EBB 209 – Providing Unbiased VBAC Access and Support with VBAC Facts® Founder, Jen Kamel

Learn more about Jen Kamel here. Follow VBAC Facts® on Facebook and Instagram.

Learn more about the American College of Obstetricians and Gynecologists (ACOG) here and ACOG’s information on VBAC here.  

Dombrowski, M., Illuzzi, J. L., Reddy, U. M., Lipkind, H. S., Lee, H. C., Lin, H., … & Xu, X. (2020). Trial of labor after two prior cesarean deliveries: patient and hospital characteristics and birth outcomes. Obstetrics & Gynecology, 136(1), pp.109-117. https://doi.org/10.1097/AOG.0000000000003845

Landon, M. B., Spong, C. Y., Thom, E., Hauth, J. C., Bloom, S. L., Varner, M. W., … & National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. (2006). Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstetrics & Gynecology, 108(1), pp.12-20. https://doi.org/10.1097/01.AOG.0000224694.32531.f3

Lundgren I, van Limbeek E, Vehvilainen-Julkunen K, Nilsson C. Clinicians’ views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a qualitative study from countries with high VBAC rates. BMC Pregnancy Childbirth. 2015 Aug 28;15:196. doi: 10.1186/s12884-015-0629-6. PMID: 26314295; PMCID: PMC4552403.  

Macones, G. A., Cahill, A., Pare, E., Stamilio, D. M., Ratcliffe, S., Stevens, E., … & Peipert, J. (2005). Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology, 192(4), pp.1223-1228. https://doi.org/10.1016/j.ajog.2004.12.082

Rebecca Dekker: Hi, everyone. On today’s podcast, we’re going to talk with Jen Kamel of VBAC Facts® about VBAC or vaginal birth after cesarean. Welcome to the Evidence Based Birth® podcast. My name is Rebecca Dekker and I’m a nurse with my PhD, and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice, see ebbirth.com/disclaimer for more details.

Hi, everyone, and welcome to today’s episode of the Evidence Based Birth® podcast. My name is Rebecca Dekker. Pronouns, she, her and I will be your host for today’s episode. Today, we are so excited to welcome Jen Kamel of VBAC Facts® to talk about VBAC or vaginal birth after cesarean. Before we start with the interview, I want to let you know that if there are any content or trigger warnings that go with this episode, we’ll post them in the description or show notes that go along with this episode.

And now I’d like to introduce our honored guest, Jen Kamel. Pronouns, she, her helps perinatal professionals and cesarean parents achieve clarity on the VBAC evidence through her educational courses, continuing education training programs and consulting services. As the founder and CEOe of VBAC Facts® and an internationally recognized consumer advocate, Jen’s mission is to increase feedback access through education, legislation changes and amplifying the consumer voice.

Jen supports perinatal professionals around the world through her online professional membership. She travels throughout the United States training perinatal professionals, presents grand rounds at hospitals and works as a legislative consultant throughout the US, focusing on midwifery legislation and regulations that threaten VBAC access.

Over the years, she has testified multiple times in front of the California medical board and legislative committees, educating legislators on the importance of VBAC access. And she served as an expert and consultant in legal proceedings. Jen says that she envisions a time when every pregnant person seeking VBAC has access to unbiased information, respectful providers and community sports they can plan the birth of their choice in the setting they desire. We are so thrilled that Jen Kamel is here. Welcome Jen, to the Evidence Based Birth® podcast.

Jen Kamel: Thank you so much for having me.

Rebecca Dekker: So Jen, we’ve known each other for a long time.

Jen Kamel: I know.

Rebecca Dekker: So this podcast is way overdue. We’re so excited you’re here. We’re thrilled you’re here to talk about VBAC. And I would love for you to share with our listeners, how you first started with your work as an advocate and educator in this field, and what inspired you to create VBAC Facts®?

Jen Kamel: Well, I was always curious about childbirth, even as a little girl. I loved reading any sort of books that I can find about childbirth and was simultaneously fascinated and a little bit scared as I think a lot of women are before they give birth. And so when I was pregnant with my first child, I planned a hospital birth with a certified nurse midwife and was planning an unmedicated vaginal delivery. And yet I also gave myself the permission to say, I’m just going to see how long I can go without an epidural. And if I want an epidural, I’m going to get an epidural.

