Advice for Pregnant Women about
C-Section, Vaginal Birth and
Vaginal Birth After Cesarean (VBAC)
From Maternity Center Association
The Maternity Center Association (MCA) is the oldest national advocacy group working to improve maternity care in the U.S. MCA works with women and health professionals to promote safe and effective maternity care.
MCA's advice to women about different ways of giving birth
As early as possible in pregnancy:
learn about c-section and vaginal birth: c-section offers important benefits in selected circumstances; however, without a clear, well-supported reason for having this surgical procedure, vaginal birth is likely to be far safer for mothers and babies
set your goals, considering what you learn and your values and preferences
take action to help reach your goals.
For help with all three steps, see resources on this website:
Your choice of maternity caregiver and place of birth may be the most important thing you can do to influence the care that you will receive. "Practice style" varies widely. Choose wisely, and be sure that you will get support for your goals. A provider's caution about use of cesarean and a rate well below the national average (well below 30%) are good signs. Enthusiasm for c-sections and a rate around or above the national average are cause for concern (apart from a high-risk specialist caring primarily for mothers and babies with very serious problems).
The booklet What Every Pregnant Woman Should Know About Cesarean Section (PDF) can help you set and reach your goals. It has a section with many tips to help you avoid an unnecessary c-section and have a safe vaginal birth. If this is your goal, it is important to become informed as early as possible and make and carry out your plans due to the current climate where more and more cesareans are being performed.
For most pregnant women who had a c-section in the past, a vaginal birth after cesarean (VBAC) is a reasonable choice. If this is your goal, it is very important to become informed as early as possible, plan ahead and put care arrangements into place. To learn more, decide and take action, see Should I choose VBAC or repeat c-section?.
You may have heard that vaginal birth is harmful, and a c-section will prevent incontinence later in life. There are many problems with this line of thinking. Before undergoing major abdominal surgery for this reason, get the facts:
These facts are presented by
the ICEA Cesarean Options committee with the
hope that parents, childbirth educators, nurses,
midwives and doctors together can effectively
reduce the rate of unnecessary cesarean sections
and consequently, their effects.
A cesarean section
is major abdominal surgery. When
a cesarean is necessary, it can be
a life saving technique for both
mother and infant.
The World Health
Organization (WHO) states that no
region in the world is justified
in having a cesarean rate greater
than 10 to 15 percent.
In the past twenty
years, the cesarean section rates
have nearly quintupled in the US
to 23.8% in 1989 and nearly quadrupled
in Canada to 18.3% in 1987-8.
A cesarean section
poses documented medical risks to
the mother's health, including infections,
hemorrhage, transfusion, injury to
other organs, anesthesia complications,
psychological complications, and
a maternal mortality two to four
times greater than that for a vaginal
An elective cesarean
section increases the risk to the
infant of premature birth and respiratory
distress syndrome, both of which
are associated with multiple complications,
intensive care and burdensome financial
costs. Even mature babies, the absences
of labor increases the risk of breathing
problems and other complications.
Cesareans can delay
the opportunity for early mother-newborn
interaction, breastfeeding and the
establishment of family bonds.
In the US and Canada,
over one-third of all cesareans are
repeat cesareans. The American College
of Obstetricians and Gynecologists
(ACOG) recommends that the concept
of routine repeat cesarean be replaced
by a specific indication for surgery,
and that most women can be counseled
and encouraged to labor and have
a vaginal birth after a cesarean
In 1989, 81.5% of
all US women with a previous cesarean
had a repeat cesarean. The VBAC rate
was 18.5%. The VBAC rate is greater
in every eastern and western European
The "once a
cesarean, always a cesarean rule
is outdated now that most of uterine
incisions are low and horizontal
and the risk of rupture of the old
scar is almost nonexistent. A review
of all VBAC literature from 1985-1990
found a rupture rate of 0.22% for
low transverse scars in 22,000 planned
labors after cesarean. (In developed
nations the rupture rate was 0.18%.)
