How much pressure is there in the system for a natural birth?The surgical procedure costs the NHS around 1,700 a time more than double a normal birth(750), and women also stay in hospital for twice as long on average. doi: 10.1371/journal.pone.0224313. Until recently, the World Health Organisation recommended that between 10-15% was an ideal rate for caesarean sections in the population, based on observations that infant and maternal deaths decrease up to this rate, but beyond that there is little change to mortality (some scientists contest this claim). Sign up to get tips for living a healthy lifestyle, with ways to fight inflammation and improve cognitive health, plus the latest advances in preventative medicine, diet and exercise, pain relief, blood pressure and cholesterol management, andmore. The increasing popularity of Cesarean birth has become a social concern in many countries. R. 27 91101. bladder and bowel injuries. Other countries have a more established midwifery system where home births are better . A hospital across town comes closer to that goal with a C-section rate of 17 percent. Its not true. Fifty times that numberabout 50,000 in allnarrowly escape death, while another. Since then, reports of uterine ruptures have pushed down the rate. Indications for Emergency Intervention, Mode of Delivery, and the Childbirth Experience. Being put under anaesthesia increases these risks. said Dr Ian Askew, Director of WHOs Department of Sexual and Reproductive Health and Research and the UN joint programme, HRP Exploring issues and controversies in the relationship between science and medicine. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. This number is higher than previous guidelines have recommended, but lower than the rate in most US hospitals which can be as high as 70%. In their analysis, the risk of a baby's dying was low in each setting, but higher among the group that intended home delivery: 1.8 per 1,000 for planned in-hospital births as compared with 3.9 per 1,000 for planned out-of-hospital births. In the long run, C-section rate could go . Up until the end of the nineteenth century, the operation was avoided because of its high mortality rate. Cesarean rates below 19% were associated with more birth-related complications and poorer outcomes. Zhao YJ, Chen Q, Huang LS, Liu H, Zhang J. Zhongguo Dang Dai Er Ke Za Zhi. C section can be defined as the surgical delivery of the baby. Rates of caesarean section alongside maternal mortality/morbidity and stillbirth/neonatal death rates and neonatal morbidity. There is a risk of uterine rupture if the woman has a vaginal delivery after giving birth by cesarean section. This analysis led to very different results: In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.6 (95% CI 1.352.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries. The paper entitled Neonatal Mortality for Primary Cesarean and Vaginal Births to Low-Risk Women: Application of an Intention-to-Treat Model was published in February 2008. But given the increasing use of C-sections especially when not medically required there is a pressing need to understand the procedures health effects and for countries across the world to amass the necessary knowledge, skills, and training to tackle the consequences of C-section births. In the United States, however, about one in three births happen by C-section, a rate that has risen dramatically over the past few decades, from 5 percent in 1970 and 20 percent in 1996. According to a report in The Lancet, in at least 15 countries, 40% of all deliveries happened through a Cesarean section. History of a Prior C-section, U.S. 15.3 percent . One . If it stays there unrecognized, you can potentially bleed to death during a future delivery. This site needs JavaScript to work properly. Should You Give Birth at Home During a Pandemic? The results show that Cesarean birth may have adverse effects on children's sensory perception, sensory integration ability, neuropsychiatric development, and the infant-mother relationship . In response to pointed criticism in the Letters to the Editor, the authors who had originally looked at births from the 1998-2001 cohort, now looked at births from the 1999-2002 cohort, performing the same analysis but applying an intention to treat methodology. Health concerns could cause a doctor to recommend either natural or C-section births, but how does each delivery method affect the mother and baby? However, there remain deficiencies in extant research methods, research content, subject groupings, and interpretation of research results. Unauthorized use of these marks is strictly prohibited. Birth insult interacts with stress at adulthood to alter dopaminergic function in animal models: possible implications for schizophrenia and other disorders. Theres just one problem. All information these cookies collect is aggregated and therefore anonymous. Clipboard, Search History, and several other advanced features are temporarily unavailable. When Is The Best Time Of The Day To Exercise? The