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Decreasing Maternal and Infant Morbidity Through the Increase of VBAC Rates, the Decrease of

C-sections and the Integration of Midwives in America’s Health Care System

Christina M. L. McQueen

Go Midwife

December, 2019

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The United States of America has some of the worst maternal morbidity rates for

industrialized nations. Out of 33 industrialized nations, The United States falls in the thirty

second placing for morbidity. We rank slightly better for maternal mortality rates, falling in at

thirtieth place while Sweden, Norway and New Zealand are the top three ranking countries with

the lowest maternal, child mortality rates (Block, xxi). Not only do they produce low maternal

and infant mortality rates, they also have low maternal and infant morbidity rates as well.

Morbidity is defined by the CDC as, “an adverse impact on a woman’s health during childbirth,

beyond what would be expected in a normal delivery.” A major contributor to maternal

morbidity in the United States is the high rate of cesarean sections seen across our nation

(Abdulfattah, et al, 2019). If low risk women with a cephalic baby would be allowed a trial of

labor after a cesarean section (TOLAC) and if vaginal birth after a cesarean section (VBAC)

rates would increase, there would be a significant decrease in morbidity rates among mothers and

infants in our nation by reducing unnecessary c-sections therefore lowering America’s morbidity

ranking.

Cesarean sections are increasing, not only in our country, but worldwide with the most

common cause for this major abdominal surgery being repeat c-sections (Abdulfatta, et al, 2019).

This is unfortunate because for the majority of women, a VBAC is a safe option and would

decrease morbidity rates for both the mother and the infant (Lundgren et al, 2016). The c-section

rate varies widely across our 50 states ranging from 23% to nearly 40% and even more startling

than that, the variation from hospital to hospital starts as low as 7.1% to the high of 69.9%. The

state-by-state c-section average is 33% (Caughey, et al, reaffirmed 2019). The World Health

Organization (WHO) states that in developed countries, cesarean sections should not exceed

15% while ACOG, the American College of Obstetrics and Gynecology, takes it one step further

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saying 15% should be the high end and it should really be a range of 10-15%. (Block, pg. 49)

Anything above 15% shows that the costs would outweigh the benefits of this major abdominal

surgery.

(Caughey, et al, reaffirmed 2019)

With VBAC rates below 10%, a significant difference from the 90’s where VBAC’s were

nearly in the 30th percentile, cesarean rates will continue to climb as more and more hospitals

decline a woman’s wish to achieving a VBAC (Caughey et al, reaffirmed 2019). According to

woman’s health advocate and doula, Anastacia Stone while lecturing on birth advocacy in 2019

in Kona, Hawaii, the national average for hospitals who decline VBACs is 40%. One reason that

hospitals are turning away mother’s seeking a VBAC is strictly due to hospital policy turning

away these mothers and that once a c-section, always a c-section is their policy (Grobman et al,

2011). ACOG states that, “attempting a VBAC is a safe and appropriate choice for most women

who have had a prior cesarean delivery, including some women who have had two previous

cesareans.” Statistics on success rates of VBACs are exactly the reason that ACOG is a

proponent for vaginal births after cesarean sections.

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(Caughey, et al, reaffirmed 2019)

There has been much research on the success rate of vaginal births after a c-section. Most

research supports a VBAC success rate of 60-80% (Committee on Practice Bulletins- Obstetrics,

2017). In their research, Tanos et al found that if given the chance, the VBAC success rate is as

high as 77%. If vaginal births after previous cesarean sections were an established practice

across our nation, morbidity would drop significantly because major abdominal surgery would

be prevented in over three quarters of mothers pregnant after a previous c-section. Turning

around the VBAC rate would have a definite impact in the cesarean rates, allowing more mothers

to obtain a vaginal birth and thus decrease morbidity for not only the mother but for their

newborns as well.

Whenever you have major surgery there are risks, benefits and drawbacks involved. When

considering a cesarean section, the risks and drawbacks include: longer hospital stays, extended

and more painful recovery, increased risk of infection, organ damage, adhesions, hemorrhage,

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embolism, hysterectomy, increase rehospitalization rates, increase complications for subsequent

pregnancies (placental insertion abnormalities is 50% more common after a cesarean), less

immediate contact with baby, decreased breastfeeding success, and twice the risk of maternal

death (Block, pg 90). In a thorough study of one thousand five hundred and one women who

gave birth to their children via cesarean section over a two year period, it was found that

morbidity did decrease over time however not enough and the study stated that c-section should

be used as a last resort because of the morbidity effecting both mom and baby (Abdulfattah, et al,

2019) The study also stated that VBACs can reduce c-section rates and decrease morbidity.