By comparison, the incidence of other
childbirth emergencies, such as prolapsed
cord, placental separation, or sudden
fetal distress is 1-3%.
ACOG states that
the hospital requirements for VBAC
are the same standards for all obstetrics.
These include the capacity to respond
to acute obstetric emergencies by
performing a cesarean within 30 minutes.
However, many hospitals in North
America that offer maternity care
do not allow or encourage women to
labor and have a VBAC.
In a review of all
the medical reports published on
VBAC from 1926-1990, 75% of all women
who planned labor after a cesarean
gave birth vaginally. Several medical
studies record VBAC rates of over
The latest statistics
indicate that 967,000 cesareans were
performed in the US in 1989. The
Public Health Citizen's Research
Group estimates that over one-half
the cesareans performed in 1987 were
unnecessary and resulted in 25,00
serious infections, 1.1 million extra
hospital days and a cost of over
$1 billion. About 500 women a year
die from bleeding, infections and
other complications of cesarean sections,
although these may be related to
the reasons the operation was performed
and not just to the procedure itself.
A cesarean costs
nearly twice as much as a vaginal
birth ($7,186 average vs. $4,334
average in 1989 in the US). It has
been estimated that in Quebec, Canada,
if the current rate of cesareans
(18.8%) were reduced to that of Finland
(11.9%), costs incurred by the provincial
health care system could be reduced
approximately $19 million per year.
The four most common
medical causes contributing to the
increase in cesarean section rates
in North America are: routine repeat
cesareans; dystocia (non-progressive
labor); breech presentation; and
fetal distress. Some reports suggest
that more careful diagnosis and management
of dystocia could halve the primary
section rate. Combined with fewer
cesareans for breech presentation
(along with more cephalic versions),
careful diagnosis of fetal distress
and active encouragement of VBAC,
these efforts have resulted in lowering
cesarean rates to less than 12% in
various parts of the world.
Up to 77% of women
for whom the indication for cesarean
delivery was a non-progressive labor
(sometimes diagnosed as cephalopelvic
disproportion or CPD) and who tried
labor again, had a VBAC for a subsequent
birth. Approximately one-third of
these women gave birth to babies
that were larger than their previous
ACOG states that
a woman with two or more previous
cesareans deliveries with low transverse
incisions who wishes to plan a VBAC
should not be discouraged from doing
so in the absence of contraindications.
Cesarean rates are
influenced by non-medical factors.
Rates are higher for women who have
private medical insurance, are private
rather than public clinic patients,
are older, are married, have higher
levels of education and are in a
higher socio-economic bracket.
In 1989, a medical
study done in Houston, Texas, concluded
that epidural analgesia is associated
with significant increases in the
incidence of cesarean section for
dystocia in women having their first
are sometimes performed for other
than maternal or fetal well-being,
such as avoidance of patient pain,
patient or provider convenience,
provider legal concerns or provider
Although rare, there
have been reports of court-ordered
cesareans performed on women against
their will. One such case was appealed,
supported by 118 US organizations,
claiming that the decision was unconstitutional
and raises complex legal, moral and
religious issues. The appeal judge
issued a forceful decision asserting
that "in virtually all cases
the question of what is to be done
is to be decided by the patient -the
pregnant woman- on behalf of herself
and her fetus."
In March 1990, an
ACOG survey of 2,213 obstetricians
documented the changing attitude
about VBAC in the US. The survey
reported that women under the care
of younger physicians and physicians
in practice for fewer years were
more likely to accept the option
of VBAC than women under the care
of older physicians and those in
practice the longest.
Of 11,814 women
admitted for labor and delivery and
attended by midwives to 84 free standing
birth centers in the US, 15.8% were
transferred to the hospital and 4.4%
had a cesarean section. Although
the women were lower than average
risk of a poor pregnancy outcome,
their cesarean rate is one-fifth
of the national average.
