November 21, 2002

Vaginal Birth after Caesarean

Why are rates for vaginal birth after caesarean section (VBAC) so low in our hospitals? This question has come up in workshops quite frequently and has also featured on the ozmidwifery list as part of a discussion around fear and its effect on labour.

As I see it, there are two main reasons why VBAC rates are hovering around 30% (or worse) when they should be around 80% according to the evidence.

The first reason is that women are left with many emotional and psychological scars after an unexpected caesarean and these are rarely dealt with adequately so they can be resolved. A woman who has been told that her body didn’t work well, that it was “too small” or “too slow to dilate” or “failed” in some way will have had a severe dent put in her perceptions of herself as a woman. Birth is the central pivotal point around whish a woman’s whole notion of herself as a sexual being revolves. If she is judged to be inadequate or a “poor performer” in this area she may well be unwilling to give a vaginal birth a try next time, because of the impact a further “failure” may have on her psyche. It may be emotionally safer to opt for an elective caesarean which is planned and predictable than to risk the potential for further psychological trauma.

A second factor is the caregiver. It is well known that it is the attitudes, practices and beliefs of the caregiver that shape a woman’s birth experience. In the case of a VBAC there are many vested interests at work : the doctor’s desire for an ordered life; the hospital’s need for scheduling and throughput of clients; the money to be made from surgery, epidurals, drugs, equipment etc. Most doctors also lack the skills and willingness to sit with women in a supportive, positive way while they labour naturally. Time is money and a caesarean takes little time in contrast to vaginal birth.

Another factor, often overlooked, is the fear and grief experienced by fathers who have been caught up in a dramatic caesarean birth. They are rarely counselled or de-briefed afterwards, and their unresolved trauma may cause them to pressure their partner for an elective caesarean the next time.

All of these issues could be dealt with in a useful way through special pre-natal programs for potential VBAC parents. Small groups, with both parents, under the leadership of a skilled facilitator could explore these and other important issues associated with caesarean births and VBAC. I am convinced we need a lot of these programs around the country and they may be a key factor in lowering the ever-climbing caesarean birth rate.

A useful resource on these kinds of classes is The VBAC Source book and Teaching Kit - an excellent outline for such a program packed with teaching strategies and factual information.

Posted by andrea at November 21, 2002 03:49 PM

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