But I just was really curious. What did labor feel like? Well, later in my pregnancy, I was about 26… Pardon me, 36, 37 weeks. My baby was breach and my midwife was, “I recommend you go have an external cephalic version and see if we can flip this baby.” And so she referred me out to the OB that she consulted with, and he was incredibly compassionate and knew I didn’t want to be seeing an OB because I wanted to midwifery care and I wanted a normal vaginal delivery. Well, we did the version, it didn’t work. And they handed me my cesarean paperwork. And I had my C-section.

And it’s funny because the operative report said, I tolerated the procedure and blah, blah, blah. But I think there is a whole emotional component that goes into having a cesarean that really only people who have had a C-section can really get. And my OB knew this was not the plan. And so I really appreciated when he planted that seed, that VBAC is an option for me. And I appreciated that because I walked out of that hospital knowing, okay, next time can be different.This time kind of sucked. This isn’t what I wanted, but next time can be different.

Well, I went onto the world and my friends and family expressed a lot of concern. They were, “I don’t understand aren’t you only supposed to have another C-section next. Isn’t it really dangerous for the baby? Don’t you want a healthy baby?” And so I experienced kind of the opposite of what a lot of people do because my OB planted this positive seed and I experienced a lot of concern from friends and family. And so that conflicting information really propelled me forward. And I realized how hard it was to find accurate information for parents, to find accurate information online.

And that really started my own personal journey. I learned how to find and evaluate medical studies. I assembled information for myself and then started answering questions online in these various VBAC groups I was in. Those are really great resources, but they’re a double edged sword because everyone is sharing information, but most people don’t have the larger context for what that information means. So I learned how to find and evaluate medical studies for myself.

I started assembling information and answering question online because it became crystal clear to me how many other parents around the world were struggling trying to find accurate information. So fast forward three and a half years later, I had my victorious VBAC and I started VBAC Facts® two weeks postpartum in 2007. And my VBAC, I came out of that, believing that there was nothing in this world that I couldn’t do.

And it really crystallized for me the tremendous injustice that happens every single day in our medical system, how much is stolen from people, how much is denied, how people are harmed, all the birth trauma, the loss of autonomy, the complications from cesareans that is just pushed under the rug. And I believe that people deserve better. They deserve transparency. They deserve ethical and respectful care and they deserve the facts. And so that’s really what VBAC Facts® was born from.

Rebecca Dekker: So how common it is VBAC, what are some basic statistics about this? Because you’re making it sound like it’s pretty hard for people to even attempt a VBAC much less get one, if you want one. So can you talk a little bit about how common they are and what some basic statistics are?

Jen Kamel: Yeah. Well, in the United States, only about 13% of people who have a prior cesarean go on to have a VBAC. The overwhelming majority have a repeat cesarean. And that’s for a variety of different reasons. They primarily, because they’re following the advice of their physician. And we have evidence that shows that if someone perceives their physician as supporting VBAC, they’re more likely to choose a VBAC.

But if someone perceives their physician supports a repeat cesarean, they’re more likely to have a repeat cesarean. And so that subtle bias, that subtle influence impacts the choices that people make. I would also argue that a lot of people don’t have access to the facts. They don’t understand what ACOG says, they don’t understand what the medical evidence says. And so it’s very easy for a physician who doesn’t attend VBAC to coerce people into repeat cesareans.

Rebecca Dekker: Okay. And when you say 13% of people who had a cesarean go on to have a VBAC the next time, that doesn’t mean there’s a 13% like success rate, right? It’s just.

Jen Kamel: Absolutely not. Yeah. I mean.

Rebecca Dekker: Okay. You explain the difference between a VBAC rate.

Jen Kamel: Yeah.

Rebecca Dekker: And a VBAC success rate?

Jen Kamel: Yeah. That’s a really great question. So it’s just a math question, right? So the VBAC rate is how many people who gave birth vaginally after a cesarean divided by the total number of people who birthed after a cesarean that year, and as opposed to a VBAC success rate. So that’s a little bit different. So that’s talking about how many people had a VBAC divided by how many people labored after a cesarean. So we’re looking at different numbers there. And the VBAC success rate, or VBAC odds. I kind of don’t like the word success.

So I try to find other ways so we can kind of move the judge away from VBAC. So VBAC odds are determined by a variety of different criteria. People who’ve had a prior vaginal delivery, or a prior VBAC have really high VBAC odds. People who had their cesarean for malpresentation or breach have really great VBAC odds. People who labored spontaneously have good VBAC odds. And so if you want to maximize your VBAC back odds, the number one thing is to hire a provider who is supportive of VBAC.

