Booby Traps Series: VBAC is a breastfeeding issue. Lack of access to VBAC is a Booby Trap for millions of moms.

Pregnant_profile_IIIThe Listening to Mothers III survey, published by Childbirth Connection this month, contained a set of sobering statistics.

This survey found that, while moms’ interest in VBAC is increasing (from 45% to 48%), “the proportion of women with a prior cesarean who reported a lack of access to VBAC grew to 56% in the current survey from 42% a decade earlier.”

How is that related to breastfeeding?  It’s a big old Booby Trap.  I’ll explain.

Between 1996 and 2007, VBAC births fell from 28.3% to 8.7%.  And that’s a key reason why, according to the CDC, the cesarean birth rate in the U.S. hovers near an all-time high, at 33% in 2010.  This despite the fact, according to the National Institutes of Health, the success rate of VBAC has remained constant at about 74%.

An estimated half of all U.S. hospitals do not permit women to attempt a VBAC.  How do we know?  The International Cesarean Awareness Network (ICAN) conducted a grassroots data collection effort, in which each delivery hospital in the country was contacted by ICAN members.  They found that 30% of hospitals had an outright VBAC ban.  Another 20% had a “de facto ban” – these hospitals didn’t have a formal prohibition, but there was no provider at the hospital would would attend a VBAC.  And of the remaining 50%, they estimated that only 10% of the surveyed hospitals were actually VBAC supportive.

So how is lack of access to VBAC a Booby Trap?

(But before we get into this discussion, I want to say that having a cesarean birth certainly doesn’t doom your chances of breastfeeding.  Many, many mothers, including myself, have breastfed without incident after a cesarean birth.  But when we evaluate policies and practices that impact breastfeeding, we need to broaden our view beyond personal experience and examine the research on large groups of women.  That’s what I’m doing in this post.)

It’s been clear for some time that cesarean birth poses challenges when it comes to breastfeeding.  Linda Smith, in The Impact of Birthing Practices on Breastfeeding compiled research showing an association between cesarean birth and many breastfeeding issues, including:

  • Significant delays in initiating the first feeding
  • Increased risk of separation from mother following birth, and increased risk of baby being admitted to the NICU
  • Delayed onset of mature milk supplies (“milk coming in”)
  • For babies:  altered sucking patterns, decreased neurological responses in the first two days, increased risk of respiratory problems in babies born by cesarean without labor, respiratory distress, low blood sugar, higher risk of infection in babies born by cesarean before 39 weeks gestation
  • For mothers:  a longer and more painful recovery, lower oxytocin and prolactin levels in the early postpartum period, increased risk of rehospitalization and infection, higher rates of anxiety and stress, higher risk of exposure to medications of concern

And possibly as a consequence, research has found that mothers who have had cesarean births:

  • Are more likely to have stopped breastfeeding within the first two weeks postpartum
  • Are more likely to not be breastfeeding at 2 months

Having a cesarean without labor, as in the case of scheduled CBACs, is independently associated with breastfeeding problems, such as lower rates of initiation, greater newborn weight loss, and reduced fetal endorphins and less endorphins (which act as pain killers) in breastmilk.  Research has also found that babies born by cesarean without labor are more likely to be delivered early – a risk factor in itself for a number of breastfeeding related problems.

A new study comparing breastfeeding outcomes of VBAC, planned CBAC, and trial of labor ending in cesarean (TOL/CBAC), offers an illustration of this effect on a large sample of women:

Women delivered by successful VBAC were 47% more likely to initiate breastfeeding than women delivered by scheduled repeat cesarean. Women who ultimately delivered by cesarean section with unsuccessful trial of labor were also more likely to breastfeed than women with a scheduled repeat cesarean section (61% vs. 58.7%, respectively). [Breastfeeding rates :  VBAC 66.6%; TOL/CBAC 61.3%; scheduled CBAC 58.9%]

It’s certainly possible that women who want to have a VBAC are also more likely to want to breastfeed, and this study did not collect information on prenatal breastfeeding intentions (one author tells me that such a survey is planned).  But looking at the cesarean-after-trial-of-labor number compared to the scheduled cesarean number is where it gets interesting.

If this were all about intention to breastfeed, and mothers trying for a VBAC were more likely to intend to breastfeed, wouldn’t you expect to see rates for the TOL/CBAC mothers clustered together with the VBAC mothers, since they headed into labor with the same intentions?  Instead, they’re clustered with the planned CBAC mothers.  To me, this suggests that something else – perhaps the associations noted – is at play.

