Based on 2013 CDC data, the overall country-wide cesarean rate average is 32.2%. (Remember from last week's Truth Tuesday's post- community birth cesarean rates are just 5%). However the rates of VBAC nationwide are just 11.3% It was once believed that the risks of a vaginal birth after cesarean highly outweighed the risks of a repeat cesarean, with patients being told the risk of uterine rupture the main concern. However, in 2017, and updated again in 2019, The American College of Obstetrics and Gynecology (ACOG) now RECOMMEND a trial of labor after cesarean (TOLAC). In fact, ACOG notes several benefits to VBAC:
In fact, ACOG (2019) also states "Given the overall data, it is reasonable to consider women with two previous low-transverse cesarean deliveries to be candidates for TOLAC and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC".
The main concerns reported with VBAC is uterine rupture. The risk of uterine rupture in a person that has not had a cesarean is .007%, or 1 in 14,286 (Zwart, 2009). After one prior cesarean, the risk of uterine rupture increases to .5-.9%, or 1-2 in 2000 (ACOG, 2019). While this is a large increase if you look at the rate as still less than 1 in 1,000, the overall risk is small. In addition, only 6% of uterine ruptures are catastrophic (less than 6 in 100,000), meaning 94% of uterine ruptures still have good outcomes.
With the actual occurrence of uterine rupture remaining low, and the benefits of VBAC truly impacting outcomes, VBACs should be offered. In addition, all low risk persons with one prior cesarean (even two as recommended by ACOG), should be offered birth in a community setting if desired! VBAC rates in a community birth setting are 87% (Cox et. al., 2015). It's also important to remember that in a community birth setting, the midwife is there continuously with the client once in active labor, monitoring (more frequently than a non-VBAC client) and assessing the well-being of both the birthing person (especially for abnormal pain) and the baby!
Washington State ranks number ONE in the country for midwife integration into the healthcare system. Washington has a cesarean rate of 27.6% and overall VBAC rate is 18.4% (CDC, 2013). Could the lower cesarean rate and increased VBAC rate be linked to the amount of midwives practicing in Washington? What do you think? Check out your state's midwifery inclusion ranking and statistics at: https://www.birthplacelab.org/how-does-your-state-rank/