Truly supportive of VBAC not someone who’s just going to let you quote, try. And then you’re going to want to labor spontaneous. And then other things that are true with any vaginal delivery, like freedom of movement, being able to eat and drink, feeling safe. All of these factors are the same, whether you’ve had a prior cesarean or not. And I think that’s a really important point to make is that sometimes people think VBAC is its own category. And in some ways it is, and in some ways it’s just like a regular vaginal delivery.

Rebecca Dekker: Yeah. Although a lot of doctors and hospitals see a VBAC as a procedure, right?

Jen Kamel: Exactly.

Rebecca Dekker: Which is why they think they can deny it to people.

Jen Kamel: Exactly. Exactly.

Rebecca Dekker: But it’s actually just what happens to your body if you leave it to go on its own.

Jen Kamel: Exactly. Well, and that’s one of the things that we see when we look at research, looking at countries that have high VBAC rates versus low VBAC rates. And I actually want to chat about that later on in our interview, just looking at what are the differences between the culture of these countries. And one of those things is just a fundamental valuing of vaginal birth.

And I don’t think we have that here in the US. We don’t value vaginal birth. We’ve really denigrated it. We’ve acted like no one gets a medal. We’ve made people feel foolish for wanting to avoid surgery by saying all that matters is a healthy baby and on and on and on. And why can’t we just support the physiological, normal conclusion of a pregnancy?

Rebecca Dekker: Are there any other basic facts or statistics you want to share?

Jen Kamel: Absolutely. So one is that VBAC is a safe, reasonable and evidence-based choice. And what I mean when I say that is the American college of OB GYNs supports VBAC and encourages people to have access. And they do that because the evidence supports VBAC. So notion that VBAC is some alternative choice is completely false. VBAC is a mainstream choice. Another thing I’d love to share is that the risks associated with VBAC are low. Just like a repeat cesarean, most people will birth their baby with no complications.

I think it’s important for people to know that the risks of VBAC are often exaggerated and the risks of cesareans are minimized. People report often hearing throughout their pregnancy warnings of uterine rupture, continually being asked if they still want to plan a VBAC. I mean, these are all red flags. If someone is, if your clinician is talking to you like this, that means they don’t really support VBAC. Whereas people are often not in informed of the risks of cesareans, like the increasing risks of placental abnormalities.

I was just talking with someone today who’s now had four cesareans because her provider doesn’t support VBAC and her provider knows she wants to have more children. And yet now after four cesareans her providers, oh, well, you should be aware of accreta. Well, that’s a conversation that should happen after the first cesarean, after the second cesarean, after the third cesarean. We shouldn’t be adding that on afterwards, after you’ve had four cesareans. People should be just as know of on complications like accreta as they are about uterine rupture.

Rebecca Dekker: So can you explain to our listeners what is a uterine rupture and what is placenta accreta?

Jen Kamel: So a uterine rupture is when both layers of the uterus separate. And a placenta accreta is when the placenta abnormally attaches to the uterine wall. And the risk of a accreta developing increases as the number of prior cesareans increase. The fundamental difference between uterine rupture and placenta accreta is that placenta accreta is associated with higher rates of maternal mortality and morbidity, then uterine rupture.

And that’s something that is often not shared. When someone develops a placenta accreta, hopefully that’s diagnosed prenatally, it not always is, ideally they would go to a hospital that has the capability and the multidisciplinary team, as well as ample blood bank, in order to effectively manage an accreta and mitigate bad outcomes. Whereas a uterine rupture really, you need an obstetrician. You need an anesthesiologist. And if there’s excessive blood loss, you need a blood bank. You simply do not require the same level of staffing and resources to manage a uterine rupture than you do in accreta.

Rebecca Dekker: So with placenta accreta, you can have a cesarean now. The placenta accreta would happen in the next pregnancy potentially.

Jen Kamel: Exactly.

Rebecca Dekker: That’s when that risk would go up.

Jen Kamel: Exactly.

Rebecca Dekker: So by having a repeat now you’re minimizing the risk of uterine rupture, but you are increasing the risk of placental problems the next time you get pregnant. So it’s especially important for people who are planning larger families, correct, to consider that?

Jen Kamel: Yeah. Absolutely people. And that’s a really important question for providers to ask birthing people and for birthing people to ask providers, if they’re not bringing it up. What about placenta, accreta? How many children do you intend on having?

Rebecca Dekker: So tell us, you mentioned that there’s a lot of misinformation and coercion when you’re pregnant after a casserian and considering a VBAC. Can you talk a little bit about what are some of the top myths that we could debunk here today?

