By Jen Kamel, Founder/Director VBAC Facts
Vaginal birth after cesarean (VBAC) rates have been slowly rising in America the last few years as more and more women become familiar with the option. (1; 2) However, our latest statistics reflect still that only 11% of women with a prior cesarean birth had a VBAC in 2014. (2) This is despite the fact that national medical organizations describe VBAC as a safe, reasonable and appropriate option for most women. (3; 4) Some women hire doulas to increase their odds. Here are six specific ways doulas can support these families as they traverse the sometimes challenging terrain of VBAC.
1. Be aware of what she is up against.
It’s huge. Almost 90% of women have repeat cesarean births in America. (2) Many members of the public still believe “once a cesarean, always a cesarean.” One third of hospitals mandate repeat cesareans and don’t “allow” VBAC – called VBAC bans – and one half of all obstetricians don’t attend VBAC. (5; 6; 7; 8) The logistics of planning a VBAC in this climate can be complicated, difficult and emotionally exhausting. Your clients will look to you for support, reassurance and resources.
2. Get educated.
The best way to provide reassurance is to learn as much as you can about VBAC. Despite the fact that many remain uneducated about the subject, everyone from the crossing guard at school to the cashier at Target has an opinion. It can be difficult for pregnant people to navigate the sea of conflicting viewpoints, and they may come to you seeking clarity. By understanding the basic medical facts and political barriers, you can help your clients by debunking misinformation. Be sure to assemble resources for your clients so you can quickly direct them to solid evidence. I find that achieving clarity on the facts helps women eliminate their confusion, conquer their fears and joyfully plan their VBACs.
3. Realize that finding a VBAC supportive provider can be really tough.
Some doctors tell parents that planning a VBAC is just as reckless as running across a busy freeway. And when parents hear this, they are scared. Make it a point to learn about the various providers in your area who attend VBACs, and what their policies are so you can help your clients find the best provider for them. Rack up bonus points by reaching out to those providers and creating a personal rapport with them.
4. Be honest with your clients.
If they have hired a provider you know isn’t supportive of VBAC, you need to tell them. This can be very difficult and even awkward. However women unanimously report that if their doula knew their provider wasn’t supportive of VBAC, they would want to be told. If you withhold this information, it can erode the trust between you and your client.
5. Keep an open in mind.
Not all women carry emotional trauma from their cesarean birth. Some women celebrate their cesareans, and other women mourn them. Some women feel that their body is broken; others don’t. There are a lot of factors that go into how a parent processes their cesarean birth. Listen to your clients, ask about their story, and be ready to refer them to your local ICAN chapter or mental health professional if they need more support or assistance.
6. Know how to support your client through another cesarean.
If client of yours has a repeat cesarean, there are a few key things that they need to hear. Let her know that it’s ok to be disappointed if she is. Assure her that having a cesarean birth doesn’t make her less of a woman or mother. Remind her that her body is not broken. And let her know that some women are candidates for VBAC after two cesareans even if the hospitals in your area have VBAC bans or very restrictive VBAC policies.
Through your work, you have the opportunity to increase VBAC access and improve maternity care in your community. Through learning about VBAC and creating alliances with VBAC supportive providers, you can create change one pregnancy at a time.
About the Author
Jen Kamel has been a consumer advocate and national speaker since she founded VBAC Facts nearly a decade ago. The mission of VBAC Facts is to increase access to vaginal birth after cesarean (VBAC) through educational programs, legislative action, and amplifying the consumer voice. Through her work, she has traveled the country as a California Board of Registered Nursing Continuing Education Provider presenting her program “The Truth About VBAC” to hundreds of professionals, providers, and highly motivated parents. She has spoken at national conferences including the American Association of Birth Centers, DONA, Lamaze, ICAN, and Human Rights in Childbirth and has been a featured guest on several radio shows and podcasts. She has testified multiple times in front of the California Medical Board on the importance of VBAC access, is a board member for the California Association of Midwives, and has served as an expert witness in a legal proceeding.
- American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. (2014). Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No 1. Obster Gynecol, 123, 693-711.
- National Center for Health Statistics. (2015, Dec 23). User guide to the 2014 natality public use file.
- American College of Obstetricians and Gynecologists. (2010, August). Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. Obstet Gynecol, 116(2), 450-463.
- National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights.
- National Institutes of Health Development Conference Panel. (2010). National Institutes of Health Consensus Development conference statement: Vaginal birth after cesarean: New Insights. March 8-10, 2010. Obstet Gynecol, 115<(6), 1279-1295.
