Does VBAC kill babies?

A couple weeks ago, I read a comment from an OB who said if his practice supported VBAC, he and his partners could each expect to have 1 "preventable" neonatal death following a uterine rupture. He asked if that was acceptable. On Dr. Amy's blog, she says that no one in the advocacy community addresses the issue of the "excess" deaths caused by VBAC. And then the NIH released information showing the neonatal death rate for VBAC was over twice as high as the rate for repeat c-section. There is ample evidence that more babies will die during VBACs than during repeat cesareans- so why should VBAC be a valid option?

First and foremost, I want to make it clear that I'm not in favor of anyone losing her baby. I simply can not imagine the grief, the pain, the countless ways someone's life would be forever changed by that kind of loss. I don't expect any woman to "take one for the team" by losing her baby during a VBAC attempt; I absolutely do not believe in vaginal birth at all costs. What I want to address here is whether or not the greater risk of neonatal death during VBACs should affect policy-level decision-making and support for VBACing moms.

After thinking about it for a couple weeks, my simple answer is no. I see a huge logical problem in arguing that VBACs should be banned (or that OBs have a legtimate right to refuse to support VBAC moms) due to the increased risk of neonatal death. While the NIH statement does show that more babies die during VBACs, they go on to say that the risk is virtually the same as it is for any first-time mom. This made me wonder, why isn't the "dead baby card" pulled out for first-time moms? Why are they not counseled to schedule their c-sections at 38 or 39 weeks so their babies won't die? If everyone can have a c-section and the noeonatal mortality rate could be cut by 60% or so, why NOT tell everyone she should deliver that way? There must be inherent benefits to vaginal delivery, and those benefits must be great enough that they outweigh the increased risk of neonatal mortality.

So why do the inherent benefits of vaginal delivery not seem to affect VBAC policy? Two words: malpractice liability. It is expected and accepted that a certain number of primiparas will lose their babies to late-term stillbirth or complications of childbirth, and those cases will (generally) not result in enormous lawsuits. One baby lost to uterine rupture, though, could destroy the livelihood of even the best OB. I've seen it said over and over: Would you risk everything to support a woman's VBAC? Would you risk your career, your savings, your family's financial security? Would you really?



The biggest problem I see is the lack of transparency and honesty in the discussion. When OBs focus on "preventable" deaths and yet don't require ALL of their mothers to schedule cesareans, it's clear that the issue isn't just preventable deaths. When others rail at advocates for not addressing "excess" deaths but don't talk about why it is only VBAC deaths that matter, they are completely missing the point the advocates are making. When we as advocates direct our ire toward providers who really are between a rock and a hard place-- you know, we're all spending so much time being pissed off and defensive that we're just not getting anywhere.


I think the NIH conference was a great start in clearing the air between activists, providers, and VBAC moms. I hope to see the issue of "excess" deaths in VBAC continue to be put in perspective on a policy level (as it was in the NIH statement), so that women can have access to complete and accurately portrayed information as they decide how to deliver their babies.

Choosing an experience: My journey to VBAC

Check out my latest blog over at Andrea Owen's site:
http://liveyourideallife.blogspot.com/2010/04/choosing-experience-my-journey-to-vbac.html

It has always troubled me that VBAC moms are criticized for choosing a "birth experience." Frankly, women who choose RCS are choosing an experience, too, albeit a very different one. I know there are a million reasons women choose RCS, I know OBs offer scare tactics, I know women who've been "fired" as patients when they refuse to schedule a cesarean. Some women truly don't have a choice, but others- most of us- do. It used to make me incredibly uncomfortable to say I wanted to VBAC because I wanted to experience vaginal birth. I felt like I had to justify my decision, defend it and prove that I wasn't some crazy VBAC lady who would sacrifice her baby in the name of a vaginal birth. That was never the point, after all. The point was being a healthy mom, delivering a healthy baby, by way of my vagina. As the weight of evidence continues to build, and VBAC continues to be shown as safe as, if not safer than, RCS, I hope more women become comfortable speaking about the experience of vaginal birth. We won't all value it the same, obviously, but those of us who do place great value on it shouldn't be afraid to talk about it!

