Public Comment: Healthy People MICH-2030-06

Submitted to U.S. Department of Health and Human Services (HHS) by Maternal Safety Foundation

January 8, 2018

MICH-2030-06: Reduce cesarean births among low-risk women with no prior births

Our organization is submitting a comment to recommend that Healthy People 2020’s MICH 7.2, or “Reduce cesarean births among low-risk women giving birth with a prior cesarean birth,” carries forward as a Healthy People 2030 objective. With sub-objectives not outlined in the proposed objectives, we wanted to express our support of including the low-risk repeat cesarean/VBAC objective for 2030.

This objective meets all five criteria required to continue as a Core Objective. The reliable, nationally representative data source is the Centers for Disease Control National Center for Health Statistics. The same effective, evidence-based interventions used to safely lower NTSV cesarean rates by promoting vaginal birth apply to any vaginal birth, even those occurring after a previous cesarean. Recently updated professional guidelines from the American College of Obstetricians and Gynecologists affirm that any hospital that can offer maternity services which include the capacity to perform an emergency cesarean are also capable of offering a trial of labor after previous cesarean (TOLAC) to most patients with one or two previous cesarean births.

Our organization’s preliminary analysis of hospital VBAC data for one-third of the country’s roughly 3000 hospitals with maternity services show that only half make VBAC routinely available, which disproportionately impacts patients in rural areas. Families with the financial means to do so may choose to stay in a hotel in a city where TOLAC is available to them until they go into labor. However, without safe, accessible, risk-appropriate options for vaginal birth accessible, most patients who want a vaginal birth are confronted with the decision to seek an alternative to medical care in a hospital for their TOLAC, such as a planned home birth, or to schedule a repeat cesarean. If repeat cesarean birth is the only option available, then these patients are being subjected to tacit coercion due to lack of safe options.

The Healthy People 2030 Advisory Committee should be made aware that the percentage of women giving birth annually is now 15.5 percent of the birthing population, or 600,000 of the 4 million births. CDC data show that the number of patients giving birth annually with a previous cesarean birth has tripled since 1980, when the estimated number was 184,000, or 5.5 percent.

Public health and quality improvement efforts have focused on preventing the first cesarean birth in first time mothers with low-risk deliveries and this rate has plateaued. However, continuing failure to provide systemic access to risk-appropriate care, inclusive of non-surgical birth options for the growing population of patients with a previous cesarean birth, leaves up to about 600,000 patients annually at risk for abnormal placentation and increased morbidity and mortality. The newly published SMFM-ACOG Obstetric Care Consensus document on Placenta Accreta Spectrum cites a 2016 study using National Inpatient Sample data which found that the overall estimated rate of placenta accreta in the United States was 1 in 272 for women with birth-related hospital discharge diagnosis.

Thank you in advance for including this objective for 2030.

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Jill Arnold