Urge more women who have previously had a caesarean section to have vaginal delivery, experts sayBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4167 (Published 03 August 2010) Cite this as: BMJ 2010;341:c4167
All rapid responses
The title of this article reads, ‘Urge more women who have previously
had a caesarean section to have vaginal delivery, experts say’.
But this is not what the American College of Obstetricians and
Gynecologists' July 2010 press release says.
Rather, ACOG says that ‘restrictive VBAC policies should not be used
to force women to undergo a repeat cesarean delivery against their will’.
These two statements are entirely different, and it is important that
we recognize this. Patient/maternal autonomy is not about urging a group
of women to have one particular birth plan; it is about allowing them to
make their own informed decision.
Also, the opening sentence of this article is not entirely accurate.
Like so many reports of ACOG’s updated VBAC guidelines, Roehr’s
choice of words, ‘Doctors in the United States have emphasised the safety
of vaginal delivery for women who have had one or two previous caesarean
sections’, omits the crucial word ‘most’, and this dangerously changes the
In fact, ACOG says, ‘Attempting a vaginal birth after cesarean (VBAC)
is a safe and appropriate choice for most women who have had a prior
cesarean delivery, including for some women who have had two previous
That’s ‘most’ and ‘some’ women. Not by any means ‘all’.
Unfortunately, some of the confusion has arisen from ACOG's decision
to talk about the ‘importance of patient autonomy’ in the same context as
the desire ‘to swing the pendulum back to fewer cesareans and a more
reasonable VBAC rate’. But who and/or what will decide when this
‘reasonable’ rate has been reached?
Certainly, if ACOG's decision to change the wording in its VBAC
guidelines (to reflect that ‘quickly gathered’ rather than ‘immediate’
emergency care should be available in case uterine rupture occurs) helps
more women who desperately ‘want’ a VBAC, then this is a good thing.
But it's equally important to remember that many women will prefer to
have a repeat cesarean, and will be completely happy with their choice.
This is because although ‘approximately 60-80% of appropriate candidates
who attempt VBAC will be successful’, this means that 20-40% of women with
the BEST chance of success will STILL be unsuccessful.
Therefore, women’s birth plan decision to have a repeat cesarean
should not be refused or disrespected in a misplaced attempt to ‘swing the
Perhaps if, instead of target rates, we let patient autonomy take a
greater role in maternity care... if we provide women with the risks and
benefits and let them decide which birth plan they prefer... if assessment
of birth outcomes includes maternal satisfaction... then the rates will
fall where they will, and more women and babies will be happier and
healthier for it.
Competing interests: No competing interests