The American Pregnancy Association estimates that 90% of women with prior cesareans are candidates for VBAC.  And the NIH estimates that 74% of the women who attempt a VBAC will end up delivering vaginally.

But that is simply not the case for millions of mothers each year.  And that’s the Booby Trap – that lack of access to VBAC is causing mothers to struggle unnecessarily with breastfeeding.

Did you have a trial of labor after cesarean, VBAC, or CBAC?  Were you unable to find a provider who would attend a VBAC?  Did your birth experience affect your breastfeeding experience?



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4 Comments | Last revised on 05/28/2013


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4 Responses to Booby Traps Series: VBAC is a breastfeeding issue. Lack of access to VBAC is a Booby Trap for millions of moms.

  1. Melissa Perry says:

    My first child was born via c-section in 2005. I did go into labor naturally before delivery but had failure to progress and a low fetal heart rate due to this slow progression. I EBF my son till he was exactly 1 year and even donated milk to the local milk bank. I was blessed with an abundant milk supply and did not encounter some mentioned struggles. With that said, with my second pregnancy I decided that I wanted to attempt a V-Bac or at the very least go into labor on my own, without the scheduled C-Section my doctor pressured me for. He strongly discouraged my want to try a V-Bac saying my tailbone was in the way and pushing out a baby was like fitting a round peg into a square hole. I did what most felt at the time was a quick reaction and left my doctor. I researched and found a practice that had both traditional Doctors and Midwives! I immediately found a midwife and together we delivered my next two babies via V-Bac with no issues in 2007 and 2011. I EBF my second till he was 15 months and I am still nursing my 23 month old!! I still get a shocked expression when I tell people that I had not 1 but 2 successful V-Bacs, if if course they even know what that is ;-) finding my midwife eliminated many booby traps for me and I love her to pieces!!!

  2. Jenny says:

    I am extremely concerned that I will not be permitted a VBAC. My births will be 19 months apart so that is a major issue for by OB. He’d prefer that I schedule the C-section, but at least the topic is open for discussion.
    I had nursing issues with my son and I’d prefer to nurse my next child as soon as possible after delivery. In addition, having a child under the age of 2 makes me want to be on my feet as soon as possible.

  3. Olga says:

    Interesting read! I had my first child naturally at a birthing clinic, and although we had a few latching issues in the beginning, happily breastfed her until just before 11 months when she weaned herself. My second was a scheduled c-section (breech), and we had endless problems with him being too tired to feed, jaundice, he didn’t latch properly for at least 4 weeks, and according to his paed, he was lactose sensitive/intolerant. He was partially breastfed (some feeds were soy/lactose-free formula) until 8 months. Apart from feeding issues, he has significant developmental delays – which could be totally unrelated – but it’s thought provoking to compare the outcome of the two different births.

  4. Dee says:

    With my first birth, I was high-risk for failing to breastfeed. I was pregnant with twins and due to a very big size discordance I was not allowed to attempt natural labour. I had a scheduled c-section without labour at 36 weeks due to the very small size of my twin A. Almost immediately after birth my twins were taken away and I didn’t see them again for several hours. Attempting to breastfeed on that first day was very hard, I was out of it and sick from the Morphine, my twins were slightly preemie and couldn’t latch plus trying to meet the needs of two babies was very overwhelming. However, before I had left the hospital I had tandem fed a couple of times. With the help of a very supportive husband (breastfed for 2 years himself), my mum (who breastfed 5 children) and my local lactation clinic I managed to keep going through some extreme difficulties including engorgement, mastitis, pain, latching issues, plus all the booby traps. As a twin mum there were a lot of people discouraging me from even trying.
    It took weeks for my twins to learn how to latch and trying to latch newborn twins at the same time is difficult beyond belief. The best advice I was given along the way was to stick it out for 8 weeks. By 8 weeks it had gotten significantly easier and I ended up nursing my twins for 20 months.
    I am pregnant again with a singleton and am determined to have a VBAC if at all possible. Since my reason for having a C-sec last time was twin A being significantly smaller than twin B (they told me A would be born fine but that B would get stuck-the bigger twin needs to come out first) there’s no reason I can’t deliver naturally this time. I am going with a midwife to ensure I get a VBAC. I’m equally determined that my baby will receive no formula this time. After being successful breastfeeding twins under difficult circumstances I’m feeling a lot more confident this time around.

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