And so I'll say it, one more time, for posterity:

The single biggest reason I wanted a VBAC was because I wanted to experience a vaginal birth.

Now go visit Andrea's wonderful blog and read the whole post! :-)

My relentless pursuit of perfectionism

I started this blog with the best of intentions. I wanted a forum where I could drop some of my usual diplomacy and really talk about the things that matter to me in the birth world. I wanted a place to develop my voice as an activist, where I could learn about myself as I continued to define and refine my thoughts about modern maternity care. In short, I wanted a place where I could say "HEY YOU GUYS! DID YOU SEE THIS?!?!" and give my untempered opinion.

But I ended up not doing much of that, and instead spent who-knows-how-long fact-checking and finding statistics to back up my opinions and making doubly sure that everything I posted was accurate, accurate, accurate. And that was useful (I guess, but damn, itt wasn't as much fun as I thought it would be!!

So a new direction: I will start posting more. I won't try to achieve perfection before I hit "publish post." I will be gracious and willing to accept it when commentors challenge my beliefs, but I won't spend so much time worrying about diplomacy. I will find my voice- my true voice- and, hopefully, that voice will be one people enjoy hearing.

Read my latest blog post

My friend Andrea Owen asked me to guest blog for her in honor of Cesarean Awareness Month! Read my post "Caveat Emptor: The Real Risks of Cesaean Section" here:

http://liveyourideallife.blogspot.com/2010/04/caveat-emptor-real-risks-of-cesarean.html

Slacktivist? Not me!

Sometimes I feel like a big fat hypocrite. I rail against the status quo of modern obstetric care, and yet all I really do to "change" things is sit here behind my keyboard and wait for women to find me on BabyCenter's VBAC board so I can encourage them to take charge of their births and make informed decisions. Am I really helping? Or am I just another slacktivist, wanting to feel like I'm involved but in actuality staying far removed from promoting actual change?

Over and over I have told women that we need to keep talking about our births and if we reach just one woman we are making a difference. Every time someone reads our posts, every time we talk to someone about our VBACs, every time we tell someone she has options, we are making a difference. I do believe this kind of ground-level advocacy is important. There is no question that individual women need support in making non-mainstream birth decisions! And yet I long for something more, something that sparks change in the system so that women are actually served by it instead of failed by it. This feeling has been so strong lately that I've been considering taking a break from all of it, turning over group ownership of the BabyCenter board to someone else, just letting all of it go. I don't have the time or motivation to be as involved as I think I should be, and this small part... oh, I just don't know.

But two things happened this week. First, Kristen from www.birthingbeautifulideas.com reminded me how critical mother-to-mother support was in her own VBAC journey. And then this morning I decided not to stay quiet when I overheard a young mother talking about how her OB told her she had to have a repeat cesarean, and that she would have to limit herself to three children because it wasn't safe to have more than three cesareans. It has never been in my comfort zone to sepak up in situations like that, but listening to this young woman talk about how her reproductive life was going to be defined by her first cesarean... it made me so angry! Exactly who does her OB think he is, to tell her how many children she can have and how she has to deliver them? She said she wants to try to deliver vaginally, but was flat-out told she can't.

When I spoke up this morning and told the entire group that my first baby was born by c-section but my other three were born vaginally, and offered to share resources and information, I made a difference no matter how small. Sure, I felt like I was being pushy and intrusive and I totally blew the pretense that I wasn't eavesdropping-- but maybe I opened a door to allow this young woman to regain control of her reproductive future. I will probably never be the kind of activist Kristen has become (and I can't say enough about how much I admire her), but maybe being a ground-level advocate really is the thing I'm supposed to be doing. I'm pretty good at it, I think. And today I might just have reached one woman.