Jen Kamel: Well, I think one is this idea that very few people are really candidates for VBAC. And the truth is most people are candidates for VBAC. And that’s especially true after one cesarean, when the risks are lowest. Well, the risks increase when we have each prior cesarean. So if someone wants to plan a VBAC, their best odds and their lowest risks is after one cesarean. The challenge is, is once someone has two, three or four cesareans, and then they’re, oh, I really want to try for a VBAC now, it’s hard because the risks increase, the number of providers who are willing to attend those births dramatically decrease.

So that’s why we really focus on getting the facts to people as soon as possible. So that way, if they want to plan a VBAC for them to have that option after one cesarean when their risks are lowest. Another myth that I see all the time is that what ACOG says, there’s so many myths about what ACOG says. And one of them is ACOG says, you can only have three prior cesareans or ACOG says, you can only have a VBAC before three cesareans. And after that, you can’t have a VBAC. I think it’s really important to clarify that ACOG does not have an upper limit on the number of prior cesareans.

They don’t say you can only have so many cesareans, and they don’t say that you can’t have a VBAC after a certain number of cesareans. ACOG maintains that people have the right to make their own medical decisions include in situations of elevated risk. The VBAC calculator is also really problematic and that’s because racism is woven within our society and within how the calculator functions. And then the calculator feeds us back VBAC odds that are colored by racism, and that results in lower predicted VBAC odds for Black and Latin people. And we actually write a whole lot about the VBAC calculator at VBACfacts.com/calculator.

Rebecca Dekker: And the calculator is something that doctors and midwives will plug in values about you and your health and then it spits out a percentage of what they think your chances are of having a VBAC, correct?

Jen Kamel: Exactly. Exactly.

Rebecca Dekker: So if your chances are low, according to the calculator, the provider’s going to be, “I don’t really want to support your VBAC because it doesn’t look like you have a good chance anyways.”

Jen Kamel: Yeah.

Rebecca Dekker: Yeah.

Jen Kamel: But one of the things that we’ve seen, there’s been a couple different studies published about the VBAC calculators, and they’ve shown that VBAC calculators chronically under-predict VBAC odds, and that’s even more so for Latin people. So I think that’s a really important thing for people to hear. And even though the latest version of the VBAC calculator has eliminated race and ethnicity, it still under-predicts VBAC odds. And we talk about that at that VBACfacts.com/calculator for people who want to learn more.

Rebecca Dekker: So having a VBAC after multiple cesarean seems there’s a lot of misinformation floating around that saying that’s absolutely not allowed when in fact ACOG doesn’t really say anything about whether or not you can have one. And even if they did, ACOG’s guidelines may guide practice for physicians, but families are not bound by them. They’re not law. Right?

Jen Kamel: Exactly. Well, and let’s just talk about like VBAC after three cesareans. There isn’t a lot of evidence available on VBAC after three cesareans. We know from the research on multiple repeat cesareans that the risks of cesareans increase, but in terms of the risk of uterine rupture, we just don’t have that data. And that transparency simply does not trickle down to parents.

Parents are told things, oh, the risk of uterine rupture is 80%. We don’t have data on that. So I think it’s important to be clear on what we know and what we don’t. And when your provider says, oh, the risk of uterine rupture after three cesareans is X amount, the truth is we don’t have solid numbers on that. And the truth is also, like I said before, ACOG doesn’t have an upper limit and ACOG acknowledges that people have the right to make their own medical decisions.

Rebecca Dekker: Something else you said earlier struck a memory in me, you were talking about the operating room and the anesthesiologists and the OB GYN. And one reason VBAC rates are so low in the United States is a while ago, ACOG put out a statement, which they’ve since changed saying you could only have a VBAC or you should only have one. If there was immediate access to a surgeon and anesthesiologist in case there was uterine rupture. Can you talk a little bit about the fallout from that and what are the guidelines saying now?

Jen Kamel: Yeah. Well, back in 2004, ACOG used very specific language and basically said that you had to have staffing, surgical staffing available in order to offer VBAC. In their subsequent guidelines in 2010, that recommendation was removed. Now they still say the ideal setting is to have a surgical staff quote “Immediately available.” But ACOG never provided any definition for what that means. And so what has happened is hospitals across the country have interpreted that immediately available recommendation to mean a whole host of things.

