Well researched and written. Carolyn, you have provided data to support the value of crafting a plan for the US as well as negating likely objections. Now I’m pondering where your research might get serious audience.
I had a VBAC a few years ago. As a multi-ethnic woman, of course the calculator privileged my “white half” and I remember torturing myself swapping racial categories and wondering which score accurately represented my odds of success.
My own mother, a Latina, was denied VBAC after a primary section for a “big” 7lb baby, because she carried late. That’s all. That’s it. Cut open 5 times, forced sterilization because after 5 cesareans your risk of bleeding to death from accreta is quite serious. I’m sure you know the history of sterilization and birth control in Latin America, as well as the history of cesareans for inadequate pelvises - the precursor to the current pseudoscientific, explicitly racist diagnosis of CPD.
I found this fascinating, although as an Australian I'm horrified by the US situation. Regarding c-sections - I had 2, both technically non-elective although the second was heavily influenced by my preference (and I went private both times for other reasons). I have a bit of shame about this and I often get a pity response when women (who haven't had sections) learn I've had 2 c-sections - but I've also noticed better quality of life in the sense that I and my friends who've had c-sections don't seem to have prolapse or long term continence issues, and my friends with vaginally deliveries do, to a degree that it just seems to be accepted as normal. My first labour didn't progress and the likelihood of instrument use was increasing had I insisted on vaginal delivery, which of course increases the likelihood of pelvic trauma. I haven't really seen any commentary on this and I know anecdotes aren't good data, but is there a potential positive for long term maternal quality of life in choosing to go for a c-section rather than wait it out? And maybe midwives call OBs when options are becoming exhausted, rather than an OB's attendance triggering a giving-up?
Thank you so much for sharing this—your story really brings to light how layered and personal birth experiences are. What strikes me most is how often we, as a society, pass judgment on the how of birth, rather than celebrating the woman and the outcome: a new life and a mother who brought them into the world. No woman should be made to feel “less than” for her delivery path—every birth story deserves to be honored.
You raise such an important and under-discussed point about long-term maternal quality of life. While we often focus on reducing unnecessary C-sections, we don’t talk nearly enough about the long-term impacts of different delivery methods—things like prolapse, incontinence, and pelvic trauma, whichcan meaningfully shape a woman’s quality of life for years to come. I haven’t seen a robust metric or body of research that centers this kind of long-term outcome, but I think we need one. I also think that having better data on this could help women make more informed choices, especially when fear or incomplete information nudges them toward scheduled C-sections.
And yes—your point about midwives vs. OBs and when the call is made really gets at the complex dynamics in birth settings (shared more of my thoughts on how truly collaborative models can reshape this below).
This is a super common myth! My mom had 5 cesareans and incontinence issues. She had never labored or pushed. My excellent PT explained that much pelvic floor damage has to do with pregnancy. I had issues myself after a primary cesarean but had no idea PT was a possibility to deal with them until I literally read a blog on the internet. I only needed a few months of care to experience long term benefits.
Note: my OB refused to refer me to PT. I had to switch care to get access to a simple referral. It’s hardly surprising women would experience long-term poor quality outcomes if their providers simply refuse to refer them out, or they may not even know this kind of care exists.
Boy oh boy, is this EXCELLENT. What a sharp take on the two systems. All systems are flawed, but as an Australian who gave birth in the UK (two public systems), I am so deeply grateful for the access I had to affordable, if not entirely free, healthcare. It was only the other week that I read a post by Violet Carol (I'll link below) that made me realise women are getting bills once they leave the hospital in the US – which I just can't even fathom dealing with at the beginning of the fourth trimester.
Also, a perspective on the C-section rates. I'm strangely not surprised that Australia's is higher – likely due to comparatively affordable private healthcare which generally means women will have an ObGyn involved. I'd love to find a statistic for Aus that breaks the c-section rate down between private and public, as well as cultural background. I've observed, especially in Sydney, a trend amongst some privileged white communities where it's just "what you do" – and, if you're expecting to have an ObGyn there, well then it just becomes a scheduling benefit too. Not my thing, but each to their own (of course, emergency c-sections aside).
Ps. So excited to have found your publication. Thanks, John, for linking!