Shifting the paradigm: VBAC should become the norm

For years I have believed that once a woman has a cesarean, the choice to deliver vaginally (VBAC) or have another c-section (RCS) for future deliveries should be entirely hers. I've believed that the risks, while different, carry roughly equivalent chances of worst-case outcomes. It is up to each of us to determine which set of risks we are most comfortable with, and go forward making the decision that will allow us to look back without regret. I have struggled to learn to support women who looked at all the evidence and still chose RCS- it is definitely not a choice I would not personally make- but in the end it was never my place to judge someone for making the decisions that she felt were right for her and her baby.

While I still don't feel I have any right to judge women who choose RCS, I have reached a point where I don't feel that is at odds with speaking up for VBAC. I recently read that over 50% of women would like to attempt VBAC, but nationally less than 10% actually do. Why is that? I'm sure there are a certain number of women for whom VBAC is legitimately not an option, but the majority are probably very good candidates and yet they choose (or are forced to choose) RCS. Why?

VBAC is vilified, there's no doubt of that. Lawyers like this Indiana Medical Malpractice Lawyer are all too willing to support the perception that VBAC is in and of itself a needlessly risky procedure that often results in poor outcomes for mothers and babies. There is a pervasive belief among the general public- and among juries- that a c-section represents everything possible being done to ensure a healthy and safe delivery, and I've often seen it said that OB's are never sued for the c-sections they perform, only the ones they don't.

But I don't really want to talk about medical malpractice, I want to talk about why major abdominal surgery is considered the normal way for a baby to be born, just because his mom has a scarred uterus. Recent studies are coming down in favor of VBAC as safer than RCS for moms and babies, and it is absolutely clear that RCS increases future risks for women and their subsequent babies- but even if the risks were equal, why do we believe the intervention is better than the natural process? Why are we burdening our healthcare system with the time and expense of so many cesarean sections when there is an equally safe (possibly safer) and much less invasive alternative?

It is time for this paradigm to shift. I'm not suggesting that the option of repeat cesarean be taken away, but I believe we need to change the starting point when a woman is choosing between VBAC and RCS. In today's obstetric world, RCS is the automatic assumption and women who don't have a compelling reason to attempt VBAC rarely do. It is even more rare for an OB to encourage a woman to choose VBAC. This is completely upside down! We shouldn't have to fight and change doctors and travel for hours to be "allowed" to labor and deliver our babies without being cut open. We should expect to deliver vaginally unless there is a compelling reason to do otherwise, and VBAC should be the first option offered to women with a previous cesarean.

A shift in our thinking, a return to normalzing birth... I'm not idealistic enough to think it would be easy, but I am not cynical enough to think it's impossible either. I still have hope that one day in the future, the 50+% of women who would like to have a VBAC will be supported and encouraged.

The Gentle Cesarean

For years now I've been a part of the VBAC support forum on BabyCenter, and I've read literally hundreds of women's cesarean birth stories. I've read some positive and empowering stories, and I've read some tragic ones that truly fit the term "birthrape." But I have never read one like the one Joanna Moorhead describes in this UK article titled "Every Bit as Magical." Professor Nick Fisk is pioneering a cesarean technique he calls the "skin-to-skin cesarean," a significant improvement over the clinical and reserved deliveries most c-section moms expect.

Picture this: Instead of being literally strapped to the table with her view obscured by a curtain, the mother is propped up so she can see her baby's birth. Instead of the surgery being performed as quickly as possible, the pace is slower, gentler. Instead of the baby being whisked away, he is immediately placed on his mother's chest. The cesarean is recognized and honored as what it is- this baby's birth- instead of being performed like just another surgery. How wonderful would this be for women who have to have cesareans?

Taking it a step further, how wonderful would it be if all mothers could expect to be treated like their births are amazing, magical, worthy of respect and consideration? No matter how our babies enter the world, birth remains one of the most powerful and unforgettable experiences we will ever have.