Now, conventional wisdom says it means 24/7 anesthesia. But when we actually look at studies of VBAC policy hospital policy say in the state of California, which there was a big study published in 2013. And the state of California is where one in eight, all us births take place. So research looking at what happens in California gives us a pretty good indication of what could be happening nationwide. And what they found was is that hospitals define immediately available in a whole host of different ways.

And this notion that if a hospital has 24/7 anesthesia, they will automatically support VBAC, that is just not the case. In fact, one third of hospitals with 24/7 anesthesia in the state of California ban VBAC. So this isn’t a safety issue. This isn’t a staffing issue. This is an issue of who is motivated to follow the evidence and honor autonomy and who isn’t. Now, of course, that’s a hard argument to make. The public doesn’t like that.

So what we do is, is we say this is about safety. It’s not safe for us to offer VBAC. And as we are all raised to believe, hospitals and physicians want what is best for us, right? They’re following the evidence. There’s nothing else impacting how they practice. And so many people buy that. But when we pull back the veil on actually what is happening in hospitals, we see that people do not receive evidence based care. And that is also true among those who wish to labor after a cesarean.

Rebecca Dekker: And from my understanding is it’s actually a minority of hospitals that have 24/7 anesthesia. So there’s this conception that most hospitals could immediately do an emergency cesarean when that’s not the case in most hospitals in the US, correct, even just for a normal labor inverse?

Jen Kamel: Absolutely. Well, and that’s where we get to the VBAC double standard. It’s this idea that you need to do X, Y, Z, and we need to have XYZ staffing in order to safely attend VBAC and yet a regular vaginal delivery isn’t held to that same standard. And so that’s really how the risk of VBAC has been marketed not only to hospital administrators and clinicians, but also to the public. And so VBAC carries this cloud of risk. And therefore we have to do all these special things for VBAC. When in reality, I mean, having immediately available anesthesia would be ideal for any hospital that has a labor and delivery unit, but we know that cannot be a reality in the United States.

And Dr. David Bernbach presented on this at the 2010 national institutes of health VBAC conference. And he itemized why we have an anesthesiologist shortage in America. One of the reasons is because anesthesiologists are aging out, there are simply not enough people going into that specialty. So we do not have the raw number of anesthesiologists in order to staff all the hospitals we have across the US. The other thing is, is that not many people are too choosing that specialty. So physicians are not choosing to become anesthesiologist.

The other issue is, is that it’s expensive to have an anesthesiologist. So if you have a hospital that only has a hundred births a year, it’s very difficult for them to justify 24/7 anesthesia when they’re only having a hundred births a year. And so what Dr. David Bernbach said was that if we said every single hospital that offers labor and delivery has to have 24/7 anesthesia, we would have 75% of all labor and delivery units closed throughout the US. So that is not a solution.

That’s not a reality. And that’s one of the many data points that ACOG surely incorporated when they revamped their ACOG guidelines in 2017 and said that community hospitals, level one, hospitals should be offering VBAC. So I think that’s something that’s really important for people to hear, because it’s so easy for things to become more restrictive. And it’s so difficult for things to open up. And right now we’re asking for people to look to what ACOG says. ACOG is clear, level one hospital should be offering VBAC.

Rebecca Dekker: You’re so right. It’s so much easier to put restrictions in place than it is to create more freedoms. And COVID, the pandemic was a perfect example with that with hospitals shutting down to doulas and other birth options, and then being very slow to open back up, and some still have not allowed doulas back in. So there’s definitely a bias towards restrictions being easier. And VBAC Facts®, which is resources on your website. You talk a lot about how birthing people can prepare for a VBAC. Do you have any tips you want to briefly share about how people can prepare for a VBAC if that’s what they want?

Jen Kamel: Sure. Well, I think the very first thing is to process, truly process your cesarean birth. Some people come out of their cesarean birth with a lot of grief and a lot of sadness questioning whether their bodies are broken. I mean, these are all important emotions to process before you get pregnant again so you’re not carrying that with you into your subsequent delivery. So that would be my first thing. My second thing would be to learn the facts. And this is why it’s important to learn the facts. There is so much misinformation that will come to you from physicians, from friends and family.

And it can be really, really hard to know what is true and what isn’t, and it can really chip away at your confidence if people are constantly questioning you. And you’re, “I don’t know. I don’t know. I don’t know.” The third step is to choose your support team. And because you have now known the facts, you can now go interview various providers and be able to get a sense of how their practice aligns with the facts.

