An extended version of this post appeared September 12, 2011 at the Transforming Maternity Care Blog at http://transform.childbirthconnection.org/2011/09/vbacquality/

According to new government statistics, 20% of the more than 4 million U.S. births each year occur to women who have previously given birth by cesarean. If evidence and national guidelines support vaginal birth after cesarean (VBAC) as a “reasonable option” for most of this population – and indeed the better option for many – it is time to be reasonable about how to make VBAC as safe, accessible, and satisfying as it can possibly be.

A QUALITY FRAMEWORK FOR VBAC

1. Help women make and carry out choices that are informed by the best quality evidence and aligned with their own values and preferences.

Rationale: Honoring people’s informed choices is the legal and ethical standard, acknowledged by all major health care bodies.

Current approach: According to the VBAC Policy Database, a voluntary monitoring project by the International Cesarean Awareness Network, half of U.S. hospitals either ban VBAC outright or have no providers willing to attend VBACs. In areas where VBACs are “offered,” women must often meet eligibility criteria that are not supported by high-quality evidence.

Why this is inadequate: Both planned VBAC and planned repeat cesarean section are reasonable choices with important potential benefits and harms but the trade-offs are very different. The current approach, intended to reduce the already low likelihood of avoidable perinatal death or injury and associated liability, has resulted in significant collateral damage: most notably an increased risk of maternal mortality and a growing prevalence of life-threatening complications for both mothers and babies in future pregnancies. The Agency for Healthcare Research and Quality (AHRQ) team that conducted the 2010 systematic review on VBAC versus routine repeat cesarean referred to the VBAC access issues as “chilling,” an assessment with which we at Childbirth Connection agree.

Another approach: We urgently need evidence-based, field-tested shared decision making tools to communicate the research evidence and help women clarify their preferences and values. Although decision support tools can help a woman select the best choice for her, system barriers including payment incentives, liability concerns, and clinician education must be addressed simultaneously to ensure that she can carry out her choice. Assessing the potential for shared decision making tools and processes to reduce liability should be a research priority.

2. Maximize the proportion of women planning VBAC who experience uncomplicated vaginal births

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