Though cesareans sections can be a life-saving medical advancement, the risks and drawbacks

must be considered and a cesarean should only be performed if necessary, for the benefit of the

mother and the infant.

Short-term and long-term morbidity is also found in the newborn. In a study by Baumert et

al, Respiratory Distress Syndrome (RDS) was diagnosed in 15.3% of later preterm babies and in

2.7% of all term infants. More infants that are born via c-section are admitted to the neonatal

intensive care unit (NICU) and they have a higher rate of perinatal death (Committee on Practice

Bulletins- Obstetrics, 2017). During Blocks in-depth research into how the maternal health care

system evolved to where it is today, she reports that the CDC indicates that infants born via

cesarean section with no medical risk factors where three times more likely to die in the first

thirty days of life than were infants who were born vaginally. Also, because these babies are

separated for longer periods of time from their mothers, there is a decrease in breastfeeding

success and, in childhood, more are seen to have food allergies than their counterparts who are

born vaginally.

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The major reason doctors, hospitals and malpractice agencies are concerned with a mother

choosing a vaginal birth after a previous c-section is the risk of uterine rupture and infant demise.

Many studies have been done regarding this serious concern. A study by Tanos et al on uterine

scar rupture found that, “Uterine rupture is more prevalent in VBAC-2 (VBAC after 2 c-

sections) patients (1.59%) in contrast to VBAC-1 (VBAC after 1 c-section) (0.72%).” Uterine

rupture is of more concern when interdelivery interval is short and the amount of time between

cesarean delivery and the subsequent pregnancy must be taken into consideration when assessing

if a mother is a VBAC candidate. Fetal demise which is presumed to be high is actually less than

one-tenth of a percent (Block, pg 90). With the risk of a woman experiencing a uterine rupture

and the risk of fetal demise being so low, it is in both the mother’s and the baby’s best interest to

attempt a trial of labor after a cesarean (TOLAC) and with the goal of achieving a VBAC.

Thapsamuthdechakorn et al found that the risk of uterine rupture can be further decreased with

careful observation of the mother and adhering to standard guidelines by the provider who is

overseeing the mother and baby. The risks of performing another c-section on a low-risk mother

with a cephalic presenting baby would outweigh the risks that come with the woman having her

baby born vaginally.

Not only are a significant percentage of VBACs a success, a vaginal birth after a cesarean

section also comes with benefits and risks, with the benefits out weighing the risks. Women who

achieve a vaginal birth after a cesarean section have several health advantages that can include,

“avoidance of major abdominal surgery and lower rates of hemorrhage, thromboembolism, and

infection, and a shorter recovery period than women with an elective repeat cesarean delivery.

Additionally, for those considering future pregnancies, VBAC may decrease risk of maternal

consequence related to multiple cesarean deliveries (eg, hysterectomy, bowel or bladder injuries,

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transfusion, infection, and abnormal placentation such as placenta previa and placenta accrete)”

(Committee on Practice Bulletins- Obstetrics, 2017). Not only do you have decreased morbidity

with the current delivery but decreased morbidity is seen for those who want to have more

children in the future which is incredibly important for the health of the mom and her subsequent

children should she choose to have more.

There is also risk associated with TOLAC but only if the woman did not have a successful

VBAC, in which case, maternal morbidity is associated with more complications (Committee on

Practice Bulletins- Obstetrics, 2017). This is why it is important to assess the probability of a

woman achieving a successful VBAC. Low-risk women with a single, cephalic presenting baby,

who has had 1 or 2 previous c-sections with a low transverse scar have a high chance of

achieving a vaginal birth. In the study, “Vaginal Birth After Cesarean Delivery,” not only do

medical professionals have to consider if the woman is a low-risk candidate for a VBAC, they

also have to take into consideration the reasoning for her previous c-section (Committee on

Practice Bulletins- Obstetricians, 2017). With both of those evaluations combined, an assessment

can be made on whether or not a TOLAC leading to a VBAC is the best option per each

individual case.