And choosing a provider is the most important thing that you will do during your pregnancy. Because the reality is they are going to be the ones to say, “Okay, now it’s time to call a cesarean. Your baby is in distressed.” And how do you really know? You don’t really know. So you have to have someone who you trust. Or the fourth step is to create your support system, your friends and family who really support you, who see you, who are going to be there, not worrying in the corner and learning how to say, “I don’t want to talk about that.”

Because there are going to be people who are going to follow you throughout your pregnancy and are going to quiz you and are going to want to question you again and again on why you’re making this quote “Risky choice.” And when you’re pregnant, it’s not time, unless you really want to, it’s not time to be defending your choices and educating the public. You really need to be thinking about what you need to be doing right now to have a peaceful pregnancy. And then my last tip is to take each moment as it comes.

A lot of people feel a lot of anxiety about whether they will need another cesarean. And I think going through all of these stem gives people the assurance that they have done everything they can. And part of what I talk a lot about in VBAC Facts® is the element of luck that’s at play at birth. And there are so many things that we can control and there are so many things that we can’t control. So being able to be kind to ourselves and have grace with ourselves, because if you need a repeat cesarean, if you are that person, that isn’t because your body is broken, it isn’t because you did anything wrong, it’s that sometimes cesareans are necessary.

Rebecca Dekker: So I assume you’re an advocate for not talking about a quote “Failed VBAC.”

Jen Kamel: Yeah. There’s so much loaded language in maternity care in general, but yeah. Failed feedback. That’s why we talk about labor after cesarean. I really like that phrase. I first heard it from Melissa Cheney and I love labor after cesarean versus trying for a VBAC. And I actually noticed earlier on, I used the word try for a VBAC.

And as soon as I said it, I was, ah. It’s so hard to eliminate that language from our vocabulary because it is so ingrained. But I really love labor after cesarean because there’s no judgment there, there is nothing tied to the outcome. It is talking about what you are doing. And no matter how your labor plays out, you chose to labor after a cesarean. There is power and agency in that decision. And to really feel that.

Rebecca Dekker: Yeah. I like that way of framing it. So I know you work a lot with expecting parents, but you also do a lot of teaching with birth professionals. What’s something you’d want more perinatal professionals to learn about with regard to VBAC?

Jen Kamel: Oh gosh. Well, we just completed a training on VBAC after two cesareans within professional membership. And I was surprised how much I learned. And then also the contrast again, between what the evidence says and what access to VBAC after two cesareans looks like. Only about, what was it, 2.9% of people in the state of California actually had a VBAC after two cesareans. It’s very, very, very low. And that’s why we advocate for people to have access to VBAC after one it’s cesarean, because access really does fall off a cliff after that. Now, if more people knew that facts about VBAC after two cesareans, I think that we would be able to increase access.

And I just want to share a couple of those quick facts. We talked a lot in the training about how the risk of VBAC after one cesarean versus two cesarean, it does increase after two. And the risk of VBAC after two cesareans versus a third cesarean, it is slightly higher with a VBAC after two cesareans. But as all of the major studies on this topic reiterate, the absolute risks are low. So we’re not talking about a tremendously high risk. We’re talking about yes, an elevated relative risk, but a low absolute risk. And so I think that is really important for people to hear coupled with the elevated risks that come with each prior cesarean.

Rebecca Dekker: What is the risk of uterine rupture if you labor after two prior cesareans?

Jen Kamel: So there’s been two now, two large studies. Those studies only included about a thousand people each. So we don’t have a ton of great research on this. One of those studies found that the risk of uterine rupture after two cesareans was 0.9%. And that wasn’t statistically different than the risk of uterine rupture after one cesarean. The other study found that the risk of uterine rupture increased from 0.9 to 1.8%.

And they did find that to be a statistically significant difference. So where’s the risk of rupture, is it 0.9? Is it 1.8? Another important factor is that one of those studies induced 35% of their total population. The other study induced over half. So those rates of uterine rupture are including induced and augmented labors. So the question really is, what would the risk be if people were laboring spontaneously? That is a question we do not have the answer to, but it would certainly be lower than 0.9 to 1.8.

Rebecca Dekker: Okay.

Jen Kamel: So that’s a really important thing for people to be considering when they’re looking at VBAC research is, did they induce people? What was the rate of induction? And did they separate out the spontaneous rate of uterine rupture? Most studies do, but some studies like these studies that have smaller sample populations don’t necessarily do that. So we have to remember that.

Rebecca Dekker: So the risk of uterine rupture goes up if you’re having your labor induced. So that’s why it’s important to know how many people are being induced in that study?

