BY RACHEL BRUNS, GUEST CONTRIBUTOR
This is part 1 of an ongoing series on maternal health care from Rachel Bruns.
I began my journey into Iowa’s maternal health system eight years ago, when I was pregnant with my first child. I asked my primary care doctor for an obstetrics recommendation and was referred to a local OBGYN group in the Des Moines metro. At the time, I trusted that referral. If I knew then what I know now, I would have made a very different decision.
After a failed induction, my daughter was born via cesarean. It wasn’t until months after my recovery that I learned how common unnecessary cesareans are and how little information families are given about vaginal birth after cesarean (VBAC). My physical therapist, who also had a cesarean and VBACs, connected me with the International Cesarean Awareness Network (ICAN) of Central Iowa, where I would later become a volunteer chapter leader.
ICAN is an all-volunteer led organization with around 100 chapters worldwide. It was started in the early 1980s by two women who worked to raise awareness about rising C-section rates and to challenge the “once a cesarean, always a cesarean” mentality that dominated the medical community. ICAN’s mission is to improve maternal-child health by reducing preventable cesareans through education, supporting cesarean recovery and advocating for vaginal birth after cesarean (VBAC).
My personal experience and those I’ve connected with through ICAN have reshaped my understanding of maternal health care in Iowa. A central driver of my advocacy since then has focused on the difficulty families face when trying to avoid repeat surgery — along with improving options for families that want midwifery-led care in hospital or out-of-hospital settings, which are proven to improve patient satisfaction, reduce costs and improve birth outcomes for both mothers and babies.
Over time, I have come to see that my experience wasn’t an anomaly — it was the predictable outcome of a system that prioritizes institutional convenience over evidence-based care and informed consent. I’ve written about how reducing unnecessary C-sections and improving access to VBAC care would be an important step to reducing Iowa’s maternal mortality and morbidity. That’s why I was pleased to see several in-depth pieces published in recent months including a series from theNew York Times and another from Business Insiderfocused on the issue of unnecessary cesareans and how many hospitals continue to ignore evidence-based practices.
Hospital practices increase unnecessary cesareans
Among theNew York Times articles, I was particularly encouraged to see reporting on how continuous Electronic Fetal Monitoring (EFM) has been described as the “worst test in medicine” and has contributed to rising C-section rates. While this information is not new to those immersed in the birth world, the hospital-based medical model has made it difficult for families to avoid EFM even when it is unnecessary.
The article “These Hospitals Figured Out How to Slash C-Section Rates” goes beyond identifying the problem and provides concrete examples of changes hospitals can make to safely reduce unnecessary C-sections. The article demonstrates that meaningful improvements don’t require radical overhauls. One highlighted hospital safely reduced its C-section rate from 40% to 25% in just a few years by expanding midwifery-led care, using provider checklists, increasing awareness about the length of labor if induced (up to three days) and engaging in data-driven conversations with clinicians about their individual C-section rates.
If the Des Moines–based hospital and clinic where I delivered my first child had adopted even a few of the highlighted practices, I believe my likely unnecessary cesarean — and many others — could have been avoided. I was shocked to learn, after both my cesarean and subsequent VBAC, that my first birth had been inaccurately labeled “failure to progress.” My provider was not following the most current ACOG guidelines or evidence. The real issue, as many providers and families discover too late, is often “failure to wait.”
One critical element not explicitly addressed in the article — but clearly essential to the hospitals that achieved improvement — is strong hospital leadership. I have shared these articles with providers and hospital administrators across Iowa, particularly those at facilities with the highest cesarean rates. I encourage families to contact their local hospital leadership and urge them to adopt evidence-based practices that improve maternal outcomes.
Another New York Times article explored placenta accreta, a life-threatening condition that was once extremely rare. According to the Placenta Accreta Foundation, rates of placenta accreta, increta and percreta have risen alongside overall cesarean rates in the U.S. The risk increases with each C-section or uterine surgery, which is why reducing unnecessary cesareans — both in first births and by expanding VBAC access— is critical.
One of my greatest frustrations in discussions with Iowa providers and hospital leaders about VBAC access is the near-total avoidance of conversations about the risks of repeat cesareans. Both VBAC and cesareans carry risks and benefits, yet I do not know anyone — including myself — who has been adequately counseled on the risks of multiple cesareans. Families seeking VBAC are often warned, sometimes inaccurately, about VBAC risks, while the cumulative risks of repeat surgery are rarely discussed. VBAC is treated as an exception requiring justification. Repeat cesarean is treated as neutral, despite compounding risk.
The Business Insider series “Business of C-Sections” underscores this disconnect, noting that only 2.5% of U.S. babies are born via elective C-section each year. Families are not demanding more surgery; the system is driving it. Another article in the series, “Cutting Costs,” highlights how financial incentives and hospital culture influence cesarean rates, showing that where a woman gives birth is one of the strongest predictors of whether she will undergo a medically unnecessary C-section.
I was interviewed for Business Insider by reporter Hannah Beckler for the article “C-Section Rates Vary Widely by Hospital. Women Often Can’t See the Data,” which discusses my efforts to obtain Iowa hospital cesarean and VBAC data through public records requests.
Some smaller Iowa hospitals are leading on VBAC
While access to Iowa hospital birth data has improved, it remains frustrating that individuals must request and analyze it themselves rather than the state publishing it in an accessible format. I publish this data on the ICAN of Central Iowa website, including visualizations highlighting hospitals with better-than-average outcomes.
Business Insider used this data to create its interactive hospital C-section map. View a slideshow of hospitals with the top highest cesarean and VBAC rates and which hospitals in Iowa are better than average.
It is important to note that some smaller, lower-volume Iowa hospitals are providing VBAC care — as they should. ACOG guidelines state that trial of labor after cesarean should be attempted at facilities capable of performing emergency deliveries. If a hospital can safely perform an emergency cesarean for a first-time birth, it should also be prepared to manage a potential emergency during VBAC. Hospitals with higher VBAC rates understand that rising cesarean rates create greater long-term risk for patients and often require transfer to higher-level facilities.
Unfortunately some hospitals continue to enforce a VBAC ban telling patients that they only provide prenatal care for repeat cesareans following a prior C-section. While some Iowa hospitals don’t outright ban it, the providers themselves refuse to provide evidence-based VBAC care or limit options for VBAC patients out-of-step with practice guidelines. Iowa families deserve access to hospital based care that respects patients autonomy and doesn’t default to major abdominal surgery unless truly necessary.
Rachel Manuel Bruns is a volunteer maternal health advocate and lives in Des Moines with her partner and two children. If looking for support on pregnancy, birth and postpartum support check out her compilation of maternal health resources. Rachel can be reached at rachel.m.bruns@gmail.com.