If research has established that VBACs are a safe and effective way to reduce maternal and

infant mortality by reducing the cesarean section rate and the American College of Obstetrics

and Gynecology recommends VBACs, why is there a rise in already high c-section rates? Also,

why do 40% of hospitals across the nation refuse women the option of having a vaginal birth

after a cesarean section? ACOG suggests a cesarean rate of 10 to 15% because that is the

percentage that is seen with a medical need for this invasive yet life-saving procedure. That

suggests that c-sections are being performed for reasons outside medical indications that would

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normally necessitate this major abdominal surgery. In order to decrease the c-section rate and

thus maternal and infant morbidity, rates for cesarean section outside medical necessity must be

reduced.

Nonmedical reasons for cesarean sections are complicated issues and it’s often difficult to

determine whether or not a c-section was in fact performed for medical or non-medical reasons.

For example, reasons for a c-section like, “failure to progress” does not give enough information

to determine if the procedure was in fact necessary or if it were performed for other reasons.

Likewise, it is unknown whether a woman who was never given the chance to have a VBAC, if

that subsequent cesarean section was indeed medically necessary. Over the last two decades,

however, the rates for non-medical cesarean sections have increased significantly (Abdulfattah et

al). A drastic cut in non-medically indicated cesareans can have a substantial impact in

decreasing maternal and infant morbidity. With that being said, there are a number of reasons

why cesarean section are preformed outside that which are medically necessary due to maternal

or fetal reasons.

Malpractice insurance claims are among one of these convoluted issues. A study by Yang

et all on “The Relationship Between Malpractice Litigation Pressure and Rates of Cesarean

Sections and Vaginal Birth After a Cesarean Section” found a correlation between malpractice

premiums and rates of cesarean section and primary cesarean section and a negative association

with VBAC rates. This study concluded that, “a ten thousand dollar decrease in premiums for

obstetricians-gynecologists would be associated with… approximately sixteen thousand more

VBACs, six thousand fewer cesarean, and three thousand six hundred fewer primary cesarean

section nationwide in 2003.” In the book, Pushed: The Painful Truth About Childcare and

Modern Maternity Care, it was found that malpractice insurers also organize conferences for

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physicians and attorneys where they can learn of the types of labor and delivery cases that would

be unwinnable in court as a way to self-protect themselves and hospitals from a malpractice

lawsuit. Medical providers can even receive continuing medical education credits for attending

these seminars (Block, pg 43). There is great incentive for doctors to perform as the malpractice

insurers suggest regardless of the morbidity that may be caused. Practicing under the malpractice

insurer’s suggestion assures a physician that if there was a lawsuit that did end up in court, they

would win, their malpractice insurance would not escalate and their medical license would not be

in jeopardy. In their findings, Abdulfattah et al identified that some cesarean sections are

performed out of the obstetrician’s fear of being sued and for profitability. Not only do c-sections

bring in more money, they also provide the obstetrician the assurance their case would hold up in

court.

The fear of malpractice lawsuits causes doctors to practice in a way that labor does not

begin spontaneously. Once interventions or inductions steer women away from the normal

physiological processes of birth, the result ends in situations where attempts to control birth

prevail and active management and augmentation of labor has begun. Active management is the

intervening in the natural labor process as means to control or prevent complications. Induction

is one type of active management and is responsible for increasing a woman’s chance of a c-

section by as much as two or three times because induction tends to create longer, more painful

labors and requires the need for further intervention (Block, pg 14). It is difficult to evaluate true

statistics for induction rates because many go unreported, however the CDC found that induction

rates occurred, at the minimum, in 21.2% of labors (Block, pg. 5). From doctor to doctor, these

rates can vary greatly. In her survey of doctors and nurses across the United States, Block found

rates to be anywhere from 90% to 50% to 31% of women being induced during labor (Block, pg

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6). With any type of interference with the natural physiological processes of birth, interventions

are more likely to be necessary and complications arise which can (and do) lead to cesarean

sections and or an increase of morbidity.

Another non-medical reason for pregnant women to have a c-section is because of

maternal request called, a cesarean section upon maternal request (CSMR). Many women are

opting, for no apparent medical need, to schedule the birth of their children. As discussed in

Pushed, there were a number of reasons found for why women were electing to have a c-section

for their first or subsequent pregnancies. One was for the sake of maintaining their pelvic floor

though there is no proof that avoiding a vaginal birth will spare their pelvic floor. In fact, the

daily pull of gravity or the pregnancy itself is enough to cause pelvic floor issues later in life

(Block, pg 54). Elective prophylactic cesarean sections are another reason women are turning to

scheduling their baby’s birth date with the thought that a cesarean can reduce potential infant

morbidity that occurs from a vaginal birth though research does not support that claim. Along

with the others, more and more women are opting for CSMR out of a trend to do so following

women of influence like Victoria Beckham who stated she was “too posh to push” or out of fear

of the pain of labor. In a study of the trends of cesarean sections, Sarmiento found that, “An

important contributor to the rising trend of CS worldwide… is the surge of cesarean section upon

maternal request.” We live in a day in age where a c-section can be performed rather safely

despite morbidity still associated with it but we have to consider if something that is life-saving

in a time of medical necessity is appropriate and beneficial to both the mother and baby when

there is no indication of the need for such an invasive procedure.