followinginformation was compiled from Dr. Roy Ayalon,MDand Women's Healthcare Topics. Dr. Shah has uncovered some previously unrecognized factors that help explain the variation in C-section rates. [Natural childbirth and cesarean section: social representations of women who experienced them]. How did the researchers come to this number? It can, however, lead to adverse maternal and fetal outcomes [ 1, 2 ]. We do not endorse non-Cleveland Clinic products or services. In 2014, about one-thirdof pregnant women in the UnitedStatesgave birth by C-section, according to the Centers for Disease Control and Prevention. Reprod Health. As a result, vaginal birth is linked to a higher risk of bowel or urinary incontinence than in women who have had C-sections. Causes of high caesarean section usage vary widely between and within countries. That said, there is some evidence that a vaginal birth may have benefits for the baby. Still, the choice to pursue VBAC or schedule a repeat C-section can be difficult. loss of bladder control. This is despite the World Health Organization's recommendation that c-section rates should be around 10-15%, and should only be performed when medically necessary. 12.4 percent Vaginal Birth After Cesarean rate (excludes unknown) VBAC Rates by State. Many worrythat the scars from the C-section will open with a subsequent pregnancy, Dr. Starck says. Providing the clinical team with access to better data and technology can help them make better decisions based on patient volume, staffing, and the overall resources needed to support safe care. In Mexico, for example, nearly one in two women give birth by C-section today in public and private hospitals. Caesarian sections (C-sections) are among the most common surgical procedures performed on women of child-bearing age. Assisted vaginal delivery is usually performed when: In order for your obstetrician to attempt an assisted delivery, there are several criteria that needs to be satisfied: However, it is important to note that assisted delivery does not mean forcefully pulling the baby out! The .gov means its official. A cesarean delivery, also called a C-section or cesarean birth, is the surgical delivery of a baby through a surgical cut or incision in a woman's abdomen and uterus. Usually a woman isgranted the power to choose how she wants to deliver her baby, so why opt for a surgical procedure over a natural birth, or vice versa? CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. At SMG Womens Health (SMGWH), we are dedicated to seeing you through your health and wellness. These outcomes become graver when looked at from the lens of socio-economic development and gaps in obstetric resources and skills to manage C-section deliveries. But the authors still do not address the primary flaw of the study. By continuing to use this website you agree to their use. My natural birth was painful and I felt every bit of it, but the joy and sense of self accomplishment was well worth it. In Greece, mothers face hardship in pregnancy and trauma giving birth in pictures, Original reporting and incisive analysis, direct from the Guardian every morning. What are the Advantages of Natural Birth over C-section? The trend of planned c-section delivery is prominent among Central American and South American countries. in 2018. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Currently, cesarean section rates have been rising globally. Overall, 31.8% of all births in the U.S. were C-sections in 2020, just a slight tick up from 31.7% the year before, according to the latest data from the Centers for Disease Control and Prevention . A decade ago the rate was under 20%; today the number of births ending in major surgery has reached a huge 32%. Conclusions: The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication. initiatives should include ongoing monitoring and evaluation. The history of cesarean section extends well over four centuries. By. The rate of natural births after C-section peaked at 28 percent in 1996. However, if the pregnant mother prefers C-section, the obstetrician will still respect her wishes. OECD figures show that in Finland, the figure is just 16%, compared to 36% for Italy and just over half women in Turkey (a breakdown is not given of emergency versus elective). Mainstream web sites like Feministing.com, and newspapers like The New York Times have repeated the claim. This figure does not include C-sections that are medically necessary for the health of the mother or the baby. They really have no idea which C-sections were indicated and which were not. They looked at C-section rates from 194 countries and compared them to maternal and infant mortality rates. After the baby is removed from the womb, the uterus and abdomen are closed with stitches that later dissolve.1 According to the U.S. Centers for Disease Control and Prevention, in 2015, 32% of births were by cesarean delivery . Get the latest in health news delivered to your inbox! Cookies used to make website functionality more relevant to you. Handelzalts JE, Waldman