Birthing Beautiful Ideas

The NIH Consensus Development Panel just released the revised draft of its Consensus Statement on Vaginal Birth After Cesarean.  (The final statement will not be released for another six weeks or so.)

After reading the revised draft, and after considering what I perceive to be its flaws–namely, a lack of discussion about VBAmC (or vaginal birth after multiple cesareans) and of the right to informed refusal–I still think that the statement itself represents a major step forward for women who want to and often have to fight to choose how they give birth to their babies.

And that’s because while I’m not sure that the statement will signal a sea change in policies and practices regarding VBAC (although I would certainly welcome such a change), I think that it gives women a powerful tool to use when discussing VBAC with their care providers.  I also think that it gives maternity care providers a powerful charge to re-evaluate their VBAC policies and practices.

Consider, for instance, the following remarks from the statement’s conclusion:

One of our major goals is to support pregnant women with a prior transverse uterine incision to make informed decisions about TOL versus ERCD. We urge clinicians and other maternity care providers to use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decision-making process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When both TOL and ERCD are medically equivalent options, a shared decision-making process should be adopted and, whenever possible, the woman’s preference should be honored.

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.

Despite the fact that I would still like stronger language regarding the “shared decision-making process” in the first paragraph above, I think that the informed consent-centered language signifies an overall victory for VBAC supporters.  As far as I can tell, this is the first document in recent history that explicitly and strongly encourages care providers to take steps to 1) fully inform women of the relative risks and benefits of VBAC and repeat cesarean, to 2) make their own policies about VBAC and their VBAC rates public, and to 3) work toward eliminating current barriers to VBAC.

The panel cannot force care providers, hospitals, or medicial societies to make these changes, but it is quite clear that they think these changes should be made.  And to have the force of an NIH consensus statement behind those changes seems quite remarkable to me.

Now let’s use that force to our advantage.