Jen Kamel: Exactly. Exactly.

Rebecca Dekker: Okay. What changes would you like to see happen in the field of perinatal work, birth work? You mentioned educating people about laboring after two prior cesareans. Is there anything else you think birth workers in particular need to be more educated on?

Jen Kamel: Yes. There is a whole host. It’s funny, I was thinking about this before our interview, and there is a whole host of things that I would love for people to know. I would love for people to know actually what ACOG’s guidelines say. And people can learn that you can go to VBACfacts.com/acog. And we talk about the highlights. I would love for people to understand actually what the evidence says. Because a lot of people don’t understand what the evidence says. I would love for people to understand the role of that non-medical factors play in this cloud of fear that follows VBAC.

Things like convenience, money, devaluing a vaginal delivery, litigation fears. I’d also love for people to know that there’s not one way to do something. I appreciate looking at how practice styles vary across the country and the world. Because as Eugene De Klerk has said many times, “Where there is variation, there is opera opportunity.” And so in this case, we’re talking about the opportunity for improvement, for improving maternity care and especially increasing access to VBAC. I would love perinatal professionals to understand how much our culture impacts VBAC rates.

And in fact, there was a really great 2019 study by Lundgren and colleagues, which looked at providers and clients in countries with high VBAC rates and what made those countries, what were the characteristics associated with high versus low VBAC rates? And the first one among high VBAC rates is that they generally that vaginal birth is the first choice. And the authors called this viewpoint vaginal birth as the obvious first choice. And the providers worked cooperatively to provide VBACs as a default, unless there is a medical reason for a repeat cesarean.

I mean, that’s a complete change of approach than what we see here in the US. Pregnant parents are also simply expected to birth vaginally, and that is the preferred choice for physical, emotional, and social reasons. Vaginal births are viewed as the safer, easier and appropriate option in low risk pregnancies. And I want you to remember that phrase, low risk pregnancies. Because cesarean is not even discussed as an option. And this is another a demonstration of how a history of cesarean is sometimes viewed as high risk as it is in our country and other times not.

And I so appreciate that complete change in perspective because so many people here in the US with a cesarean scar, just think they’re high risk. And I want to challenge you with this notion that in other countries you would not be considered a high risk birth. So a previous cesarean alone was not considered risky. Now in low VBAC countries like the US, the opposite was true. A VBAC is viewed as possible, but that it was dependent on a variety of factors.

Providers in pregnant parents expressed that everyone involved must be in support of a VBAC and that the pros and cons of cesarean and vaginal births should be discussed and considered. The other theme the authors discovered was that there was a difference between viewing VBAC as ordinary care versus special care. In high VBAC countries, VBAC is just a normal part of pregnancy care. Although providers may offer a few you more precautions for pregnant parents with a history of cesarean, the remainder of care is the same as any other pregnant person.

So the providers support by motivating, increasing confidence, positivity, and providing extra support and care at the labor stage where the previous cesarean occurred. And parents reflect that this positive routine care with calm and confident providers affects how they feel about their own births. Now let’s counter that to countries with low rates of VBAC like the US providers and pregnant parents view VBACs as special and needing specialized care, both believe that special hospitals, which we were just talking about or areas on the hospitals, how you need extra provider training and a special level of trust was needed between providers and pregnant parents. I mean, this contrast is stark. 

So what this study tells us is that changing the VBAC rate depends largely on the structures within which the parents’ birth options are defined the structures and the professionals in it work towards a unified pro VBAC culture which improves VBAC rates. And while it is true that an individual desire for VBAC affects whether someone has a repeat cesarean or a VBAC their desire for a VBAC is influenced by the surrounding culture. So when VBAC is the assumed default, more VBACs are wanted and achieved. And in places where fewer VBACs the decision making process around the mode of birth is complex and layered.

And it often involves evidence that is changing or induces stress for parents. So I would love to see every single hospital that has an L and D unit offering VBAC as ACOG recommends. I would love to see community VBAC a with midwives, more available across the country. I’d love to see integration of midwives into the healthcare system. I would love to see elevating outcomes over ego and competition. And when I say that, I think specifically about when midwives transfer to hospitals, when advanced care is needed.

I dream of a world when birthing people receive accurate honest information from any physician that they speak to, a place where resources for clinicians to process trauma are easy and available, but ultimately I would love to move the focal point of power and responsibility from the provider to birthing parents, which I think would also mitigate lawsuits, which is a whole nother longer topic for another day likely.

