Monday, April 7, 2014

MANA Study Part 4: Vaginal Birth After Cesarean

You are reading Part 4 of my MANA study series. Click to view:

MANA Study Part 1: Intrapartum Mortality Rates

MANA Study Part 2: Neonatal Mortality Rates

MANA Study Part 3: Total Mortality Rates

MANA Study Part 4: Vaginal Birth after Cesarean (currently reading)


April 4, 2017 Update: a new study from the Midwives Alliance of North America (MANA) confirms that attempting a VBAC at home comes with a much higher risk of neonatal death. The study Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States looked at planned, midwife-attended births in a home or freestanding birth center. In the study, they use the term LAC (Labor after Cesarean) instead of using the term TOLAC or attempted VBAC.
Rates are as follows for women attempting birth at home or freestanding birth center:
Women with prior vaginal birth, no cesarean history: 1.03/1000
Women attempting VBAC with prior vaginal birth: 1.27/1000
Women attempting VBAC without prior vaginal birth: 10.2/1000

Yes, you read that outrageously awful rate correctly: 10 neonatal deaths per one thousand!

Compare those rates to USA hospitals: 
Hospital CNMs (lower risk pregnancies) = 0.35/1000 to 0.55/1000
Hospital MDs (higher risk pregnancies) = 0.43/1000 to 0.63/1000
Hospital attempted VBACs* = 1.3/1000
Hospital repeat cesarean = 0.5/1000

* The hospital attempted VBAC group includes a higher risk group of women. It includes women with and without prior vaginal birth, with and without higher risk medical conditions and also includes fetal deaths - death of baby in uterus prior to onset of labor from 28 weeks gestation and beyond. Fetal deaths were not included in the home and birth center rates above (meaning, the rates would be higher for the home and birth center births if fetal deaths were included).


For today's post I am discussing VBAC, HBAC and the MANA study outcomes for HBACs. Let's first lay out the different acronyms:

VBAC -- Vaginal Birth After Cesarean
HBAC -- Home Birth After Cesarean
TOLAC -- Trial Of Labor After Cesarean
ERCD -- Elective Repeat Cesarean Delivery
RCS -- Repeat Cesarean Section

TOLAC refers to all women who have had a previous cesarean section (or more than one) who attempt a vaginal birth. The outcome for TOLAC may be vaginal birth (VBAC) or it may be repeat cesarean section. TOLAC therefore includes outcomes for both.

ERCD refers to all women who decided to forgo an attempt at vaginal birth. ERCD is a bit of a deceiving term. While a cesarean section in this group is labeled as “elective” it also includes women who medically needed cesarean sections for reasons aside from having a previous cesarean section (which would mean it is not actually an elective cesarean section). Because women with chronic illnesses, or other such medical contraindications for TOLAC, are lumped into the ERCD group, the risks of ERCD may be overestimated.


I'm briefly going to discuss various aspects surrounding VBAC before discussing the startling increased risk for babies born at home to mothers attempting a HBAC.