How Does a CBAC Affect Women?
Unfortunately, not all women who want a VBAC will have one.
On average, in a typical high-intervention hospital setting, 60-80% of women who try for a VBAC will have one (Grobman 2010). This means that about 20-40% will have a CBAC instead.
Although these rates can be improved by carefully selecting lower-intervention care providers (Rusillo 2008, Avery 2004) and avoiding many common interventions (Catling-Paull 2011), the VBAC rate, alas, will never be 100%. Yet the experiences of women who did not get a much-desired VBAC has been significantly understudied.
How are the women who do not get a VBAC impacted afterwards? How do they feel about their CBAC experience? Do they regret having tried for a VBAC? Would they want to try again? What does the research say about the emotional impact of a CBAC?
How Do Women Feel About Their CBACs?
One study surveyed women who had CBACs (Chigbu 2007) and asked them about their emotional responses to it. This survey indicated that CBAC mothers felt:
- Dashed expectations
- Feelings of inadequacy as a mother
- Frustration with experiencing the pain and trauma of both labor and surgery.
Women with a prior vaginal birth before the CBAC had more positive assessments than those without a prior vaginal birth, but all women were affected to some degree.
Another study (Shorten and Shorten 2012) differentiated the emotional responses of women by final mode of delivery. Unsurprisingly, women who had a spontaneous VBAC reported the most satisfaction. Women who had instrumental births (forceps or vacuum extractor) or a cesarean during labor reported the least satisfaction, compared with women who had a spontaneous VBAC (the highest satisfaction score) or an Elective Repeat Cesarean Section (ERCS). Interestingly, women who had an instrumental VBAC had lower satisfaction scores than women who had a cesarean in labor. Since instrumental delivery can be invasive and may involve perineal damage, this may be the source of dissatisfaction.
This points out the importance of offering emotional support both to women who have a CBAC and to those who have had a traumatic VBAC. Few resources exist that specifically address the needs of either group of women. CBAC mothers' needs are assumed to be the same as the woman who had an unexpected primary cesarean, when in reality, her needs are often different. And many people assume that as long as the mother got a VBAC, everything will be fine, when in reality, trauma and ambivalent feelings can happen even in VBAC moms. More research is needed on how best to offer support to women in both of these groups.
What about the popular perception among healthcare providers that most CBAC moms wish afterwards that they had just chosen a repeat cesarean? Some women do wish this, but often it's a passing reaction to the disappointment of the birth and the difficulty of dealing with both a hard labor and a surgical recovery. The Shorten study asked women their reactions 6-8 weeks after the birth, whereas some of the other studies asked women their perceptions years later; how women feel about their CBAC often depends on when they are asked about it.
What we've seen in ICAN is that immediately afterwards, it's not uncommon for CBAC mothers to wish they'd just had a repeat cesarean. But given more time, many women report that they were glad that they had a trial of labor, even if it didn't end in a VBAC.
This is supported in the research. For example, Cleary-Goldman 2005 found that, although disappointed at not having a VBAC, 92% of women who had a CBAC “were pleased that they had attempted a vaginal birth.” They concluded:
"Although the most satisfied patients were those who succeeded at vaginal birth, most women valued the opportunity to attempt a vaginal birth regardless of outcome."
This was a result also found by Phillips (2009). Indeed, Chigbu (2007) noted, "This survey revealed that most women still would prefer to be delivered vaginally after 2 previous cesarean deliveries." This reflects the reality that many women would still choose to have another chance at VBAC, even after having had a CBAC.
However, each woman is different and there is no "right" way to feel about a CBAC. Each person's experience is unique and her feelings about it perfectly valid.
Improving Support for CBAC Mothers
There remains much work to be done on how to improve support for women who have had a CBAC. This work needs to acknowledge the uniqueness of each mother's situation and provide support specific to her needs.
For example, many people in the birth field assume that the best way to heal a CBAC is to have a VBAC. Yet while a VBAC can be healing, it never makes the reality of a CBAC completely go away. Sometimes a VBAC can make a CBAC experience even more painful in retrospective as the mother processes the CBAC in a new and different way.
Furthermore, in some women a VBAC is medically contraindicated, the woman is done having children, cannot find a supportive provider, or does not wish to labor again. Little research has been done on how to support women who will never have a VBAC. They also need help integrating their experiences into their lives.
In addition, information is desperately needed on how best to support women who experienced any sort of birth trauma, whatever the source (Beck and Watson, 2010). Although many grassroots organizations like Solace for Mothers and TABS (Trauma and Birth Stress) exist to support women after traumatic births, little research has been done into the efficacy of their approaches.
The few surveys on CBAC that have been done show the emotional impact a CBAC (or traumatic VBAC) can have, but the topic is glaringly understudied. More research is needed on the experiences of these mothers and what can be done to help support them.
As Chigbu (2007) concluded:
Maternity caregivers should understand the varied emotional and psychological impact of an unsuccessful trial of VBAC. Following an unsuccessful trial of VBAC women should be given targeted psychological support to improve their overall experience, especially those who have never been delivered vaginally.
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