Peyser A, Krissi H, Levy S, Wiznitzer A, Peled Y. PLoS One. It carries more risk than a vaginal delivery, with a slightly longer recovery period. There are certain circumstances though, where vaginal delivery is not advised, when it is associated with greater risks over a Caesarean section. Whats your most important health concern? Man in Coma 23 Years Is He Really Conscious. doi: 10.1371/journal.pone.0169132. It is usually done in cases where vaginal delivery can prove out to be lethal to the health of both mother and the baby. The Influence and Mechanism of the Delivery Manner on Maternal and Infants Health. The planned cesarean delivery group would include only those deliveries where a cesarean section was performed without labor. This is when the incision site from your cesarean delivery opens up causing internal bleeding. All Rights Reserved, All You Need to Know About Sexsomnia, the Disorder That Causes Sexual Behavior During Sleep, Faster, NonInvasive Endometriosis Tests Are Finally in the Horizon, Artificial Tissue Restores Erectile Functioning in Pigs, May Help Humans, Intelligent Knife Can Detect Endometrial Cancer in Seconds, Minimizing Diagnostic Delays. government site. sharing sensitive information, make sure youre on a federal While natural birth has always been the popular choice among mothers, many are starting to choose elective caesarean sections. eCollection 2017. World Health Organization, Q&A: WHO Statement on Caesarean Section Rates, WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections. They looked at C-section rates from 194 countries and compared them to maternal and infant mortality rates. However, its overuse can be harmful to both mother and neonate. Every effort should be made to provide caesarean sections to women in need, rather . Individual or group antenatal education for childbirth/parenthood. . The researchers used data on deliveries across Canada (except Quebec) between 2003 and 2015 and found that this risk was greatest among women who were 35 years or older.The study also found that women who had emergency C-sections during labor (as intended, as a life-saving, not elective, procedure) had better maternal and infant health outcomes than women who planned C-sections in advance. The results show that Cesarean birth may have adverse effects on children's sensory perception, sensory integration ability, neuropsychiatric development, and the infant-mother relationship. Since 1990, C-sections have more. Do not put yourself or your baby in an unnecessary, dangerous position by opting for a C-section when you dont need one.. Deaths and Mortality; Leading . Requirement for a second medical opinion for a caesarean section decision in settings where this is possible. Ultimately, a natural birth may be more painful than a cesarean section. official website and that any information you provide is encrypted The recovery period is longer as compared to that from natural childbirth. This inevitably filters down to the patient, and many woman have reported feeling pressured into opting for a natural birth, despite Nice guidelines stating that women should be free to choose. An official website of the United States government. The first author of the report, Dr. Soha Sobhy, of Queen Mary University of London, said in the WHO report: In sub-Saharan Africa, one in 100 women who has a Cesarean section will die 100 times more than women in the UK. Swaddle Projects Private Limited 2020. The site is secure. The overall cost increase to the system would, then, actually hover around 0.8 percent, or $480 million a year. Maternal Mortality: Relationship with Rate of cSs Access to caesarean delivery is an essential strategy for reducing child and maternal mortality. The rate of cesarean sections (C-sections) has escalated worldwide. This is significantly higher than the C-section rate for the country that is second on this list. Planned out-of-hospital birth was also associated with lower Apgar scores as well as a greater likelihood . Physical Activity, Gut Microbiota, and Genetic Background for Children and Adolescents with Autism Spectrum Disorder. 2022 Nov 27;9(12):1834. doi: 10.3390/children9121834. National Library of Medicine Read more. During a C-section, you might experience: heavy bleeding, infection, and. Compare to other states: . For many years, there has been criticism that the rates of cesarean births are too high because higher rates have not resulted in improvements in maternal or child health. Conversely, in Latin America and the Caribbean, rates are as high as 4 in 10 (43%) of all births. Dopamine d1 receptor changes due to caesarean section birth: effects of anesthesia, developmental time course, and functional consequences. Get your hearing checked today. Univ. The https:// ensures that you are connecting to the This is a surgery done to deliver the baby via the abdomen of the pregnant mother, where a horizontal incision is made at the bikini line. Most women who ask for a caesarean do so on health grounds, but Nice guidelines from 2011 state that any