Rebecca Dekker: So what are some of the countries where there are high VBAC rates?

Jen Kamel: Scandinavian countries have higher VBAC rates.

Rebecca Dekker: Okay.

Jen Kamel: I mean, we’re looking at countries that are ultimately, they just have a completely different approach to healthcare, which I think is really foreign for a lot of US people to wrap their brains around.

Rebecca Dekker: And they’re largely midwife driven care in those countries.

Jen Kamel: exactly.

Rebecca Dekker: So.

Jen Kamel: Exactly.

Rebecca Dekker: So I think it’s interesting. You said it’s typically presented as VBAC is the default choice, and you almost have to get permission to have surgery, whereas in the US, it’s the opposite. We say, it’s your choice, but they kind of often don’t really give you a choice because they’re coercing and pressuring you into having a repeat cesarean. Is that kind of what the research is showing?

Jen Kamel: Well, I would say in the US, it’s not even presented as a choice. In the US, I think the informed consent conversation looks a lot like this. Someone comes in with a prior cesarean, the OB says, oh, I see you’ve had a prior cesarean. So we’re going to schedule your C-section for this date because that’s, what’s best for you and your baby. And the person says, okay. That’s the beginning of the end of it.

Rebecca Dekker: Yeah.

Jen Kamel: I mean, people don’t get real information and their provider who they trust is telling them that I think this is the best choice for you. And so that’s what people go along with.

Rebecca Dekker: Interesting. Okay. So that’s what we typically see in the US, even though they say there’s a choice that it really repeats Darren is the default choice that’s presented. And some people are even asked to schedule their cesarean in the first trimester.

Jen Kamel: Absolutely.

Rebecca Dekker: In the first trimester you’re asked to schedule it. Yeah.

Jen Kamel: Yeah. Even the first appointment. I mean, that seed is planted and fertilized and roots that entire pregnancy of a repeat cesarean is your only choice if you care about your baby. If you don’t care about your baby, then you can always consider this risky thing about VBAC but for people who care about their baby and want the safest choice, it’s the repeat cesarean.

Rebecca Dekker: So it sounds like a red flag. If you’re wanting a VBAC and in your very first prenatal appointment, they want to schedule your cesarean.

Jen Kamel: It is absolutely a red flag. Absolutely.

Rebecca Dekker: So at VBAC Facts®, I know you have a lot going on. Do you have any current projects or upcoming projects that we should look out for?

Jen Kamel: Well, we just had that training on VBAC after two cesareans and I went to my membership.

Rebecca Dekker: And this is in. Yeah. The VBAC Facts® professional membership. I just want to.

Jen Kamel: Yes.

Rebecca Dekker: Clarify that.

Jen Kamel: Yes.

Rebecca Dekker: Okay. Yeah.

Jen Kamel: Yes. Which is available at VBACfacts.com/membership. And so we just had this training, this two hour training on VBAC after two cesareans. And I went to the membership and I said, what do you guys want next? And people said, we want to handout that we can give our patients of VBAC after two cesarean. So that’s what we’re working on right now is developing a beautiful two page handout that summarizes all of the evidence on VBAC after two cesareans that our members can give to their patients and they can easily and quickly and reliably get up to speed on the facts so they can decide what’s best for them.

Rebecca Dekker: Awesome. And I see on your homepage VBACfacts.com, you’ve got a couple of free downloads for parents as well. One about debunking uterine rupture myths, and secrets to planning a VBAC.

Jen Kamel: Yes. And we also have another one that debunks common VBAC myths using language directly from ACOGs VBAC guidelines. I really love that one. That’s at VBACAfacts.com/VBACmyths.

Rebecca Dekker: Awesome. Well, thank you so much, Jen, for coming on the podcast today. We appreciate all the work you do to get the evidence out there about VBAC. I know our, our missions are very much in alignment between Evidence Based Birth® and VBAC Facts®. So we thank you for sharing your knowledge with our listeners.

Jen Kamel: Thank you so much for having me. It was a great time.

Rebecca Dekker: Today’s podcast was brought to you by the Evidence Based Birth® professional membership. The free articles and podcasts we provide to the public are supported by our professional membership program at Evidence Based Birth®. Our members are professionals in the child birth field who are committed to being change agents in their community. Professional members at EBB get access to continuing education courses with up to 23 contact hours, live monthly training sessions, an exclusive library of printer friendly PDFs to share with your clients and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans as well as scholarships for students and for people of color to learn more, visit ebbirth.com/membership.