Once a Cesarean, Rarely a Choice

Gina agreed to write from the NIH VBAC conference for RH Reality Check as an advocate, a writer and a valued voice in birth activism. For more coverage of the conference, please visit Gina’s coverage on her site The Feminist Breeder!

This week the National Institutes of Health held a consensus conference on the topic of Vaginal Birth After Cesarean (VBAC.)  The purpose of this conference is 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 percent, a VBAC rate of only 7.8 percent, and nearly 40 percent 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 this 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 their stories about the ways that forced cesareans have affected their lives or their practice.

Photo courtesy of The Feminist BreederPhoto courtesy of The Feminist Breeder

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 validate 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 NIH consensus will have a positive impact on VBAC access in this country.  From a birth activist’s point of view, the statements made during the conference 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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  • powerhousemama

    I was fortunate enough to have had the choice in 1990 to have a vbac….I cannot believe how fast we are moving backwards.

  • ctbirthadvocate

    While I enjoy the statement the panel did release, I am saddened by the lack of stress on a womans right to informed refusal, without the threat of legal action, court ordered cesareans, or Child Protective Services being called.

    I think we are still on a very slippery slope for women when it comes to maternity care, especially the option for a VBAC.

    I do hope this is a step in the right direction though.

  • pheasantweber

    I was born cesarean in 85. Mom had two more 87 and 91 both vaginal. I never even knew this would become a hot topic! I have never been pregnant either though.

    Hope it moves into the right direction too!

  • smjesq

    Pheasantweber, I am so glad to read your comment — particularly beause of your age.  We need lots of strong smart well-informed young women like you to continue to advocate for women’s bodily integrity and autonomy.  It is profoundly shocking that a health care professional, an attorney, an ethicist, or a hospital executive — serving on a panel under the auspices of a cabinet-level department of a Democratic administration — would question whether prepgnant and birthing women have the same constitutional right to refuse invasive and potentially dangerous surgery that every other adult in the United States has. 

    IMHO, birth is (or should be) a non-partisan issue — in many ways, a common ground on which honest pro-life and pro-choice advocates can meet and find an area of agreement.  As Lynn Paltrow regularly reminds us, 84% of American women give birth at some point in their lives.  Each and every woman and girl in the U.S. is at risk of having her  life and her autonomy subordinated to the opinions and whim of doctors and hospital admininstrators unless the legal right of informed refusal of unwanted surgery is affirmed.

    Great blog today, Gina.  Your assessment of the NIH VBAC conference, both the good parts and the scary parts, is right on the mark.