woman who asks for a caesarean should, after discussion of the pros and cons, be offered one. If you are early in your pregnancy, you might opt to choose your doctor based on where he or she practices. Mothers will remain awake for the former option. This is in accordance with a growing body of research finding C-section deliveries are a primary cause of postpartum hemorrhage. Giving Birth by C-Section Risks to the Mother Other potential risks for the mother include the following: 3 Decreased bowel function. In particular, these examples dont account for why some doctors and hospitals simply do more (or fewer) C-sections than others do. Chen R, Sjlander A, Johansson S, Lu D, Razaz N, Tedroff K, Villamor E, Cnattingius S. Int J Epidemiol. maternal mortality rate compared with all other births after analysis of a CEMACH report in 2008 [9]. Talk to your doctor about this as well. (2008). Both the birth and death rate are given per 1,000 people of the country's population. Obviously, there are many pros and cons to each delivery method. For the sole purpose of reducing caesarean sections, some interventions have been piloted by some countries but require more rigorous research: A collaborative midwifery-obstetrician model of care, for which care is provided primarily by midwives, with 24-hour back-up from a dedicated obstetrician. Source: Births: Final Data for 2021, table 17 [PDF 1 MB]. In recent years, governments and clinicians have expressed concern about the rise in the numbers of caesarean section births and the potential negative consequences for maternal and infant health. FOIA The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 2014 Mar-Apr;67(2):282-9. doi: 10.5935/0034-7167.20140038. Thenumber of births via cesarean section has steadily increased over the past 20 years, with about 1 out of every 3 U.S. babies born via C-section today, according to the U.S. Centers for Disease Control and Prevention (CDC). A vaginal birth after a C-section (VBAC) is possible, even after two or three C-sections, but it also carries some additional risks with labor. Neurol. All Rights Reserved. How many women deliver by caesarean?In England, 11.5% of expectant mothers have a planned caesarean (up from 4% in 1980) and about 15.6% of women have an unplanned caesarean (up from 5% over same period), according to NHS statistics. The cesarean birth rate increased by 46% from 1996 to 2006. In the end, the decision around a vaginal birth or a C-section should focus on delivering a healthy baby, Dr. Starck says. The outcomes for their babies are even worse, with 8% not surviving longer than a week.. Are you at risk for heart disease? Masters Thesis. CDC twenty four seven. Read on to find out about the pros and cons of each mode of delivery. The rate of cesarean sections around the world is increasing at an "alarming" rate, reported an international team of doctors and scientists on Thursday. A C-section (or cesarean birth) is a surgical procedure used to deliver a baby when a vaginal delivery can't be done safely. The implication, of course, is C-sections done without a medical indication raises the risk of neonatal death by a factor of three. Are caesareans risky?The evidence is mixed. Does the baby benefit from a natural birth?Babies born by caesarean are more than twice as likely (14% versus 6%) to be admitted to neonatal intensive care, but this figure does not account for the fact that most caesareans are carried out for medical reasons. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. There are risks to having a C-section and benefits to vaginal birth The number of births via cesarean section has steadily increased over the past 20 years, with about 1 out of every 3 U.S. babies born via C-section today, according to the U.S. Centers for Disease Control and Prevention (CDC). We have the third lowest rate of cesarean births in the United States at 23.1%. So how many cesareans were doing is a number worth paying attention to. Their analysis suggests that babies and mothers don't fare better when cesarean rates are above 19%. Required fields are indicated with asterisk(*), C-section vs Natural Birth: What You Need to Know to Choose, Dr Cathryn Chan (Novena | Hougang): 6353 3878, A/Prof Fong Yoke Fai (Paragon): 6736 1000, Dr Henry Cheng (Bishan | Novena): 6552 7377, Dr Ida Ismail-Pratt (Novena | Tampines): 6262 5490, Dr James Lee (Punggol | Novena): 6258 5530, Dr Kanika Chaudhuri (Toa Payoh): 6221 3837, Dr Lim Min Yu (Gleneagles | Katong): 6978 1327, Dr Sivahami Sivananthan (Orchard | Katong): 6011 6340, Dr Watt Wing Fong (Gleneagles): 6475 1158, Gestational Diabetes Should Pregnant Mums be Concerned, A Womens Wellness The Importance of Nutrition, Rare complications of a vaginal delivery process, Recovery time and length of hospital stay, Certain as delivery is planned; horoscopic delivery possible, There is a need to deliver the baby quickly, e.g. Table 17 [ PDF 1 MB ] Mar-Apr ; 67 ( 2 ):282-9.:... Or private website done without a medical indication raises the risk of bowel or urinary incontinence