a way she doesn’t want, but it’s okay to force her to stay pregnant until birth if she doesn’t have the goal and desire of a “healthy” live child.

  • mandamama

    yes, ProChoice….because then I will gladly adopt that living, breathing HUMAN child.  exactly.  

  • colleen

    because then I will gladly adopt

    So, other women should be forced to gestate so that you can take their children? If you wish to adopt a child why not adopt one of the 100,000 children always available for placement out of the foster care system? http://photolisting.adoption.com/

  • led

    Just curious, mandamama, are you ready to adopt all the children resulting from the 1.2 million abortions performed annually in the US? Or as the previous commenter pointed out, the many thousands of children waiting in the adoption system?

  • pregtivist

    I think CPC Watcher’s point is that we as women send mixed messages on the issue of choice.  We cannot on the one hand insist that it’s acceptable for someone else’s moral code, beliefs about when life begins and thoughts about viability of fetuses to trump the decision of a pregnant woman herself (and all women seeking abortions are necessarily pregnant) knowing that the stakes are highest for her and then turn around and say it’s not okay for someone’s thoughts about acceptable risk, the appropiate length of gestation/labor and malpractice concerns to trump the decision of the pregnant woman herself.  We’ve already acknowledged in the former scenario that women need to be protected from themselves and their poor decisions and once we’ve done that, there’s no going back, especially when one of the possible outcomes of an unsuccessful VBAC is that the baby could die.  I’m sure you have your reasons for thinking there is a stark difference between the two scenarios mandamama, but unfortunately that’s not the way the world works.  Women are either capable adults who should be able to make their own decisions about their bodies or they are not.  I believe the panelist’s words were it’s along the lines of “it’s not a settled matter of law…and he’s right, thanks to all of the attacks on Roe v. Wade, it is not.

  • prochoiceferret

    yes, ProChoice….because then I will gladly adopt that living, breathing HUMAN child. exactly.

    Ah. So slavery is okay as long as it’s for your benefit… which, actually, is how slave owners usually work!

     

    Just remember, mandamama, the Dred Scott decision. Pregnant women who don’t want to be pregnant are not your slaves. They are people, with wills and desires of their own. Talk to one sometime—I’m sure she won’t be too keen on the idea of being your personal baby-dispenser.

  • rachelleavitt

    I think this is an interesting discussion because I think part of the legal grounds that physicians feel they can force a woman to have a c-section is based on the fact that the woman may be killing a child.  Seems to be the same grounds to oppose abortion.  

     

    I myself feel like abortion is wrong because I feel like it does show a disregard for the sanctity of human life, but do I have a right to force another woman to believe the same thing?  I’m not sure I do, especially when there is no way to prove when life truly has any meaning.  I do think adoption is a better way, but again, you can’t force someone to adopt your viewpoints.  A better way to go about it would be to provide more support and assistance and information those who are making that choice.

     

    Same goes for VBAC.  Assistance, information, and support are what women need in both cases.  

  • crowepps

    Isn’t the whole POINT of the ProLife movement to make sure there is no longer a middle ground?  To change things so that ‘society’s’ beliefs about the best interest of the fetus are imposed on the woman regardless of her beliefs?

     

    Perhaps you might want to rethink your ProLife stance, because the varied and constant iterations of their belief that women become pregnant reluctantly, are opponents of their fetus throughout pregnancy, and are too stupid and selfish to be allowed to make their own choices is exactly how you got where you are now.

     

    The middle ground is where women get to make their own choices.  When you oppose choice for other women, it shouldn’t surprise you to find out that you also destroyed your OWN ability to make choices.

  • mandamama

    well so much for “friendly” lol

     

    yes, I have adopted once and yes,  I plan to colleen, though not to be my slaves, oddly enough. 

  • colleen

    though not to be my slaves, oddly enough.

    What are you talking about? I said nothing about you using children as slaves.

  • irenen

    Recent studies conducted by ICAN (International Cesarean Awareness Network) prove the fact that women are still able to have a vaginal birth after a cesarean – http://www.childwiki.com/index.php/Vaginal_Birth_After_A_Cesarean