VBAC Success - the latest studies

Vaginal Birth After Cesarean or VBAC has been a highly controversial topic for the past few years. But not any longer. 

World-wide studies are showing that not only is vaginal birth after a cesarean safe, but successful. A study released in summer 2013 from King Abdullah University Hospital in Jordan, reported among 207 women, 117 or 57% achieved a successful VBAC. Parity of ≥ 2 was significantly associated with increased odds of success (OR = 2.7, 95% CI: 1.2, 6.2). Compared with women who had no previous VBAC, those with previous VBAC had higher odds of success (OR = 3.8 (95% CI: 1.5, 9.5). We concluded that women with a previous cesarean section who achieved a cervical dilatation of ≥ 7 cm before caesarean, had a previous history of successful VBAC and had parity of ≥ 2, have the greatest likelihood of successful VBAC. (Journal of Obstetrics & Gynaecology 2013 July 33(5):474-8.) 

Another study, this one from New Zealand, showed a 73% VBAC rate between 2008-2009. Increasing parity increased the chances of another vaginal delivery. Variables that lead to a failed VBAC included BMI=25 in women of single parity, labor augmentation and epidural anesthesia. (New Zealand Medical Journal 2013 Sept 27; 126(1383): 49-57). 

Most recently (November 2013), a study from the UK shows of 143,970 women in the cohort, just over half of the women with a primary cesarean who were eligible for a TOLAC attempted a VBAC. Of those, almost 66% achieved a successful vaginal delivery. (British Journal of Obstetrics/Gynecology doi: 10.1111/1471-0528.12508). 

How can women wisely choose VBAC? First and foremost, women need to choose both a careprovider and hospital who will support them in their VBAC. The International Cesarean Awareness Network has identified hospitals who do not offer VBAC. To identify whether or not a provider or hospital supports VBAC, call that hospital and then ask for the names of at least three providers. More information about selecting providers and hospitals can be found at the website VBAC.com.  On that website, author and VBAC researcher Nicette Jukelevics also gives an extensive list of resources for those wanting additional information on VBAC. You may also utilize the VBAC Finder here  

What does all of this say? It says that the research is there. The evidence is speaking. Expectant mothers need to have this education available to them in whatever source of media they use – childbirth education classes, online : blogs and websites, and social media. 

Are you aware of the new video set for 2015 release about VBAC? View the trailer below and then be sure to visit www.themamasherpas.com for additional information!

Analysis of the Wide Variation In Cesarean Birth Rates in US Hospitals: Another Call for Childbirth Education

Implied.  Under the radar.  Hinted at.  All of these can be used to describe the latest in a flurry of articles suggesting that childbirth education be ramped up and that evidence-based information be more readily available to pregnant women.

For example:

In the United States, childbirth is the most common reason for hospitalization…and it often brings in a substantial portion of revenue for the hospital.  With the current US cesarean rate wavering at 32.8%, it is any wonder that an examination of the drastic variation in rates among hospitals has been launched.

In a recent article published in HealthAffairs, authors Katy Backes Kozhimannil, Michael Law and Beth Virnig worked with data from 2009 and examined 593 US hospitals.   They found that cesarean birth rates varied tenfold across hospitals – from 7.1% to 69.9%. 

Cesarean delivery is an important, potentially lifesaving, medical procedure and some variance in hospital rates would be expected based on differences in patient characteristics. In order to address this, researchers also examined cesarean rates among a subgroup of lower-risk patients: mothers whose pregnancies were not preterm, breech, or multiple gestation and who had no history of cesarean delivery.

Among this group of women with lower-risk pregnancies, in which more limited variation might be expected, hospital cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent.
"We were surprised to find greater variation in hospital cesarean rates among lower-risk women. The variations we uncovered were striking in their magnitude, and were not explained by hospital size, geographic location, or teaching status," said lead author Katy B. Kozhimannil, Ph.D., assistant professor in the University of Minnesota School of Public Health. "The scale of this variation signals potential quality issues that should be quite alarming to women, clinicians, hospitals and policymakers."