Rate Rises to Highest Ever
Reported in the United States
• More than one fourth
of all children born in 2002
were delivered by cesarean;
the total cesarean
delivery rate of 26.1 percent
was the highest level ever reported
in the United States. The cesarean
delivery rate declined during
the late 1980s through the mid-1990s
but has been on the rise since
• The number of cesarean
births to women with no previous
cesarean birth jumped 7%.
• The rate of vaginal
births after previous cesarean
delivery (VBACs) dropped 23%.
Has this resulted in better
outcomes for mothers and babies?
• Infant Mortality: The
US ranks 28th in infant mortality
among industrialized nations
Czech Republic and Cuba) as
of 1998 (most recent numbers
available). (Child Health
Maternal Child Health Bureau,
Health Resources and Services
Administration, US Department
of Health and Human Services
• Maternal Mortality:
In 1999, the US ranked 21st
in the world for maternal death.
CDC estimates that maternal
deaths are underreported by
one half to two thirds, and
that half of
US maternal deaths are preventable.
The rate of death due to childbirth
has not decreased since
1982, and increased in 1999.
(Ina May’s Guide to Childbirth.
Ina May Gaskin. Bantam, 2003.
What is a reasonable
cesarean section rate? Only
10 to 15%!
“… the World Health
Organization concluded that
… there was no justification
for any region to have a
cesarean rate more than 10 to
15 percent (58). As for midwives,
in looking at six studies of
hospital-based midwives, all
but one study reported rates
of 10 percent or less, while
of 29 studies of midwives attending
births outside of the hospital,
none reported a cesarean rate
over seven percent (20).”
(Cesarean section: What you
need to know. Henci Goer http://www.parentsplace.com/print/0,,241096,00.html)
QUADRUPLES THE RISK OF MATERNAL DEATH FOR IMMEDIATE RELEASE
October 1, 2003
Contact: Rae Davies, Executive Director
Phone: (888) 282-CIMS Fax: (904) 285-2120
The Coalition for Improving Maternity
Services views with alarm a recent study showing
that U.S. women having cesarean sections are
four times more likely to die compared with
women having vaginal births.1 Investigators
reported a maternal death rate of 36 per 100,000
cesarean operations versus 9 per 100,000 vaginal
births. This is the difference attributable
to the surgery itself, not any complications
that might have led to the need for surgery.
Based on calculations of what constitutes a
reasonable cesarean rate versus the actual
U.S. cesarean rate,* 135 women die every year
as a result of having surgery they did not
Moreover, the difference in
mortality rates between cesarean section and
vaginal birth is almost certainly larger than
it appears. Investigators only considered deaths
occurring up to 1 year after delivery. Some
surgically-related deaths—scar tissue
causing a twisted bowel, for example—may
occur after the 1-year cut-off.
In a press release entitled
“Weighing the Pros and Cons of Cesarean
Delivery,” the American College of
Obstetricians and Gynecologists offered the
theory that cesarean section benefits mothers
by protecting against pelvic floor prolapse
as a counterbalance to the fact that it was
associated with an increased maternal death
rate.2 The research, however, does not support
this theory. While some studies do report a
short-term benefit with cesarean section for
a few women,3 none find long-term differences
in symptoms resulting from pelvic floor weakness
or injury to maternal tissues.3-7 Other studies
report considerable percentages of women with
urinary or bowel problems in the early weeks
and months after cesarean surgery.8-9
The finding that cesarean section
offers no long-term advantages holds true even
without taking into account that many features
of standard obstetric management cause or contribute
to weakness or damage, and the use of these
features could be greatly reduced or eliminated.
These include episiotomy, fundal pressure (pushing
down on the woman’s belly to expel the
baby), vacuum extraction, forceps delivery,
and how and in what positions women are directed
to push.10 Indeed, the ACOG press release acknowledges
that vaginal instrumental delivery produces
the worst results. Epidural analgesia also
contributes indirectly by increasing the need
for vaginal instrumental delivery and episiotomy.11-12
Had women birthing vaginally received optimal
care, the incidence of pelvic floor laxity
and genital injury would likely have been much
CIMS contends that reducing
the use of injurious practices would do far
more to improve maternal health and well-being
than substituting major abdominal surgery.