An answer to the need to decrease maternal and infant mortality through the reduction of

c-section and an in increase of VBACs is to follow the model seen in some of the countries with

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the best maternal and infant outcomes such as the Netherlands, Sweden and Denmark. In these

countries, obstetricians only attend women who are high risk pregnancies while the rest of low

risk women are attended with individual support by a midwife. Statistics cited by Block from a

study of over five hundred births published by the British Medical Journal, found that midwives

had a rate of less than 4% for c-sections, 2% episiotomy rate and a less than 2% forceps rate.

There were no maternal deaths and the number of infant mortality rates were on par with in-

hospital rates for low-risk women. The World Health Organization (WHO) states that,

“midwives are the most appropriate primary health care providers to be assigned to the care of

normal birth” (Block, pg. xxiii). Ina May Gaskin’s The Farm, a birth center, is an example of

why the WHO says that midwives are the most appropriate care providers for normal birth. The

Farm has delivered over 3,000 babies with a low 1.7% cesarean rate, no maternal deaths and an

incredibly low infant mortality rate of .39% (Block, pg 96). Midwives are trained in how to

oversee the natural, physiological process of birth and when you see trained midwives

implemented in the management of normal birth, an increase of maternal and infant positive

outcomes occurs as well as a decrease in maternal and infant morbidity.

The University of California Los Angeles has a network of hospitals. One of their

locations, a hospital in Santa Monica, has recently had a shift take place in their labor and

delivery ward. Midwives now run the labor floor and attend all low risk mothers and the

obstetricians simply oversee the high-risk cases. The midwives have also begun to teach the

obstetricians on the normal and natural process of labor and delivery and the success rates among

that hospital are impressive. As a result of midwives taking over the labor floor, the hospital

reports that, “our caesarian section rate is 12%, and vacuum or forceps assisted delivery rate is

4%. We do induce labor in approximately 10% of labors, for reasons the family and we believe

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to be important; most commonly overdue pregnancies. We rarely perform episiotomies, an

annual rate of 1%” (UCLA Obstetrics and Gynecology). UCLA labor and delivery bases their

care off of their philosophy of birth: labor and birth are normal and physiological processes,

pregnant women and their significant others are cared for as a unit, and technology and

interventions are used judiciously. Their midwifery model of care is thus, “Watchful waiting and

non-intervention in normal processes. Appropriate use of interventions and technology for

current or potential health problems. Consultation, collaboration and referral with other members

of the health care team as needed to provide optimal health care.” If more hospitals in America

would follow this trend, there would be a significant drop in maternal and infant morbidity and

mortality.

In a recent study by Vedam et al, titled “Mapping Integration of Midwives Across the

United States: Impact on Access, Equity, and Outcomes,” they discovered that when midwives

are a part of the maternal care during labor and delivery, there were, “high rates of vaginal

delivery, vaginal births after cesareans, and breastfeeding and significantly lower rates of

cesarean, preterm birth, low birth weight infants, and neonatal deaths.” The integration of

midwives were also shown to be associated with a substantially higher rate of physiological

birth, less obstetric intervention and a decrease in adverse neonatal outcomes. They concluded

that the integration of midwives in the health care system is a, “key determinant of optimal

newborn outcomes.” If the United States would implement this midwifery care model into

maternal health care across the nation the impact would be significant.

When Obstetricians and midwives work together, they operate in the skillset they trained

for. Obstetricians are educated in how to intervene in complications that can and do arise during

the uncertain moments of labor and delivery. Midwives, on the other hand, are trained in how to

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support and nurture the physiological process that labor is. When these two skilled providers

form an interprofessional teamwork system, mothers and newborns receive optimal care and

morbidity for both the mother and child is decreased. When midwives oversee low-risk women,

cesarean sections decrease, vaginal births after cesareans increase, intervention and inductions

decrease as well as other life-impacting factors. Working together in ways that exemplifies both

the midwife’s and obstetrician’s skillset can lead to decreased morbidity rates across our nation

and have great impact on mothers, children and families. Implementing the interprofessional

teamwork system of midwifes and obstetricians working together across America can be the

answer to the morbidity crisis women and newborns face in our Nation.

