Wednesday, August 4, 2010

BMJ Letter published: ACOG wants to allow, not urge, more VBACs

My letter, published in the British Medical Journal on 4th August 2010, was in response to the publication: 'Urge more women who have previously had a caesarean section to have vaginal delivery, experts say', by Bob Roehr.

It says:

The title of this article reads, ‘Urge more women who have previously had a caesarean section to have vaginal delivery, experts say’.

But this is not what the American College of Obstetricians and Gynecologists' July 2010 press release says.

Rather, ACOG says that ‘restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will’.

These two statements are entirely different, and it is important that we recognize this. Patient/maternal autonomy is not about urging a group of women to have one particular birth plan; it is about allowing them to make their own informed decision.

Also, the opening sentence of this article is not entirely accurate.

Like so many reports of ACOG’s updated VBAC guidelines, Roehr’s choice of words, ‘Doctors in the United States have emphasised the safety of vaginal delivery for women who have had one or two previous caesarean sections’, omits the crucial word ‘most’, and this dangerously changes the message intended.

In fact, ACOG says, ‘Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans.’

That’s ‘most’ and ‘some’ women. Not by any means ‘all’.

Unfortunately, some of the confusion has arisen from ACOG's decision to talk about the ‘importance of patient autonomy’ in the same context as the desire ‘to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate’. But who and/or what will decide when this ‘reasonable’ rate has been reached?

Certainly, if ACOG's decision to change the wording in its VBAC guidelines (to reflect that ‘quickly gathered’ rather than ‘immediate’ emergency care should be available in case uterine rupture occurs) helps more women who desperately ‘want’ a VBAC, then this is a good thing.

But it's equally important to remember that many women will prefer to have a repeat cesarean, and will be completely happy with their choice. This is because although ‘approximately 60-80% of appropriate candidates who attempt VBAC will be successful’, this means that 20-40% of women with the BEST chance of success will STILL be unsuccessful.

Therefore, women’s birth plan decision to have a repeat cesarean should not be refused or disrespected in a misplaced attempt to ‘swing the pendulum back’.

Perhaps if, instead of target rates, we let patient autonomy take a greater role in maternity care... if we provide women with the risks and benefits and let them decide which birth plan they prefer... if assessment of birth outcomes includes maternal satisfaction... then the rates will fall where they will, and more women and babies will be happier and healthier for it.

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