Providing women with a trial of labor after a cesarean delivery helps reduce cesarean rates and is a form of patient-centered care. However, deciding who is an appropriate candidate for vaginal birth after cesarean (VBAC) requires weighing the patient’s unique medical history and their future childbearing plans.
In the past, race and ethnicity were factors in calculations used to predict the success of VBAC in patients, but they have since been removed. New research led by OB-GYNs at NewYork-Presbyterian and Weill Cornell Medicine surveyed physicians to understand how aware they were of the new recommendations. Below, Julia Cron, MD, FACOG, Vice Chair of Obstetrics and Gynecology at NewYork-Presbyterian and Weill Cornell Medicine, shares findings from this survey and discusses efforts to eliminate racial and ethnic biases from clinical algorithms.
History of VBAC Calculators
As medical providers, we try to reduce bias. Having objective data, such as calculators, can help us mitigate some bias and better counsel patients. The original VBAC calculator was developed by the National Institute of Child Health and Human Development (NICHD) and published in 2007.
The calculator considered several variables, including race and ethnicity. Since then, there has been a lot of discussion and research devoted to the use of race in clinical algorithms, and it is now quite clear that race is not a biologic construct like weight and age. Instead, race is a proxy for variables that demonstrate the impact of racism. Including race in the calculator falsely elevated the prediction that the VBAC would be unsuccessful for minority patients.
As a result, in 2021, the American College of Obstetricians and Gynecologists issued a practice advisory highlighting the limitation of the VBAC calculator and encouraging clinicians to use a revised calculator without race and ethnicity adjustments.
Provider Survey Results
In 2022, we conducted a survey of obstetrics providers at eight hospitals within the NewYork-Presbyterian system to assess whether they were aware of the availability of the revised VBAC calculator. We partnered with NewYork-Presbyterian’s Dalio Center for Health Justice to develop the 11-item questionnaire that asked if providers used a VBAC calculator, if they were aware of the revisions, and if they thought race contributed to the success of a VBAC.
We received 125 survey responses. Surprisingly, 23% of providers were unaware of the 2021 revisions. We also learned that 65% of providers said they use a calculator, leaving 35% who do not. That begs the question: What are they using, and it is better to use a calculator or not? Our main takeaway was that there was a need to educate obstetrics providers about both the calculator and the importance of recognizing race as a social construct, not a biologic variable that impacts labor and delivery.
Addressing Implicit Bias
Over the past few years, racism in medicine has been brought to the forefront, but I think it’s still not on many people’s radars. The issue of unconscious bias is real. I’ve gone through a lot of these trainings, and it is really eye-opening. It gives you the tools to recognize some of your own unconscious bias. There is strong data to support that we can't completely rid ourselves of unconscious bias, but recognizing it is the first step to mitigating it.
Removing race and ethnicity as variables from VBAC calculators can help provide more equitable maternal care.
After identifying gaps in knowledge about the VBAC calculator and race in clinical algorithms, we instituted a training for all obstetrics providers within the NewYork-Presbyterian system using a web-based training program from the California Health Care Foundation that highlights awareness about racism in medicine, particularly in the obstetrics setting. All our clinicians are now encouraged to participate in this training.
Rethinking Clinical Algorithms
The provider survey was just one part of NewYork-Presbyterian’s commitment to eliminate race adjustments as part of clinical algorithms and clinical decision support tools. Along with several area hospitals, in 2021 we joined the New York City Department of Health and Mental Hygiene’s Coalition to End Racism in Clinical Algorithms (CERCA) to examine algorithms used across medicine, from kidney and pulmonary function tests to the VBAC calculators. My hope is that we will continue to advance the acceptance of race as a social construct, not a biologic variable, so that we can provide equitable care to all.