Childbirth is a natural, physiological process rarely requiring interventions if left to

unfold spontaneously. Allowing mothers to go through the labor process uninterrupted increases

health for the child and minimizes the recovery and potential for complications post-delivery.

Based on the research presented and the compelling evidence done by medical researchers over

the years, decreasing morbidity for mothers and infants can be accomplished by decreasing non-

medically based cesarean sections, increasing VBACs and by following the model of the top-

ranking countries for maternal and child outcomes. By integrating midwives to the labor floor,

not only would the c-section rate drop down to the recommended rate suggested by ACOG,

VBACs would increase, induction rates and interventions would decrease and other

augmentations to labor would be reserved for those that are medically necessary. Implementing

these solutions and bringing awareness to the medical community, along with mothers and

families, will have a lasting, positive influence on America’s healthcare system and as well as

the citizens who rely so heavily upon it.

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Work Cited

Abdulfattah, Nada, et al. “Incidence of Maternal Morbidity and Mortality Following Cesarean Delivery.” Bahrain Medical Bulletin, vol. 41, no. 3, Sept. 2019, pp. 138–140. EBSCOhost,ezproxy.losrios.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=138117095&site=ehost-live&scope=site.

Baumert, Małgorzata, et al. “Cesarean Delivery and Respiratory Distress in Late Preterm and Term Infants.” Central European Journal of Medicine, vol. 7, no. 2, Apr. 2012, pp. 230–234. EBSCOhost, doi:10.2478/s11536-011-0139-5.

Block, Jennifer. Pushed: The Painful Truth about Childbirth and Modern Maternity Care. Da Capo/Lifelong, 2008.

Caughey, Aaron B. et al. “Safe Prevention of the Primary Cesarean Delivery.” ACOG, TheAmerican College of Obstetrics and Gynecologists, Mar. 2014, Reaffirmed, 2019. www.acog.org/Clinical-Guidance-and-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery?IsMobileSet=false.

Committee on Practice Bulletins- Obstetrics. “Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery.” The American College of Obstetricians and Gynecologists, November, 2017, pp. 1-17.

Grobman, William A., et al. “The Change in the Rate of Vaginal Birth after Caesarean Section.”Paediatric & Perinatal Epidemiology, vol. 25, no. 1, Jan. 2011, pp. 37–43. EBSCOhost, doi:10.1111/j.1365-3016.2010.01169.x.

Lundgren, Ingela, et al. “Clinicians’ Views of Factors of Importance for Improving the Rate of VBAC (Vaginal Birth after Caesarean Section): a Study from Countries with Low VBAC Rates.” BMC Pregnancy and Childbirth, vol. 16, no. 1, 2016, doi:10.1186/s12884-016-1144-0.

“Nurse Midwives.” Nurse Midwives - UCLA Obstetrics and Gynecology, Santa Monica, CA, https://www.uclahealth.org/obgyn/nurse-midwives.

Sarmiento, Andres. “Trends in Cesarean Section.” In Tech Open. September, 2018.https://www.intechopen.com/books/caesarean-section/trends-in-cesarean-section

Tanos, Vasilios, and Zara Abigail Toney. “Uterine Scar Rupture - Prediction, Prevention, Diagnosis, and Management.” Best Practice & Research Clinical Obstetrics & Gynaecology, vol. 59, Aug. 2019, pp. 115–131. EBSCOhost, doi:10.1016/j.bpobgyn.2019.01.009.

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Thapsamuthdechakorn, Aram, et al. “Factors Associated with Successful Trial of Labor after Cesarean Section: A Retrospective Cohort Study.” Journal of Pregnancy, June 2018, pp. 1–5. EBSCOhost, doi:10.1155/2018/6140982.

Vedam, Saraswathi, et al. “Mapping Integration of Midwives across the United States: Impact onAccess, Equity, and Outcomes.” PLoS ONE, vol. 13, no. 2, Feb. 2018, pp. 1–20. EBSCOhost, doi:10.1371/journal.pone.0192523.

Yang, Y Tony et al. “Relationship between malpractice litigation pressure and rates of cesareansection and vaginal birth after cesarean section.” Medical care vol. 47,2 (2009): 234-42. doi:10.1097/MLR.0b013e31818475de