Kozhimannil and her colleagues suggested recommended four major policies to reduce variations:

First, women need to be offered the right care for their own pregnancies. Evidence from earlier studies shows women with healthy pregnancies benefit from care provided by midwives, support from trained doulas, and access to care in licensed birth centers. Women with low-risk pregnancies should have access to care options that may benefit them, with strong referral systems and specialized care for complications that may arise.

More and better data on the quality of maternity care are needed to support the rapidly advancing clinical evidence base in obstetrics. Clinicians and hospitals cannot improve maternity care, and insurers cannot pay for such improvements, without clear and consistent measures of quality.
Tying Medicaid payment policies to quality improvement programs may influence hospital policies and practices and provide incentives and reward hospitals and clinicians for providing consistent, evidence-based care.

Finally, information about cesarean rates and maternity care should be more readily available to pregnant women, who have time, motivation, and interest to research their options. However, they lack access to unbiased, publicly-reported information about cesarean delivery rates and other aspects of maternity care.

Yet, another clear mandate for the need for childbirth education.  

And not childbirth education in the form of regurgitated hospital expectations and current policy…”unbiased, publicly-reported information about cesarean delivery rates and other aspects of maternity care.”

Kozhimannil et al. Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality and Cost Issues.  Health Affairs March 2013, Vol. 32, No. 3.

Extrapolating: A "SMH" Moment for Childbirth Education!

I recently came across this photo on my Facebook newsfeed.

www.theperfectbirth.com 

I sat there a few minutes and, in a mindset that my high school Algebra teacher would have loved, tried to reverse the statistics.  If 2/3 of the guidelines for medical practice that OB/Gyns use is not based on evidence- based science, that means that only 1/3 of the guidelines for medical practice that OB/Gyns use IS based on evidence- based science.

Then I went on to apply this to a human relationship:  if your partner in a relationship was only honest with you 1/3 of the time, would you stay in that relationship?

Wow, I thought, that really changes the perspective!  And if a person WOULD stay in a relationship like that, WHY?

Extrapolating, why would you want to stay in a relationship where someone lied 66% of the time?  And why would they lie 66% of the time anyway?  To make themselves look better?  To lure you? To protect themselves from....? To hide what they are doing?  Are they too afraid to admit they don't know the truth?

Now, return from that tangent and refocus on maternity care.  Here are the facts:

1. 23% of discharges from US hospitals are childbearing women/newborns.
2. The preterm birth rate has only enjoyed modest decline - .1% over the last year.
3. Low birthweight births continue to rise.
4. The US maternity morbidity/mortality stats are not improving.
5. The US infant morbidity/mortality stats are not improving.
6. The US cesarean rate is still climbing.
7. The state of non-nurse midwifery is out of control (I am not implying legislative control, here).
8. The number of "drive through" childbirth education classes are increasing.

Since "we" are not practicing evidence-based maternity care and since "our" statistics are worse than 40+ other nations in the world...

WHAT IS KEEPING "US" FROM PRACTICING EVIDENCE-BASED CARE?

WHY DON'T "WE" CARE MORE ABOUT OUR FELLOW MAN AND FUTURE SOCIETIES?

AND WHEN WILL "WE" STOP BICKERING AMONGST OURSELVES AND DO SOMETHING?

Extrapolating again, why would you want to stay in a practice where someone lied 66% of the time?  And why would they lie 66% of the time anyway?  To make themselves look better?  To lure you? To protect themselves from....? To hide what they are doing?  Are they too afraid to admit they don't know the truth?

References:
*http://transform.childbirthconnection.org/resources/datacenter/factsandfigures/ 

The Perfect Response by Barbara Harper

My long-time friend, Barbara Harper (founder of Waterbirth International), posted this on her Facebook page. I found her dialogue so phenomenal, I asked her permission to reprint.  So here it is..in Barbara’s words….