Thanks so much for sharing a bit of your experience, @kiya! I’d love to see that C-section data too—for both Australia and the U.S. It’s such a tough one to make sense of, given the mix of medical factors and patient/provider preferences. That complexity makes it really hard to cleanly separate truly elective C-sections from those that are medically necessary.
Anecdotally, I see two extremes in the U.S.: on one end, more women are choosing scheduled C-sections for a mix of reasons—ease, fear, convenience, or wanting to proactively avoid pelvic trauma. On the other, there’s a growing movement toward unmedicated, “natural” births, including a rise in home births and strong commitments to vaginal delivery, even in situations where complications arise and a C-section ends up being needed.
My take? The goal should always be a healthy mom and a healthy baby. How someone chooses—or needs—to deliver should be just that: a choice. The more we can destigmatize all paths to birth and keep the focus on healthy outcomes, the better.
As a Canadian, my experience of pregnancy and postpartum care is closer to that of Australia. I have to agree that it’s important to get American women more care and more maternity leave. However, that c-section difference really interests me. I appreciate you acknowledging you don’t know why it is, but I think one answer is reliance on midwife care. By the time a woman who struggling in birth gets from her midwife to an OB, they may feel like the only intervention they have time for is a C-section. Sometimes seems that way here in Canada.
Thanks Vera for sharing your experience and thoughts on the C-section rate—a true conundrum around the world! A critique of the midwife model is exactly what you point out — that the OB is called in as back up "too late", inadvertently resulting in higher intervention. I think the counter to this (and a model I am personally interested) is truly collaborative midwife/OB models like Oula (https://oulahealth.com/), which has shown a 30% lower c-section rate here in the U.S. The takeaway for me is, when we get OBs and midwives really working together as a team (hard but possible!) and centering a patient and her wants and needs across the whole journey, we can improve outcome, inclusive of c-section rate. All that said, my view is this is one metric and not the most important metric we should be focusing on. Healthy mom and healthy baby is what matters!
Well researched and written. Carolyn, you have provided data to support the value of crafting a plan for the US as well as negating likely objections. Now I’m pondering where your research might get serious audience.
The time is now to fix the system- care for women after their reproductive years is not any better. Thank you for writing such a great article!
I had a VBAC a few years ago. As a multi-ethnic woman, of course the calculator privileged my “white half” and I remember torturing myself swapping racial categories and wondering which score accurately represented my odds of success.
My own mother, a Latina, was denied VBAC after a primary section for a “big” 7lb baby, because she carried late. That’s all. That’s it. Cut open 5 times, forced sterilization because after 5 cesareans your risk of bleeding to death from accreta is quite serious. I’m sure you know the history of sterilization and birth control in Latin America, as well as the history of cesareans for inadequate pelvises - the precursor to the current pseudoscientific, explicitly racist diagnosis of CPD.
Obstetrics automates racism. Not only in the VBAC calculator. That’s simply what it does. That’s the history of obstetrics and that is the present of obstetrics and that is the future of obstetrics without some kind of intervention, moral reckoning, or call for reparation. https://www.inquirer.com/news/inq2/more-perfect-union-maternal-morbidity-philadelphia-medicine-history-racism-20220712.html
I found this fascinating, although as an Australian I'm horrified by the US situation. Regarding c-sections - I had 2, both technically non-elective although the second was heavily influenced by my preference (and I went private both times for other reasons). I have a bit of shame about this and I often get a pity response when women (who haven't had sections) learn I've had 2 c-sections - but I've also noticed better quality of life in the sense that I and my friends who've had c-sections don't seem to have prolapse or long term continence issues, and my friends with vaginally deliveries do, to a degree that it just seems to be accepted as normal. My first labour didn't progress and the likelihood of instrument use was increasing had I insisted on vaginal delivery, which of course increases the likelihood of pelvic trauma. I haven't really seen any commentary on this and I know anecdotes aren't good data, but is there a potential positive for long term maternal quality of life in choosing to go for a c-section rather than wait it out? And maybe midwives call OBs when options are becoming exhausted, rather than an OB's attendance triggering a giving-up?
Thank you so much for sharing this—your story really brings to light how layered and personal birth experiences are. What strikes me most is how often we, as a society, pass judgment on the how of birth, rather than celebrating the woman and the outcome: a new life and a mother who brought them into the world. No woman should be made to feel “less than” for her delivery path—every birth story deserves to be honored.
