A vaginal birth after caesarean (known as a VBAC) is when a woman who has had a caesarean has a vaginal birth down the track.

In Australia, about 12% of women have a vaginal birth for a subsequent baby after a caesarean. A VBAC is much more common in some other countries, including in several Scandinavian ones, where 45-55% of women have one.

So what’s involved? What are the risks? And who’s most likely to give birth vaginally the next time round?

What happens? What are the risks?

When a woman chooses a VBAC she is cared for much like she would during a planned vaginal birth.

However, an induction of labour is avoided as much as possible, due to the slightly increased risk of the caesarean scar opening up (known as uterine rupture). This is because the medication used in inductions can stimulate strong contractions that put a greater strain on the scar.

In fact, one of the main reasons women may be recommended to have a repeat caesarean over a vaginal birth is due to an increased chance of her caesarean scar rupturing.

This is when layers of the uterus (womb) separate and an emergency caesarean is needed to deliver the baby and repair the uterus.

Uterine rupture is rare. It occurs in about 0.2-0.7% of women with a history of a previous caesarean. A uterine rupture can also happen without a previous caesarean, but this is even rarer.

However, uterine rupture is a medical emergency. A large European study found 13% of babies died after a uterine rupture and 10% of women needed to have their uterus removed.

The risk of uterine rupture increases if women have what’s known as complicated or classical caesarean scars, and for women who have had more than two previous caesareans.

Most care providers recommend you avoid getting pregnant again for around 12 months after a caesarean, to allow full healing of the scar and to reduce the risk of the scar rupturing.

National guidelines recommend women attempt a VBAC in hospital in case emergency care is needed after uterine rupture.

During a VBAC, recommendations are for closer monitoring of the baby’s heart rate and vigilance for abnormal pain that could indicate a rupture is happening.

If labour is not progressing, a caesarean would then usually be advised.

Why avoid multiple caesareans?

There are also risks with repeat caesareans. These include slower recovery, increased risks of the placenta growing abnormally in subsequent pregnancies (placenta accreta), or low in front of the cervix (placenta praevia), and being readmitted to hospital for infection.

Women reported birth trauma and post-traumatic stress more commonly after a caesarean than a vaginal birth, especially if the caesarean was not planned.

Women who had a traumatic caesarean or disrespectful care in their previous birth may choose a VBAC to prevent re-traumatisation and to try to regain control over their birth.

We looked at what happened to women

The most common reason for a caesarean section in Australia is a repeat caesarean. Our new research looked at what this means for VBAC.

We analysed data about 172,000 low-risk women who gave birth for the first time in New South Wales between 2001 and 2016.

We found women who had an initial spontaneous vaginal birth had a 91.3% chance of having subsequent vaginal births. However, if they had a caesarean, their probability of having a VBAC was 4.6% after an elective caesarean and 9% after an emergency one.

We also confirmed what national data and previous studies have shown – there are lower VBAC rates (meaning higher rates of repeat caesareans) in private hospitals compared to public hospitals.

We found the probability of subsequent elective caesarean births was higher in private hospitals (84.9%) compared to public hospitals (76.9%).

Our study did not specifically address why this might be the case. However, we know that in private hospitals women access private obstetric care and experience higher caesarean rates overall.

What increases the chance of success?

When women plan a VBAC there is a 60-80% chance of having a vaginal birth in the next birth.

The success rates are higher for women who are younger, have a lower body mass index, have had a previous vaginal birth, give birth in a home-like environment or with midwife-led care.

For instance, an Australian study found women who accessed continuity of care with a midwife were more likely to have a successful VBAC compared to having no continuity of care and seeing different care providers each time.

An Australian national survey we conducted found having continuity of care with a midwife when planning a VBAC can increase women’s sense of control and confidence, increase their chance to be upright and active in labour and result in a better relationship with their health-care provider.

Why is this important?

With the rise of caesareans globally, including in Australia, it is more important than ever to value vaginal birth and support women to have a VBAC if this is what they choose.

Our research is also a reminder that how a woman gives birth the first time greatly influences how she gives birth after that. For too many women, this can lead to multiple caesareans, not all of them needed.

Hannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney University; Hazel Keedle, Senior Lecturer of Midwifery, Western Sydney University, and Lilian Peters, Adjunct Research Fellow, Western Sydney University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

The death of premature twins in Byron Bay in an apparent “wild birth”, or free birth, last week has prompted fresh concerns about giving birth without a midwife or medical assistance.

This follows another case from Victoria this year, where a baby was born in a critical condition following a reported free birth.

It’s unclear how common free birthing is, as data is not collected, but there is some evidence free births increased during the COVID pandemic.

Planned home births also became more popular during the pandemic, as women preferred to stay away from hospitals and wanted their support people with them.

But while free births and home births might sound similar, they are a very different practice, with free births much riskier. So what’s the difference, and why might people opt for a free birth?

What are home births?

Planned home births involve care from midwives, who are registered experts in childbirth, in a woman’s home.

These registered midwives work privately, or are part of around 20 publicly funded home birth programs nationally that are attached to hospitals.

They provide care during the pregnancy, labour and birth, and in the first six weeks following the birth.

The research shows that for women with low risk pregnancies, planned home births attended by competent midwives (with links to a responsive mainstream maternity system) are safe.

Home births result in less intervention than hospital births and women perceive their experience more positively.

What are free births?

A free birth is when a woman chooses to have a baby, usually at home, without a registered health professional such as a midwife or doctor in attendance.

Different terms such as unassisted birth or wild pregnancy or birth are also used to refer to free birth.

The parents may hire an unregulated birth worker or doula to be a support at the birth but they do not have the training or medical equipment needed to manage emergencies.

Women may have limited or no health care antenatally, meaning risk factors such as twins and breech presentations (the baby coming bottom first) are not detected beforehand and given the right kind of specialist care.

Why do some people choose to free birth?

We have been studying the reasons women and their partners choose to free birth for more than a decade. We found a previous traumatic birth and/or feeling coerced into choices that are not what the woman wants were the main drivers for avoiding mainstream maternity care.

Australia’s childbirth intervention rates – for induction or augmentation of labour, episiotomy (cutting the tissue between the vaginal opening and the anus) and caesarean section – are comparatively high.

One in ten women report disrespectful or abusive care in childbirth and some decide to make different choices for future births.

Lack of options for a natural birth and birth choices such as home birth or birth centre birth also played a major role in women’s decision to free birth.

Publicly funded home birth programs have very strict criteria around who can be accepted into the program, excluding many women.

In other countries such as the United Kingdom, Netherlands and New Zealand, publicly funded home births are easier to access.

Only around 200 midwives provide private midwifery services for home births nationally. Private midwives are yet to obtain insurance for home births, which means they are risking their livelihoods if something goes wrong and they are sued.

The cost of a home birth with a private midwife is not covered by Medicare and only some health funds rebate some of the cost. This means women can be out of pocket A$6-8,000.

Access to home birth is an even greater issue in rural and remote Australia.

How to make mainstream care more inclusive

Many women feel constrained by their birth choices in Australia. After years of research and listening to thousands of women, it’s clear more can be done to reduce the desire to free birth.

As my co-authors and I outline in our book, Birthing Outside the System: The Canary in the Coal Mine, this can be achieved by:

• making respectful care a reality so women aren’t traumatised and alienated by maternity care and want to engage with it
• supporting midwifery care. Women are seeking more physiological and social ways of birthing, minimising birth interventions, and midwives are the experts in this space
• supporting women’s access to their chosen place of birth and model of care and not limiting choice with high out-of-pocket expenses
• providing more flexible, acceptable options for women experiencing risk factors during pregnancy and/or birth, such as having a previous caesarean birth, having twins or having a baby in breech position. Women experiencing these complications experience pressure to have a caesarean section
• getting the framework right with policies, guidelines, education, research, regulation and professional leadership.

Ensuring women’s rights and choices are informed and respected means they’re less likely to feel they’re left with no other option.

Hannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney University

This article is republished from The Conversation under a Creative Commons license. Read the original article.