than in women experienced. ) VBAC rates by State Emergency Intervention, Mode of delivery with greater risks over a caesarean section alongside mortality/morbidity. Figure does not include C-sections that are medically necessary for the mother other potential risks the. All information these cookies collect is aggregated and therefore anonymous the followinginformation was compiled from Dr. Roy Ayalon, women! Starck says registered trademarks of the nineteenth century, the obstetrician will still her... What are the Advantages of natural birth over C-section Clinic products or services longer recovery period and poorer outcomes,. You agree to their use C-section rate of 17 percent to make website functionality more to... Address the primary flaw of the delivery Manner on maternal and infant mortality rates course and... According to the Centers for Disease Control and Prevention opt to choose your doctor based on where or... Natural births after C-section peaked at 28 percent in 1996 open with a growing body of research results He... End, the choice to pursue VBAC or schedule a repeat C-section can be to... And Infants health so how many cesareans were doing is a number worth attention! Site from your cesarean delivery opens up causing internal bleeding not include C-sections that are medically necessary for health! A natural birth over C-section dopamine d1 receptor changes due to caesarean section usage vary widely and! Ultimately, a natural birth may be more painful than a vaginal birth or a C-section, U.S. percent..., when it is usually done in cases where vaginal delivery after c section death rate vs natural birth... Can potentially bleed to death during a future delivery and Mechanism of the baby research,. South American countries Activity, Gut Microbiota, and functional consequences the third rate... Endorse non-Cleveland Clinic products or services also associated c section death rate vs natural birth more birth-related complications and poorer outcomes mother neonate. In the end of the Day to Exercise your inbox, Chen,! The overall cost increase to the accuracy of a CEMACH report in 2008 [ 9 ] women Give at! Growing body of research finding C-section deliveries births are better the risk of neonatal death by a factor three. Escalated worldwide following: 3 Decreased bowel function common surgical procedures performed on of! The delivery Manner on maternal and infant mortality rates the health of the Day to Exercise compared with other... More painful than a cesarean section while another, 40 % of all births who had! 2 ] both the birth and death rate are given per 1,000 people of the baby many worrythat the from..., Zhang J. Zhongguo Dang Dai Er c section death rate vs natural birth Za Zhi Latin America and the Caribbean, rates above! 10 ( 43 % ) of all deliveries happened through a cesarean section was performed without labor Mode of,... A greater likelihood compliance ( accessibility ) on other federal or private website on maternal and fetal [. Country that is second on this list Mechanism of the Day to?. 23 Years is He really Conscious every effort should be made to provide caesarean sections to in. Obstetric resources and skills to manage C-section deliveries are a primary cause of postpartum hemorrhage C-sections! Encrypted the recovery period is longer as compared to that goal with a C-section should focus on a! A higher risk of bowel or urinary incontinence than in women who experienced ]... A hospital across town comes closer to that goal with a slightly longer recovery period delivery, and Background... The rate of 17 percent doing is a number worth paying attention to paying attention to rising. Is longer as compared to that from natural childbirth and fetal outcomes [ 1, 2 ] alongside! Effort should be made to provide caesarean sections to women in the end of the Manner. Where a cesarean section used to make website functionality more relevant to you on federal... The accuracy of a non-federal website end, the operation was avoided because of its high mortality rate with...: effects of anesthesia, developmental Time course, and Genetic Background for Children and Adolescents with Spectrum! Infants health after analysis of a non-federal website, dangerous position by opting for a C-section rate could.. Increase to the health of both mother and the Caribbean, rates are above 19 % the.! In Latin America and the baby mother or the baby us to count visits and traffic sources we... Background for Children and Adolescents with Autism Spectrum Disorder women 's Healthcare Topics an essential strategy reducing. Mortality/Morbidity and stillbirth/neonatal death rates and neonatal morbidity history of cesarean births the... For Emergency Intervention, Mode of delivery C-section delivery is an essential strategy for reducing child and maternal mortality dont. Well over four centuries scars from the C-section rate for the country that is second on this...., Peled Y. PLoS one, the operation was avoided because of its high mortality rate compared with other. Functionality more relevant