- Leeman, L., Beagle, M., & Espey, E. (2013). Diminishing availability of trial of labor after cesarean delivery in New Mexico hospitals. Obstet Gynecol, 122(2 Pt 1), 242-247.
- Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy and Childbirth.
- Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US).
Jen Kamel, thank you for writing this post and for all your work toward helping birthing families to receive fair and evidence based care. I appreciate all your efforts and contributions. They are substantial. As a long time DONA doula, and doula trainer, point number 4 concerns me. It is not my place as a doula to tell a client that they are with the wrong provider or facility. What I can do as a doula is ask my client if they want information about the characteristics and behavior of a vbac friendly HCP and facility, how to determine if their choice is considered supportive, etc. If they say no, I respect that.
If they say yes, than I have some information I can share, that they may read and hopefully this sparks them to ask more questions of their HCP, inquire and examine more closely policies, standard practices and explore their options, etc. In no way, should I tell them that their choice is not vbac friendly or supportive. Certainly another doula may have been at different births with the same HCP/hospital and have observed a different situation. My role is to support my client and provide information (but not my opinion) if my client would like more. Thanks for listening.
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Sharon, Giving people questions to ask is a great idea. The problem is some providers are not entirely honest. They say one thing and then as the due date gets closer, they say another.
“Certainly another doula may have been at different births with the same HCP/hospital and have observed a different situation.”
There is a difference between a single birth and seeing a provider in action multiple times and witnessing a pattern. I’m talking about sharing if you see a consistent pattern.
Doulas, childbirth educators, and nurses generally know who is supportive of VBAC in their community and who isn’t. They know who cuts an episiotomy every time and who doesn’t. They know who “clears the board” at 6pm and who doesn’t. This is not the kind of information that a provider is going to openly share with a patient during a VBAC consult.
Example: The provider tells a woman that she can wait to go into labor spontaneously. And then at 38 weeks says they need to schedule a cesarean at 40 weeks “just in case.”
If you know that this is the provider’s style, and your client won’t learn that this is their style until 38 weeks, is that withholding important information (not opinion) from your client? “They require a repeat cesarean at 40 weeks” is not opinion. If that is the way they practice, that’s a fact. And that is exactly the kind of information some women are hoping their doulas will provide to them because they know they can’t get it elsewhere.
I know some doulas believe in giving their clients a clear heads up about their provider choice and others don’t. I think doulas who don’t should be very clear – maybe in the interview or contract – that they will not share information regarding providers even if they have seen providers bait & switch, lie to women, or be abusive. Parents need to know that their doula will not share this kind of information with them because that is a real key distinction between doulas.
When I asked parents if they would want their doula to tell them if their provider wasn’t VBAC supportive, every single one said yes. And I know the sense of betrayal they would feel if it came to light that their doula wasn’t honest. It would be such a punch in the gut after being subject to a bait & switch, blatant misinformation, coercion, or abuse… and then they came to realize that their doula – who they trusted – knew of this behavior pattern and didn’t disclose it.
Sharon — Thank you for your comment and raising this concern. You are quite right that discussing what a doula has previously experienced with or heard about a provider is a delicate area.Your suggestion of how to broach the topic is spot on and a great addition to this topic. Yes, we absolutely have to remain in our Scope of Practice and our role as sources of evidence-based information. Supporting informed decision making is part of our role and we should not assume that a client has all of the information about their provider that we might. I would likely open this conversation by asking the client why the provider was chosen and then look to find out exactly how in-depth has VBAC been discussed. I might suggest questions the client could ask to ensure that the provider is on board and we don’t have a situation where the provider is saying, “If everything looks good, we can do a trial of labor” yet the client is hearing “If there isn’t anything wrong, I can have a VBAC.” Those are two very different statements and supporting the client in gaining clarity around what is meant by “everything looks good” and “trial of labor” is important to help set expectations.
What we don’t want is for the client to find out later that her provider is not VBAC supportive and her doula knew that yet didn’t share this information or encourage her to delve deeper to get details on their criteria for VBAC patients, number of successful VBACs, length of trial of labor, etc. For the client, this could very much feel like a betrayal by the doula. To your point, we have to find out the client’s perspective and information base then proceed to offer additional information and support. Thanks again for raising this and offering a clear path for doulas to discuss this with their clients. — Adrianne Gordon, DONA International Blog Manager
Jen, thanks so much for this, as usual. I had the pleasure of hearing you speak in Santa Barbara a few months ago. And, I’m currently on call for a VBAC mama now! ❤️✌️
Thank you so much for this blog post. I took your online class a while ago and it has been such a help in assisting my clients and just spreading the word about VBAC. This particular posts is a big encouragement to me as a doula.