Due to the increasing trend toward non-vaginal childbirth, health care analysts have recently suggested decreasing the primary cesarean delivery rate and increasing the VBAC rate as key strategies in decreasing the U.S. cesarean rate. A recent Amish study brings some light into achieving this goal.The cesarean section (C-section) rate in the United States has risen from 5.5 percent in 1970 to 16.5 percent in 1980 to 21 percent in 1996 to 32.9 percent in 2009. If these trends continue, the 2020 cesarean rate will be 56.2 percent. The vaginal birth after cesarean (VBAC) rate has fallen from a high of 28.3 percent in 1996 to 8.5 percent in 2006.
LaFarge Birth Center Study
The 2010 National Institute of Health Consensus Statement and American College of Obstetricians and Gynecologists revised guidelines encourage a trial of labor after cesarean (TOLAC) as a means of increasing VBACs to decrease the high C-section rate in the U.S. To investigate how local culture and natural birthing practices can affect vaginal birth and TOLAC, researchers reviewed retrospective data from 1993-2010 of all the women admitted into a birthing center in LaFarge, Wisconsin. Rates of cesarean deliveries, TOLAC and VBAC deliveries and perinatal outcomes for 927 deliveries were analyzed. The results of the study are staggering: The cesarean rate was four percent, the TOLAC rate was 100 percent, and the VBAC rate was 95 percent. According to the research team, “There were no cases of uterine rupture and no maternal deaths [and] the neonatal death rate of 5.4 of 1,000 was comparable to that of Wisconsin and the United States.”
This study shows that a low C-section and high VBAC rate with good maternal and neonatal outcomes can be obtained in a non-hospital setting with skilled birth clinicians and basic resources.
Learning From The Amish
Multiple cultural factors contributed to the low rate of cesarean delivery among women using the birthing center in this Amish community. According to the study, “these factors included infrequent inductions, active management of labor, external cephalic version, vaginal breech delivery, vaginal delivery of twins, encouragement of TOLAC, and continuous labor support without electronic fetal monitoring or epidural analgesia. The clinician mix and medicolegal climate were also quite different in the LaFarge Birthing Center, with community-based physicians and staff who knew the community and culture well and were respected for issues other than childbirth.”
The LaFarge Birthing Center was developed as an alternative to homebirth for Amish women. Initially, higher-risk patients were encouraged to give birth in the hospital. It became apparent, however, that a majority of higher-risk Amish patients were having their babies at home rather than at the hospital.
Some noteworthy birth-related idiosyncrasies within the Amish community in the study include:
- Amish women of Southwest Wisconsin generally give birth at home attended by an unlicensed birth attendant, mother, mother-in-law, or neighbor.
- Their community ascribes religious and cultural value to childbearing.
- Contraception, including sterilization, is prohibited.
- Advanced maternal age and grand multiparity are common.
- Unlike most people in America whose lives are completely centered in the medical model, health insurance of any kind and participation in such programs as Social Security, Medicare, and Medicaid are rare in Amish communities.
Sources for this article include:
- Wall E, Roberts R, Deutchman M, Heston W, Atwood L, Ireland B. Trial of Labor After Cesarean (TOLAC), Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section: American Academy of Family Physicians; 2005.
- National Institutes of Health Consensus Development Conference Panel. National Institutes of Health Consensus Development conference statement: vaginal birth after cesarean: new insights March 8-10, 2010. Obstet Gynecol. 2010;115(6):1279-1295.
- Hamilton B, Martin J, Ventura S. Births: Preliminary Data for 2009. National Statistics Reports. Vol 59. Hyattsville, MD: National Center for Health Statistics; 2010.
- Healthypeople.gov. Maternal Infant and Child Health. Healthy People 2020 topics and objectives. http://healthypeople.gov/2020/ topicsobjectives2020/objectiveslist.aspx?topicid=26. Accessed Nov 6, 2011.
- Appropriate technology for birth. Lancet. 1985; 2(8452): 436-437.