Increased risk of maternal death is but one
of the many hazards of cesarean section. (See
CIMS fact sheet, The Risks of Cesarean Delivery
to Mother and Baby.)
*The 2002 cesarean rate was 26%.
This means that about one million of the 4
million U.S. women giving birth every year
have cesarean sections.13 The World Health
Organization recommends no more than a 10%
to 15% cesarean rate.14 If the U.S. cesarean
rate were halved, 500,000 fewer women annually
would have had cesarean sections. The death
rate among them would have been 9 per 100,000
(45 women) rather than 36 per 100,000 (180
women) – a difference of 135 lives.
1. Harper MA et al. Pregnancy-related death
and health care services. Obstet Gynecol 2003;102(2):273-8.
2. ACOG. Weighing the pros and cons of cesarean
delivery. ACOG News Release, Jul 31, 2003.
Access at: http://www.acog.org/from_home/publications/press_releases/nr07-31-03.cfm
3. Rortviet G et al. Urinary incontinence after
vaginal delivery or cesarean section. N Engl
J Med 2003;348:900-7.
4. Gordon H and Logue M. Perineal muscle function
after childbirth. Lancet 1985;2:123-5.
5. MacLennan AH et al. The prevalence of pelvic
floor disorders and their relationship to gender,
age, parity and mode of delivery. Br J Obstet
6. Nygaard IE, Rao SSC, and Dawson JD. Anal
incontinence after anal sphincter disruption:
a 30-year retrospective cohort study. Obstet
7. Viktrup L et al. The symptom of stress incontinence
caused by pregnancy or delivery in primiparas.
Obstet Gynecol 1992;79(6):945-9.
8. Declercq ER et al. Listening to Mothers:
Report of the First National U.S. Survey of
Women’s Childbearing Experiences. New
York: Maternity Center Association, Oct 2002.
9. Lydon-Rochelle MT, Holt VL, and Martin DP.
Delivery method and self-reported postpartum
general health status among primiparous women.
Paediatr Perinat Epidem 2001;15:232-40.
10. Goer H. Preserving pelvic floor, genital,
and anal sphincter integrity in childbirth:
elective cesarean is not the solution. Medscape
Ob/Gyn & Women’s Health 2003, in
11. Carroll TG et al. Epidural analgesia and
severe perineal laceration in a community-based
obstetric practice. J Am Board Fam Pract 2003;16(1):1-6.
12. Robinson JN et al. Epidural analgesia and
third- or fourth-degree lacerations in nulliparas.
Obstet Gynecol 1999 B;94(2):259-62.
13. Hamilton BE, Martin JA, and Sutton PD.
Births: preliminary data for 2002. Nat Vital
Stat Rep 2003;51(11).
14. World Health Organization. Appropriate
technology for birth. Lancet 1985;2(8452):436-437.
P.O. Box 2346¦ Ponte Vedra Beach, FL
Stillbirth after Cesarean:
Since the famous Gordon Smith article in the Lancet in 2003* that analyzed 120,000 singleton second births, it is well-known that a previous cesarean section causes an unexplained stillbirth - in the next pregnancy in 1 in 1000 pregnancies. Women are not informed of this fact when they sign the consent for cesarean section.
Since there are 1 million cesareans per year in America, all of them lacking proper informed consent, I am looking for women who are willing to join a class-action suit for damages that resulted from lack of informed consent.
Conservatively, 120,000 women have another pregnancy after the cesarean, which results in 120 unexplained stillbirths (not the result of birth defects, diabetes, high blood pressure, etc.) in America per year. Even 10 or 20 angry women with unexplained stillbirths following a cesarean will compose an impressive class-action suit.
I am hoping to interest women who have experienced stillbirth after cesarean in joining a class-action suit that will change the current trend of increasing cesareans (27.6% in 2003) or at least improve informed consent.