There was a commentator on the radio in Miami this morning (10/18/12) extolling the virtues of planned cesarean surgery and induction because you can guarantee that your doctor will be there as one reason to "control" the birth of your baby. This was my response:

To the uninformed person who commented on the convenience and safety of inductions and scheduled cesarean surgery instead of waiting for the perfectly timed dance of undisturbed childbirth: 

Barbara Harper

All human beings are programmed by brain wiring and influenced by the environmental signals to initiate the birth process through a complex set of chemical, hormonal and neurological transmitters. The new human needs that process to fully engage and activate parts of the brain that contribute to health, well-being, cardiovascular stability, respiratory function, neurological development and even feelings of love and attachment. 

When we arbitrarily assign a date to chemically initiate the process, the innate programming gets shut down, cannot function in the same way as the biological imperative would have, had things been left alone. The human being perceives this "jump start" as a threat and begins to prepare its body and brain to survive in an environment that is stress filled and possibly life threatening. All of the bodily functions that control the neurological, cardiovascular, respiratory, metabolic adaptive mechanisms are put on high alert and remain there. This over stimulation of the psychoneuroimmunological system creates and lays down the patterns for future problems such as heart disease, high blood pressure, diabetes, chronic obstructive pulmonary disease and even some psychiatric disorders. 

This may be difficult for the uninformed consumer to begin to see the connections between the use of a simple drug to stimulate the uterine contractions or a surgical procedure to remove a human being from the habitat in which brain development is meant to take place, but the growing field of epigenetics and pre and perinatal psychology are rapidly filling in the gaps in our understanding that what we do in the birth process has life-long consequences on human health, the development of character, mental stability and perhaps even drug addiction. Tall order? Perhaps we are only beginning to realize the long term effects of this violation of an innate biological agenda - because that is what early chemical induction is!

As they say, "don't mess with Mother Nature!"

These scientific principals and the evidence to support this thesis are contained in my forth coming book, "Embracing The Miracle: How Pregnancy, Birth and the First Hour Influence Human Potential."  There are already many books and hundreds of research studies from which to broaden your understanding of allowing nature to fulfill its destiny in the creation of new human beings. Parenting For Peace by Marcy Axeness is a great book for any potential parent or grandparent along with my other book, Gentle Birth Choices . 

Ten Facts About Maternity Care You Should Know

A profession that recommends best practice care yet shuns evidence-based care is contradictory and in danger of implosion if the receivers of that care discover the contradiction.  Therefore, a combination of fact distortion and suppression of education is the key to avoiding revelation and implosion.

1.    The maternal mortality rate in the US is 12.1 deaths per 100,000 live births.  This number is greater than 40 other countries in the world. (Source: Amnesty USA Deadly Delivery: The Maternal Health Care Crisis in the USA, 2010).
 

2.    Cesarean sections are partly to blame for the rise in the US Maternity mortality rate. (Source: California Maternity Quality Care Collaborative, 2011).

3.    The FDA has not approved the drug Cytotec for use as an induction agent for childbirth.  http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm111315.htm

4.    The US Food and Drug Administration has issued alerts about the use of vacuum extractors used during labor/birth, including fetal hemorrhage, shock and death. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm230309.htm

5.    The Joint Commission, the body that accredits US hospitals, encourages a reduction of cesarean rates to the limit suggested by the World Health Organization ~ 15-20%. (Source: The Joint Commission Specifications Manual for Joint Commission National Quality Core Measures, 2010).

6.    “A baby born by cesarean surgery is more likely to be admitted to a neonatal intensive care unit or NICU physically separated from his or her mother, thus making establishing breastfeeding more difficult.” (Source:  Impact of Birthing Practices on Breastfeeding, 2011).

