In 1985 the World Health Organization stated that, “There is no justification for any region to have CS [Cesarean section] rates higher than 10-15%.” In 2010, WHO set out to review both the underuse (under 10%) and the overuse (over 15%) of cesareans worldwide.
Looking at data for 2008, the 2010 WHO report found that 54 countries had cesarean rates below 10%; 69 countries had cesarean rates above 15%; and, just 14 countries had rates in the suggested 10 to 15% range. Worldwide, medically unnecessary cesareans use a disproportionate share of global economic resources. According to the report, 6.2 million unnecessary cesareans were performed worldwide in 2008 at a cost of approximately $432 million.
Brazil has the highest cesarean rate in the world at 45.9% and Chad has the lowest, 0.4%. The countries within the recommended range of cesareans (10 to 15%) are the Philippines, Vietnam, United Arab Emirates, Cape Verde, Kazakhstan, Kuwait, Guatemala, Republic of Moldova, Montenegro, Namibia, Saudi Arabia, Honduras, Netherlands, Armenia, Ukraine, and the Syrian Arab Republic.
The United States has the 15th highest cesarean rate in the world, at 30.3%. WHO estimates that the cost of the 673,047 unnecessary US cesareans in 2008 was $687,167,996. According to the CDC the US rate has increased again and is now at 32%. New Jersey has the highest cesarean rate in the US at 38.3% and Utah has the lowest at 22.2%.
VAGINAL BIRTHS AFTER CESAREANS (VBACs)
Since the 1960s, studies have suggested that repeat cesareans—which contribute significantly to the overall cesarean rate—are not always necessary. In 1980, the National Institutes of Health (NIH) Consensus Development Conference Panel questioned the necessity of routine repeat cesarean deliveries. As a result of this statement and citizen advocacy, VBACs increased in the 1980s and through the mid to late nineties. However, since 1997, a decline in VBACS has contributed to the overall increase in cesarean delivery. In the chart below, notice the parallels between increased cesareans and decreased VBACs.
The decline in VBACs that started in the late 1990s was precipitated by 1999 guidelines released by the American College of Obstetricians and Gynecologists (ACOG) directing that VBACS only take place in facilities where emergency cesarean deliveries can be immediately performed. Evidence to support this guideline (consensus and expert opinion) was rated as Level C by ACOG and yet it had far reaching effects.
A 2007 study showed that in the years following these guidelines, the availability of VBAC services significantly decreased, especially among smaller or more isolated hospitals. Thirty percent of hospitals stopped offering trial of labor all together because they could not provide immediate surgical and anesthesia services and this is not expected to change. There are currently too few anesthesia providers to ensure “immediate” anesthesia availability for all hospitals providing childbirth services and these shortages are expected to increase in the future.
Nonetheless, in 2010, a National Institute of Health (NIH) synthesis of the published literature on VBAC concluded that, “…VBAC is a reasonable and safe choice for the majority of women with prior cesareans. Moreover, there is emerging evidence of serious harms related to multiple cesareans.”
A TRIAL OF LABOR AND FEAR OF LIABILITY
The VBAC success rate is impressive—for 60 to 80% of women with previous cesareans, a trial of labor is successful. And, according to the NIH, “…the vaginal delivery rate after trial of labor has remained constant at approximately 74%.” However, few hospitals offer a trial of labor. A 2012 study, for example, found that 44% of California hospitals do not offer a trial of labor.
Even though a trial of labor is highly likely to be successful, access to it is limited because of liability concerns related to the fear of uterine rupture, an extremely rare complication that occurs in less than 1% of births. The words “uterine rupture” evoke terrifying images of the uterus tearing in two. In truth, the uterus typically tears slowly, not all at once, and is accompanied by noticeable symptoms. Uterine rupture can happen to any woman in any pregnancy. It can even happen before labor begins, although this is not common.
Uterine ruptures, of course, are more common in trials of labor than in elective cesarean surgery, but there is no way to predict them. Here are some possible risk factors:
- Women with a classical and low vertical uterine scar have more risk of uterine rupture than women with a low transverse uterine incision.
- Induction of labor has been associated with uterine rupture, even in vaginal births. One side effect of the induction drug, Cytotec, for example, is uterine rupture.
- More than one cesarean
- Unfavorable cervix status at the time of admission.
- Pregnancy interval of less than 18 months
- Single layer closure for the initial cesarean
- A previous vaginal birth decreases the risk of uterine rupture.
No woman has died from a uterine rupture.The risk of maternal death related to elective cesarean delivery is higher than for trial of labor because, ultimately, vaginal birth is safer than surgery.
A 2009 ACOG survey showed that 30% of obstetricians stopped offering trials of labors and VBACs because of fears of litigation. Risk of liability is among the primary reasons for performing a cesarean. Studies have also shown than even modest improvements in the medical-legal climate (caps on noneconomic damages and reductions in physician malpractice premiums) could result in more VBACs and fewer cesareans.
BENEFITS OF LABOR
Research has shown that going into labor, even if it later leads to a cesarean is beneficial to the baby. Hormones that come into play only after labor has begun improve the baby’s respiratory system and state of alertness at birth. Overall, the major benefit of trial of labor is the 74 percent likelihood of VBAC success and the avoidance of the health risks associated with multiple cesarean deliveries.
HOW TO INCREASE VBAC SUCCESS
Current statistics show that the success of a VBAC is strongly influenced by environment. Though the overall VBAC rate is currently only 10 to 20%, Certified Nurse-Midwives (CNMS) have a successful VBAC rate of 68.9% overall. In some practices, the rate is as high as 80 to 90%.
If you would like to try VBAC, your best bet is to carefully research the practitioner and facility you want to use. Select a practitioner with at least a 70% success rate with VBACs, one who feels that you are a good candidate and who will actively encourage you through the rough spots of labor and delivery.
When you tour the facility you are considering, listen carefully to your intuition about the place. Aside from asking about their success rate with VBACs, talk to the staff and listen for encouragement about VBAC. If you don’t feel that the staff is enthusiastic about this concept, consider using another facility, Chose a doula with VBAC experience.
Here are some helpful resources. Many of the VBAC books are from the 1980s during the first wave of VBAC advocacy.
Cut, Stapled, and Mended: When One Women Reclaimed Her Body and Gave Birth on Her Own Terms After Cesarean by Roanna Rosewood. Roanna is the co-founder and host of BirthPlanRadio.com, and the executive action chair of Human Rights in Childbirth
VBACFacts, Jennifer Kamel’s advocacy website.
The Business of Baby by Jennifer Margulis
Silent Knife by Lois Estner and Nancy Wainer Cohen
The Vaginal Birth After Cesarean Experience by Lynn Baptisti Richards
Birthing from Within by Pam England. Pam created this birthing method from her own cesarean experience and subsequent VBAC.
The Thinking Woman’s Guide to a Better Birth by Henci Goer
Ina May’s Guide to Childbirth by Ina May Gaskin