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
Rationale: Morbidity in VBAC labors is highly concentrated in the women who have unplanned cesareans in labor. Having a VBAC also reduces risks in subsequent pregnancies and virtually ensures that future births will be vaginal, while having a repeat cesarean sharply increases risks in subsequent pregnancies and virtually ensures that future births will be surgical. Repeat cesarean costs payers significantly more than VBAC and has significant downstream economic costs because of these effects in subsequent pregnancies.
Current approach: Several researchers have attempted to create prediction tools to select the women most likely to give birth vaginally, and some clinicians and hospitals have imposed strict eligibility criteria for planned VBAC. Significantly less attention has been given to care processes that may enhance a woman’s likelihood of having a safe vaginal birth.
Why this is inadequate: Calculating the likelihood of vaginal birth can support informed choice. However, the AHRQ systematic review concluded that none of the available prediction tools adequately selected women for successful trial of labor. Moreover, some groups with lower likelihoods of vaginal birth, such as women with high BMI or multiple prior cesareans, also face higher-than-average likelihood of harm if they end up with a cesarean.
Another approach: The AHRQ researchers emphasized the need to incorporate “non-medical factors,” like provider and facility characteristics, in prediction tools to enhance their usefulness, as these appear to more strongly affect VBAC likelihood than factors intrinsic to the woman. In addition, research is urgently needed to identify labor care strategies to promote safe vaginal birth in women with prior cesareans, in particular the potential contribution of midwives and doulas. A randomized controlled trial examining the impact of doula care on VBAC labors is currently underway in Canada.
3. Provide the best possible response to obstetric emergencies including uterine rupture
Rationale: Uterine rupture occurs in about 4.7 per 1000 VBAC labors and is an obstetric emergency requiring prompt delivery. Although the outcome is usually favorable for both infants and mothers, morbidity and mortality may be minimized if the team is prepared, communicates well, and responds quickly and in a coordinated fashion.
Current approach: The small chance of a sudden emergency with high risk of serious fetal and maternal harm resulted in ACOG’s recommendation that a surgical team should be “immediately available” for VBAC labors. Although in 2010 ACOG tempered this recommendation somewhat, the response to the possibility of uterine rupture continues to favor requiring women to consent to cesareans in order to access maternity care.
Why this is approach is inadequate: The AHRQ researchers identified several other obstetric emergencies that occur with similar frequency as uterine rupture and result in similar likelihoods of serious harm but for which the obstetric community does not deem 24/7 cesarean capability to be necessary. For these obstetric emergencies, rather than forbidding labor, hospitals have begun focusing on proven patient safety strategies like enhancing teamwork, implementing checklists, and conducting drills and simulations.
Another approach: The emerging concept of “high reliability obstetrics” provides a framework for preventing adverse events and managing them in a consistent fashion when they occur despite prevention efforts. This requires a multi-disciplinary commitment to preparedness, teamwork, communication, and documentation. Various safety courses teach teamwork and management of emergencies in obstetrics. A systematic review of multi-disciplinary simulation training found that such programs improved knowledge, skills, and team performance in obstetric emergencies and were associated with improved neonatal outcome.
BRINGING BACK VBAC
If VBAC is a reasonable option for most women, we need a reasonable approach to ensuring quality and safety in VBAC. Like maternity care generally, transforming VBAC care will take multi-stakeholder commitment to system reform. With so much inertia in the system, consumers and advocates must maintain a strong voice to push for positive change. Childbirth Connection’s Action Center provides more ideas for engaging in maternity care transformation.