7.    Women’s birthing preferences are shaped by economic position and availability of local birthing options. (Source:  Social Science & Medicine, 2012 Aug. 75(4) 709-16)

8.    All drugs given to a mother during labor cross the placenta to the fetus/baby.   (Source: Anesthesiology 1995 83(2) 300-308)

9.    The US breastfeeding rate on initiation is 76.9% (2009), 47.2% at 6 months, and 25.5% at 12 months. (Source: CDC Report Card, 2012)

10. There are 14 risks of formula feeding infants.  INFACT Canada has a brief annotated bibliography that is in a pdf format and easy to print and give to parents and care providers.  http://www.infactcanada.ca/fourteen%20risks%20of%20formula%20feeding.pdf

Lamaze Push for Your Baby --> Parents Share

The Technicalities of Teaching Childbirth Education Part 10: Problem Solving

I have assembled 10 key principles of teaching effective childbirth education classes, and am briefly addressing them in this blog.  In no particular order, they are:

1. Know how to teach
2. Preparation of a dynamic course lesson plan
3. Being Organized
4. Evidence-based knowledge base
5. Learner Assessment
6. Critical Thinking
7. Robust teaching techniques
8. Motivational skills for engaging students
9. Compassionate listening 
10. Problem solving

When expectant parents attend their childbirth education classes, they envision a class where they will learn some cute breathing, how to massage their partner’s hand and see a movie.  What they don’t expect is the depth and clarity with which subject matter is presented and how important informed consent actually is.

Informed consent is a very powerful tool.  On the American Medical Association website, I found this definition of informed consent:

In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:

·         The patient's diagnosis, if known;

·         The nature and purpose of a proposed treatment or procedure;

·         The risks and benefits of a proposed treatment or procedure;

·         Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);

·         The risks and benefits of the alternative treatment or procedure; and

·         The risks and benefits of not receiving or undergoing a treatment or procedure.

For some women, childbirth is a simple event that occurs with minimal complication and minimal intervention.  For others, many decision need to be made and these decisions can have a long lasting impact on many lives.  Problem solving in the form of informed consent, therefore, is a vital part of childbirth education class that shouldn’t be dismissed!

What sometimes seems very clear to the childbirth educator may be fraught with conflict for the expectant parents who are attending.  For example:

Problem: “I want to go natural but am afraid of the pain.”

Solution: Attend childbirth education classes and understand the source of the pain, why this is different pain than other types.

Problem: “I want to birth unmedicated but what if I can’t?”

Solution: Arm yourself with the knowledge base about medications and all of the nonpharmacologic alternatives.  Use informed consent and birth with flexibility.

Problem: “I want to use the doctor I’ve seen for years but he/she won’t go along with my birth plan.”

Solution: For many care providers, including nurses, birth plans are four letter words.  Just like in all walks of life, these care providers may have encountered birth plans from parents who are demanding, unyielding and just downright nasty.  This tends to spoil things for the rest of the group.  Find out if it is the birth plan itself, or just one part of the plan.  If it is just one section of the plan or one option, discuss the evidence based findings/research with the care provider.  Find out why they feel the way they do and perhaps either you or they may change their minds!  If it is still a reasonable sticking point, an expectant mother and her support team can always seek a second opinion and ultimately change providers if necessary.

Still parents may not be aware that they may need to give informed consent before, during and after the birth of their child.  The Childbirth Connection offers these tips to help parents explore issues with their careprovider:

Make a list of questions before each visit, and during the visit jot down the answers. You may wish to bring your partner or someone else who is close to you to listen to what is said. This is not the time to be shy; nothing is off limits. 

While talking with caregivers, you can say:

·         I don't understand.

·         Please explain this to me.

·         What could happen to me or my baby if I do that? Or if I don't?

·         What are my other options?

·         Please show me the research to support what you're recommending.

·         Where can I get more information?

·         I have some information I'd like to share with you.

·         I'm uncomfortable with what you are recommending.

·         I'm not ready to make a decision yet.

·         I'm thinking about getting a second opinion.

Any question that you have is worth asking. When answers are not clear, ask again until you understand.

Problem solving is not just a skill for the childbearing year, but for all of life – it is a life skill.  Take the time in childbirth class to clearly explain good problem-solving techniques by way of informed consent.  This will help parents become more empowered and even better parents!