NIH panel on VBAC, or: Give me liberty

Recently the National Institutes of Health convened a panel to examine the "issue" of vaginal birth after Cesarean (VBAC). Evidence was reviewed, testimonies heard, and a consensus statement released.

While cautiously optimistic that the issue was being reviewed at all, birth advocates had reasons to be concerned.

First, in 2006, a similar panel convened regarding the issue of Cesarean delivery on maternal request (CDMR). What they found was that there was "inadequate evidence to recommend for or against." Which is ridiculous, really, given that the risks of Cesarean to mother and baby are well documented, and they become even clearer particularly when there's not a potential medical indication and therefore benefit (such as resolving fetal distress, interrupting an obstructed labor, etc). So basically, they treated a natural process as having no greater weight than a surgical one and so came out stating that the scales were balanced. The ridiculous presumptiousness of assuming that they know everything there is to know about human labor and birth, that its impact on mother and baby and family and society at the time of birth and forever after is able to be scientifically measured and accounted for--and that even if it were, that the choice is theirs to make-- is outweighed only by the fact that in the case of debating VBAC, vaginal birth (which will happen, come hell or high water, as the natural end of a full-term pregnancy) is treated as the "intervention," something to be "done" as that which needs to be justified, while surgical delivery is treated as the control--the status quo, the "innocent until proven guilty." You can read more on the limitations of that panel's decision here.

Anyway. Henci Goer very cogently articulated the concerns going into the VBAC panel here. The Unnecessarean takes up the other end by articulating the concerns coming out of it. Both are very much worth reading, as are the comments; they contain a good deal of backstory on the lengths that doctors and courts are willing to go to in order to maintain control over birthing women's choices (some particularly sickening facts of court-ordered Cesarean cases, in paritcular), and one commenter shares the following quote from Sheila Kitzinger:

No one would deny that each infant and particularly every maternal death is tragedy to be prevented if at all possible, nor that modern obstetric care, which has developed in the hospital setting, has been at least partly responsible for the dramatic decrease in both maternal and peri-natal mortality over the past half century. But it is not necessarily perverse to question whether our present priority should be to reach minimum figures for peri-natal mortality at any price when this includes giving up things which free human beings have often felt to be more important than their own survival- such as freedom to live their own lives their own way and to make individual choices in line with their own sense of values.

Living out here as we do, in Virginia--home of liberty and rebellion in two major wars, the Revolutionary and the Civil War (not to wander too off-topic, but we recently watched Gettysburg and I was amazed to realize that far from what I learned in history, the Civil War was not about "OMG The South is racist," because the north was, too; it was about whether or not the states had the right to withdraw from a federal government making decisions they didn't feel were in their best interest. I'm inclined to believe that the founders intended that they SHOULD have this right, and so the whole outcome, viewed through that light, feels completely different to me) --I'm struck by the fact that this is exactly what "Give me liberty or give me death" MEANS. It doesn't have to mean death at the hands of the British army--it might mean facing down the (albeit very small) risk of a uterine rupture. Or the right to refuse chemotherapy. Or drink raw milk, or refuse vaccination. People have chosen the risks of freedom over the "safety" of relative captivity here for a long time ("ships are safe in harbor, but that's not what ships are for"), and parents have long been accepted as the proxy decisionmakers for their children, able to elect for one or the other on behalf of those too young to make the decision themselves, but this right is quickly being eroded, now beginning before birth.

So basically, while a small battle or two was somewhat won (recommending that ACOG drop its strict recommendation that only facilities with "immediately available" operating room personnel "perform" VBAC), the war (having any power to compel them to do so, plus the greater--central-- issue of a pregnant woman's right to what essentially amounts to constitutional personhood and self-determination--ie, informed refusal of surgery without regard to whether her physician "feels she is a good candidate") was not.

So. Henci Goer's signature line contains the quote below, which sums up the reaction to this latest news:

“You are not required to complete the work, nor are you free to cease from it.”
Pirke Avot 3:18

Let the work go forward.