You raise such an important and under-discussed point about long-term maternal quality of life. While we often focus on reducing unnecessary C-sections, we don’t talk nearly enough about the long-term impacts of different delivery methods—things like prolapse, incontinence, and pelvic trauma, whichcan meaningfully shape a woman’s quality of life for years to come. I haven’t seen a robust metric or body of research that centers this kind of long-term outcome, but I think we need one. I also think that having better data on this could help women make more informed choices, especially when fear or incomplete information nudges them toward scheduled C-sections.
And yes—your point about midwives vs. OBs and when the call is made really gets at the complex dynamics in birth settings (shared more of my thoughts on how truly collaborative models can reshape this below).
Appreciate you being part of this conversation!
This is a super common myth! My mom had 5 cesareans and incontinence issues. She had never labored or pushed. My excellent PT explained that much pelvic floor damage has to do with pregnancy. I had issues myself after a primary cesarean but had no idea PT was a possibility to deal with them until I literally read a blog on the internet. I only needed a few months of care to experience long term benefits.
Note: my OB refused to refer me to PT. I had to switch care to get access to a simple referral. It’s hardly surprising women would experience long-term poor quality outcomes if their providers simply refuse to refer them out, or they may not even know this kind of care exists.
Boy oh boy, is this EXCELLENT. What a sharp take on the two systems. All systems are flawed, but as an Australian who gave birth in the UK (two public systems), I am so deeply grateful for the access I had to affordable, if not entirely free, healthcare. It was only the other week that I read a post by Violet Carol (I'll link below) that made me realise women are getting bills once they leave the hospital in the US – which I just can't even fathom dealing with at the beginning of the fourth trimester.
Also, a perspective on the C-section rates. I'm strangely not surprised that Australia's is higher – likely due to comparatively affordable private healthcare which generally means women will have an ObGyn involved. I'd love to find a statistic for Aus that breaks the c-section rate down between private and public, as well as cultural background. I've observed, especially in Sydney, a trend amongst some privileged white communities where it's just "what you do" – and, if you're expecting to have an ObGyn there, well then it just becomes a scheduling benefit too. Not my thing, but each to their own (of course, emergency c-sections aside).
Ps. So excited to have found your publication. Thanks, John, for linking!
Referenced blog: https://motherloveletters.substack.com/p/an-itemized-billing-statement-hates
Thanks so much for sharing a bit of your experience, @kiya! I’d love to see that C-section data too—for both Australia and the U.S. It’s such a tough one to make sense of, given the mix of medical factors and patient/provider preferences. That complexity makes it really hard to cleanly separate truly elective C-sections from those that are medically necessary.
Anecdotally, I see two extremes in the U.S.: on one end, more women are choosing scheduled C-sections for a mix of reasons—ease, fear, convenience, or wanting to proactively avoid pelvic trauma. On the other, there’s a growing movement toward unmedicated, “natural” births, including a rise in home births and strong commitments to vaginal delivery, even in situations where complications arise and a C-section ends up being needed.
My take? The goal should always be a healthy mom and a healthy baby. How someone chooses—or needs—to deliver should be just that: a choice. The more we can destigmatize all paths to birth and keep the focus on healthy outcomes, the better.
As a Canadian, my experience of pregnancy and postpartum care is closer to that of Australia. I have to agree that it’s important to get American women more care and more maternity leave. However, that c-section difference really interests me. I appreciate you acknowledging you don’t know why it is, but I think one answer is reliance on midwife care. By the time a woman who struggling in birth gets from her midwife to an OB, they may feel like the only intervention they have time for is a C-section. Sometimes seems that way here in Canada.
Thanks Vera for sharing your experience and thoughts on the C-section rate—a true conundrum around the world! A critique of the midwife model is exactly what you point out — that the OB is called in as back up "too late", inadvertently resulting in higher intervention. I think the counter to this (and a model I am personally interested) is truly collaborative midwife/OB models like Oula (https://oulahealth.com/), which has shown a 30% lower c-section rate here in the U.S. The takeaway for me is, when we get OBs and midwives really working together as a team (hard but possible!) and centering a patient and her wants and needs across the whole journey, we can improve outcome, inclusive of c-section rate. All that said, my view is this is one metric and not the most important metric we should be focusing on. Healthy mom and healthy baby is what matters!
Fantastic solution, thanks for sharing it with me and taking the time to respond!