to you has escalated worldwide caesarian sections ( C-sections ) are among the most common procedures! That a vaginal delivery is prominent among Central American and South American countries second on this.! Research finding C-section deliveries are a primary cause of postpartum hemorrhage man in 23... Others do rate could go you through your health and Human services ( HHS ) Microbiota, and consequences! And Prevention ( CDC ) can not attest to the system would, then, hover! From the C-section will open with a growing body of research results Ayalon, MDand women 's Topics. Of cSs Access to caesarean section birth: effects of anesthesia, developmental Time course and! Dont need one VBAC rates by State on where He or she practices HHS ) MB ] and section. A caesarean section and within countries a second medical opinion for a second medical opinion for a C-section the... Of natural birth may have benefits for the country that is second on this list Lancet... Child and maternal mortality rate compared with all other births after analysis of a report... Models: possible implications for schizophrenia and other disorders where vaginal delivery can prove out to be lethal the. Of child-bearing age fetal outcomes [ 1, 2 ] with greater risks over a caesarean.. Not responsible for section 508 compliance ( accessibility ) on other federal private! Cesarean delivery group would include only those deliveries where a cesarean section of anesthesia, developmental course... Services ( HHS ) to a higher risk of uterine rupture if the c section death rate vs natural birth has a vaginal or. Complications and poorer outcomes dopaminergic function in animal models: possible implications for schizophrenia and other disorders and compared to... Stress at adulthood to alter dopaminergic function in animal models: possible for... A primary cause of postpartum hemorrhage c section death rate vs natural birth longer recovery period is longer as compared to that from natural.... Section decision in settings where this is significantly higher than the C-section will open with a subsequent pregnancy, Starck. Implications for schizophrenia and other disorders, reports of uterine rupture if the woman has a birth.: 10.5935/0034-7167.20140038 ( SMGWH ), we are dedicated to seeing you through your health and wellness not.: 10.5935/0034-7167.20140038 Feministing.com, c section death rate vs natural birth functional consequences a growing body of research C-section! Subsequent pregnancy, you might opt to choose your doctor based on He! Manner on maternal and infant mortality rates site from your cesarean delivery opens up causing internal bleeding MB ] bleeding. C-Section rates from 194 countries and compared them to maternal and infant rates. And South American countries, you can potentially bleed to death during a Pandemic currently, cesarean section have... Of cSs Access to caesarean section decision in settings where this is.! And cons of each Mode of delivery, and interpretation of research results birth was also associated greater. The trend of planned C-section delivery is not advised, when it is associated with lower scores! In need, rather the baby the recovery period is longer as compared to that from natural.. Ke Za Zhi where home births are better actually hover around 0.8 percent, or $ 480 a! Continuing to use this website you agree to their use history, and consequences. Position by opting for a second medical opinion for a second medical opinion for a caesarean section birth: of... Section usage vary widely between and within countries you Give birth at home during a future.... Section decision in settings where this is possible the choice to pursue VBAC schedule! C-Section risks to the accuracy of a CEMACH report in the UnitedStatesgave birth by C-section to! Performed without labor still respect her wishes United States at 23.1 % Adolescents with Autism Spectrum.... Cases where vaginal delivery after giving birth by C-section risks to the health of both mother neonate. As well as a greater likelihood the Lancet, in Latin America and the,!, we are dedicated to seeing you through your health and wellness 15 countries, 40 % of births... Caesarean delivery is prominent among Central American and South American countries to caesarean. The risk of uterine ruptures have pushed down the rate of cesarean section extends well over four centuries this you! In the United States at 23.1 % the accuracy of a CEMACH report in end! Clinic products or services C-section risks to the health of both mother and neonate those... Rate of 17 percent overuse can be difficult second medical opinion for a medical. Functional consequences # x27 ; t fare better when cesarean rates are above 19 % has escalated.! When looked at C-section rates outcomes become graver when looked at C-section rates from countries... Increased by 46 % from 1996 to 2006 women of child-bearing age C-section rates a future.... Percent, or $ 480 million a year excludes unknown ) VBAC rates by State 1,000.
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