One of things that really, really perturbs me is the use of rates of VBACs and rates of c-sections as performance measures. I think that these measures might have been well-intentioned but are terribly flawed indicators of maternity care. In short I think that efforts to 'keep down the rate of c-sections', or 'increase the rate of VBACs' are bad policy, for a lot of very good reasons.
1. It places a value judgement on how birth occurs - in short by having a publicly stated goal to reduce the c-section rate or increase the rate of vaginal births after c-sections - it sends a message to moms. That message is "physiological birth is superior to surgical birth" - in short many women get the message that they have failed if they have a c-section or do not attempt/succeed with a VBAC. Birth no longer is about bringing home a healthy baby and a mom who is in the best physical and emotional health as possible - it becomes about how the birth occurred. It's time to realize that a c-section is not a failure and that a vaginal birth is not an accomplishment. A healthy mom and a healthy baby is an accomplishment - as is a process that facilitates that outcome and respects the emotional and physical needs of both mother and baby.
2. The unintended consequences of this focus might be really, really ugly. When the focus shifts to how birth occurs, inevitably there are trade-offs. The trade-off of having a low c-section rate might be an increase in the number of births that are assisted by forceps and vacuum. The trade-off of having a low c-section rate might be a decrease in the rate of inductions after 40 weeks and an increase in the number of still births. The trade-off of having a low c-section rate overall might be an increase in the number of emergent c-sections that occur when delivery with 30 or 20 minutes is critical to avoiding long-term disability. The trade-off of increasing VBACs might be an increase in uterine ruptures. The trade-off having a low c-section rate might mean more 3rd and 4th degree tears. The trade-off of a low c-section rate might be an increase in the rate of severe birth traumas. The trade-off might mean putting the process of how birth occurs ahead of the genuine desires and needs of the patient.
Are these trade-offs ones that we really want to make?
3. These are not indicators that tell us anything meaningful about the quality of care or appropriateness of the care received by maternity patients. By focussing on these measures, and actively seeking to reduce c-section rates or increase the rates of VBACs - we are not measuring what matters or moving closer to achieving the goal of maternity care that is actually better. Effort needs to be made to find the measures that really reflect good quality care and to report on those things.
It's time to quit focussing on reducing the cesarean rate or increasing the rate of VBACs - these measures and goals should be immediately scrapped. Yesterday wouldn't be soon in enough in my opinion.
Mothers and babies deserve better - they deserve quality care that places genuine outcomes that matter ahead of the specific mode of delivery.
Excellent post! My sister-in-law is a physical therapist who works with many children who have cerebral palsy. When I was pregnant with my first, she told me that she would choose an elective C-section to avoid the risk of a child with CP. When she told me that, I was shocked, but I have since become more educated of the risks of vaginal birth (that you have so eloquently explained). While I did deliver vaginally and unmedicated, I was mentally prepared for the fact that a C-section might be necessary for the health of my son. It is not that difficult to understand these trade-offs.
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