July 26, 2012 — Summary of "Trial of Labor Versus Repeat Cesarean: Are Patients Making an Informed Decision?" Bernstein et al., American Journal of Obstetrics and Gynecology, July 5, 2012.
The caesarean section rate in the U.S. has climbed steadily in recent decades, reaching nearly 33% in 2007, according to Sarah Bernstein and colleagues from the St. Luke's-Roosevelt Hospital Center in New York. Meanwhile, the rate of vaginal birth after caesarean (VBAC) has fluctuated -- largely as a result of shifting guidelines from various organizations and the "medical-legal environment" -- peaking at about 28.3% in 1996 but falling to 8.7% in 2006, the researchers noted.
Bernstein and colleagues wrote that many women who may be eligible for trial of labor after caesarean (TOLAC) choose instead to have an elective repeat c-section (ERCS). The researchers hypothesized that this trend is related to poor patient education. They noted that a woman cannot properly give her informed consent to TOLAC or ERCS if she is unaware of the risks and benefits of the two procedures.
The study aimed to discover if the low VBAC rate in the U.S. "is due, in part to insufficient informed consent about the risks and benefits" of TOLAC.
The study involved 155 women who were eligible for TOLAC and were admitted to St. Luke's-Roosevelt Hospital for delivery from November 2010 to July 2011. The study group did not include women who had more than one prior c-section, a prior classical uterine scar, a prior myomectomy, multiple gestation, or other medical complications precluding a trial of labor. All of the participants had received prenatal care and counseling in a private physician office or the hospital's clinic.
The women were given a questionnaire to complete prior to their scheduled ERCS or admission for a TOLAC. Questions were based on information from an American Congress of Obstetricians and Gynecologists bulletin and covered demographics, prior c-section experience, family planning goals, perceived provider preference for c-section or trial of labor, factors affecting the patient's choice, and the benefits and risks of each procedure.
Of the 155 participants, 87 presented for TOLAC and 68 presented for ERCS. Only 4% of ERCS patients and 13% of TOLAC patients knew that their chance of a successful TOLAC was 60% to 80%, while 73% of ERCS patients and 54% of TOLAC patients stated that they "did not know."
At least half of participants in both groups knew there was an increased risk of damage to organs, excessive bleeding and infection associated with ERCS, but fewer than 30% knew that ERCS was associated with increased risk of maternal death, neonatal respiratory problems and admission to the neonatal intensive care unit.
More than half of ERCS patients did not realize the recovery time from a c-section is longer than a vaginal delivery and 46% were unaware of increased complication rates with each successive c-section procedure.
Physician preference also played a significant role in women's decisions to choose ERCS or TOLAC. When women thought their provider preferred ERCS, 86% chose that method. Similarly, when women thought their provider preferred TOLAC, 78% chose that option. Among women who said their provider had no preference or did not know the provider's preference, half chose ERCS and half chose TOLAC.
Overall, the researchers observed a lack of knowledge about the risks and benefits of ERCS and TOLAC. "Our respondents showed insufficiencies in the area of comprehension, a major tenet of informed consent," the researchers wrote, adding that the women "lacked awareness and understanding of their situation and possibilities."
The findings also suggested that doctor bias affects women's decisions, "with unduly influence on patient's voluntary decision making," according to the researchers.
The researchers noted that St. Luke's-Roosevelt has a 33% VBAC rate and an older, more-educated population than average. Therefore, there might be "wider knowledge gaps" throughout the U.S. in different populations, they wrote. They suggested further research to determine how counseling styles and decision aids might influence delivery preference and patients' knowledge base.
Debra Ness, publisher & president, National Partnership
Andrea Friedman, associate editor & director of reproductive health programs, National Partnership
Marya Torrez, associate editor & senior reproductive health policy counsel, National Partnership
Melissa Safford, associate editor & policy advocate for reproductive health, National Partnership
Perry Sacks, assistant editor & health program associate, National Partnership
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Amanda Wolfe, editor-in-chief
Heather Drost, Hanna Jaquith, Marcelle Maginnis, Ashley Marchand and Michelle Stuckey, staff writers
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