Six Reasons to Be Optimistic about the NIH Consensus Development Conference on VBAC

by Judith Rooks, CNM, MPH, FACNM

Many of you already know about the upcoming NIH Consensus Development Conference on Vaginal Birth After Cesarean (VBAC): New Insights, March 8-10, at the NIH Campus in Bethesda, Maryland. Many midwifery advocates, including me, have had a bad taste in our mouths about NIH conferences on cesarean sections based on the 2006 NIH “State-of-the Science” conference on Cesarean Delivery on Maternal Request. The people who did the review of the literature and prepared the background paper for the 2006 conference on elective cesareans seemed, in my humble opinion, to be biased and made ridiculous decisions about what evidence should be considered during the conference. They concluded that “no information exists,” thus asserting that no one knows anything about the relative risks of attempting to have your first baby vaginally compared to having an elective cesarean.

However, I’d like to draw your attention to the March 2010 conference tagline “New Insights.” I’m taking this as a hint that NIH is aware of the damage caused by unnecessary cesareans and would like to encourage more women to try trial of labor after cesarean (TOLAC). We don’t know if there will be a midwife on the panel that will have the final say on the report resulting from this conference. The identity of panel members will not be revealed until the conference opens. Nevertheless, there are lots of reasons to be optimistic about this conference.

1. Mona T. Lydon-Rochelle, CNM, PhD, MPH, will present an important paper on the short-term benefits and harms to the mother of attempting a TOLAC versus having an elective repeat cesarean delivery and factors that influence maternal outcomes.
   
2. Lucky Jain, MD, MBA will do a presentation on the short-term benefits and harms to the baby of its mother’s attempt to have a VBAC versus having an elective repeat cesarean delivery, and factors that influence short-term outcomes for the baby should be very good. Every pregnant woman who is faced with making this decision should know the information he will present.
   
3. Emmanuel Bujold, MD, FRCSC, will explore differences between the American Congress of Obstetricians and Gynecologists’ (ACOG’s) VBAC guidelines compared to those of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and probably those of the OBGYN organizations of other countries.
   
4. I expect that a paper by David Birnbach, MD, MPH, will be important, too. People need to know that there is a shortage of OB anesthesiologists and nurse anesthetists to provide epidurals. This is also relevant to the new ACNM Position Statement on Nitrous Oxide Analgesia During Labor.
   
5. Howard Minkoff, MD, will present a paper on the “Immediately Available Physician Standard,” which should be very interesting and important.
   
6. Ditto for a paper by Miriam Kuppermann, PhD, MPH, on understanding risk, patient and provider preferences, and obstetric decision making; a paper by Anne Drapkin Lyerly, MD, on the medical ethics of VBACs; and a medical reporter’s paper on mother’s stories.

Overall, this should be a very good and important conference. Please don’t be discouraged from registering and participating because you were so discouraged about the 2006 NIH conference on elective cesareans. Midwifery advocates need to be there in force, especially articulate midwives who are knowledgeable about issues related to VBAC and problems related to lack of access to TOLACs. This is an important issue for midwives, and we need to make NIH and the entire maternity care community see that we are actively engaged with the scientific and professional issues surrounding VBACs.

Washington State Stacks Financial Incentives in Favor of Vaginal Birth

The state of Washington is taking an innovative step toward tackling rising cesarean section rates by eliminating the profit motive. Beginning this month, the state’s Medicaid reimbursement for uncomplicated cesarean sections dropped from approximately $3,600 to about $1,000—the same reimbursement provided for complicated vaginal birth.

Because the cost of vaginal birth is lower than the cost of c-section, the new payment structure rewards health care providers for supporting vaginal birth rather than for performing c-sections. Nearly half of all births in Washington are reimbursed through Medicaid, so the change is expected to have far-reaching effects. In fact, the state has already received calls from hospitals requesting assistance to revise the protocols they use to decide when a cesarean section is necessary.

A recent Crosscut.com article by Carolyn McConnell explains why this is an excellent way to improve maternal and infant health. It’s also in line with #5 and #7 of ACNM’s Seven Key Principles for Health Reform.

What do you think? Would you like to see the rest of the country adopt Washington’s new strategy?

SOGC Says No More Automatic Cesareans for Breech Babies

Whether you’re aiming for a hospital, birth center, or home delivery, if you get the news that your baby is in the breech position, chances are you’ll be advised to have a cesarean section. But on Wednesday, the Society of Obstetricians and Gynaecologists of Canada (SOGC) released new guidelines for health professionals that turn the breech issue upside down. They state that health professionals should not automatically recommend cesarean sections for women carrying breech babies.

After a comprehensive review of research, SOGC concluded that vaginal breech birth is a safe option in some cases:

“The evidence is clear that attempting a vaginal delivery is a legitimate option in some breech pregnancies,” said Dr. André Lalonde, Executive Vice-President of the Society of Obstetricians and Gynaecologists of Canada. “The onus is now on us as a profession to ensure that Canadian obstetricians have the necessary training to offer women the choice to deliver vaginally when possible.”