March 18, 2010
NIH Conference Calls VBAC a “Reasonable Option,” Stops Short of Ensuring Pregnant Women’s Right of Informed Refusal
Report by Jessica Claire Haney
The National Institutes of Health (NIH) convened a three-day Consensus Development Conference entitled “Vaginal Birth After Cesarean: New Insights,” March 8-10, 2010. The purpose of the conference was to examine the rates, patterns, and utilization of vaginal birth after cesarean (VBAC) and trial of labor (TOL) and the benefits and risks of TOL versus elective repeat cesarean delivery (ERCD).
Among the panel’s findings was the conclusion that TOL is safer for the mother than ERCD and that the risk of uterine rupture for mothers with previous cesarean deliveries is less than 1%, the same or less than other possible obstetric emergencies. Since VBACs are successful 60-80% of the time when attempted, the current VBAC rate of approximately 7% is clearly problematic.
The panel showed that the current medico-legal environment “exerts a chilling effect on the availability of TOL,” availability that decreased after the American College of Obstetricians and Gynecologists (ACOG) issued a statement in 1999 that anesthesia and surgical facilities must be “immediately available” in any hospital where TOL and VBAC are allowed. Today, some 45% of hospitals in the U.S. have policies banning VBACs. (See ICAN Q&A: “What to Do if Your Hospital Has ‘Banned’ VBAC").
The NIH panel report concluded that “TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision.” The report included recommendations that
- ACOG and the American Society of Anesthesiologists (ASA) “reassess” their requirement for “immediately available” surgical and anesthesia personnel for TOL and VBAC
- providers, consumers and members of the insurance community “collaborate on the development of integrated services that could mitigate or even eliminate barriers to TOL”
- providers make their TOL policy and VBAC rates public
The report noted that risks and benefits “differ for the woman and her fetus” and said this “conundrum” is complicated by the fact there is not enough evidence about medical and nonmedical factors, including the effect of TOL versus ERCD on mental health, breastfeeding, and mother-infant bonding. Additional research and the funding of research were recommended.
The first day of the conference focused on the presentation of the findings of the independent panel. While the data presented were based on obstetrical models and did not include details about births outside the hospital setting, birth activists in attendance were vocal during the question and answer sessions, raising the issues of homebirth and of non-medical outcomes of cesarean delivery, including postpartum depression and post-traumatic stress disorder.
The second day presented more medical data and a discussion of ethics and also highlighted stories of mothers compiled by Rita Rubin of USA Today. Birth activists were pleased that this moving presentation shared women’s personal experiences, particularly since the panel had acknowledged a paucity of data on mental health outcomes related to cesarean delivery.
On the third day, the panel made its draft statement available in the morning and took public comments before reconvening. Of concern to many in the audience was panelists’ failure to confirm that women have the right of informed refusal of a surgical delivery that may cause harm.
When the panel presented its revised report in an afternoon press briefing, Susan Jenkins, legal counsel for The Big Push for Midwives (http://www.thebigpushformidwives.org/ ), was rebuffed when raising the issue. Jenkins cited pro-informed-refusal law review literature and noted that conference attendees wanted the panel to “take a position affirming that pregnant women should be considered persons with constitutional rights the same as any other adult persons.” The panel’s ethicist replied that the right to refuse is “controversial” and “unsettled” and beyond the scope of the panel. When pressed, he reiterated the report’s statement in favor of helping a woman make a decision that reflects her values, “What if her values and preference is to say ‘no’ at the end of all this?” Jenkins asked. No response was given as there were “other people waiting on queue” to ask questions and Jenkins was told to get back in line.
The revised report, made available later that evening, cited as one of its major goals to support women to make informed decisions about TOL versus ERCD. In contrast to the current climate in which women are often not given complete information about risks and benefits, the report called for “a shared decision-making process” and said that women’s preferences should be honored “whenever possible,” language that was added to the revised draft after the morning’s public discussion but that still did not affirm a woman’s right of informed refusal.
Despite disappointment that the document does not grant pregnant women full constitutional rights at autonomous human beings, members of the birth community were largely encouraged by the pro-VBAC recommendations of the panel and its call for ACOG and the ASA to reevaluate their positions. Many birth activists have been continuing the dialogue around this conference in the blogosphere and on Twitter. For more information, visit the following blogs and websites.
NIH VBAC Conference Homepage: http://consensus.nih.gov/2010/vbac.htm
NIH VBAC Conference Statement: http://consensus.nih.gov/2010/vbacstatement.htm
International Cesarean Awareness Network’s statement on the conference:
Lamaze International’s statement on the conference: http://www.lamaze.org/IntheNews/NewsReleases/LamazesStatementontheNIHConsensusMeeting/tabid/861/Default.aspx
NIH Conference coverage by Momotics blog: http://momotics.com/category/nih-vbac/
RH Reality Check: http://www.rhrealitycheck.org/blog/2010/03/09/oncecesarean-rarelychoice
“Once a Cesarean, Rarely a Choice” by Gina Crosley-Corcoran of The Feminist Breeder Blog at http://thefeministbreeder.com/, where Twitter feed from the conference is available for viewing
The Unnecessarean -- http://www.theunnecesarean.com/
Including an open thread on VBAC and informed consent
and the article “NIH VBAC Consensus Development Conference: Gift Horse or Trojan Horse?”
Birth Action Coalition’s “Thoughts on Right of Refusal of Treatment”
“Panel Urges New Look at Caesarean Guidelines” by Denise Grady, The New York Times
“Panel: Vaginal Birth After Cesarean Not Common” by Brenda Wilson, National Public Radio Morning Edition Segment
Also of interest:
“Risks of Cesarean Section” Fact Sheet from the Coalition for Improving Maternity Services (CIMS) (February 2010):
“Deadly Delivery” Report from Amnesty International (March 2010)
or summary at http://mothering.com/pregnancy-birth/amnesty-international-demands-action-to-improve-maternal-health-care
Upcoming related conferences:
Midwifery Today Annual Conference
Philadelphia, Pennsylvania, April 14–18, 2010
16th Annual DONA International Conference
Albuquerque, New Mexico, August 5-8, 2010.
7th International Black Midwives and Healers Conference: “Weaving the Cultural Traditions of Midwifery”
Los Angeles, CA, October 8-10, 2010
International Cesarean Awareness Network Conference
St. Louis, MO, April 8-10, 2011