Must One Cesarean Section Lead to Another? The VBAC Mothers Say No : Obstetrics: Patients and doctors have reasons to prefer surgery, but more and more hospitals require labor first. Normal birth is less risky.
Esther Zorn 10 years ago took a lonely journey from the familiar landscape of medical technology to the uncertain terrain of trust in her own body.
She had a VBAC--a vaginal-birth-after-Cesarean. And it changed the course of her life.
“I felt, after I had given birth to my daughter, that I had regained the blueprint for birthing that I could now pass on,” said Zorn, whose own birth in 1952 was by Cesarean delivery. “It was a feeling that I had regained something I had lost, way back.”
From this “blueprint” she built a cause: the Syracuse-based Cesarean Prevention Movement, now called the International Cesarean Awareness Network and 80 chapters strong. Zorn calls it an organization born of necessity.
Cesarean section is the most common major surgery in the United States, accounting for about 24% of all deliveries--some 957,000 a year, at a cost of $3 billion. The U.S. rate is one of the highest in the world and has risen 400% in 20 years.
Half of these Cesareans are unnecessary, research has shown, including most repeat C-sections, which account for a third of the operations performed each year.
About 80% of all women who have had Cesareans are capable of giving birth and should be encouraged to try, according to the American College of Obstetricians and Gynecologists.
VBAC is safer than surgery for both mother and baby. Mothers are out of the hospital sooner and recover more quickly. The death rate is as much as four times higher among women who have C-sections, and they are five to 10 times more likely to suffer from complications than women who deliver vaginally. Cesarean-delivered babies are seven times more likely to suffer from respiratory distress.
Yet in 1989, only 18% of women who had had Cesareans chose the VBAC route. Among their reasons: time, money, lack of support and fear--for women, the fear of the unknown, of another long labor ending in surgery; for physicians, fear of malpractice claims.
For doctors, elective Cesareans virtually eliminate the risk of legal action, require less work, can be scheduled conveniently and often are more lucrative. Although some insurance carriers have eliminated the “Cesarean incentive,” many doctors still earn as much as 40% more money for a C-section delivery.
“I don’t think it’s blatant, knife-happy, money-hungry physicians out there doing Cesareans for the money,” Zorn said. “I don’t think it’s as simple as that, but VBACs are going to take a bite out of their pocket.”
Dr. William Spellacy, a Florida obstetrician, suggested in a journal article that physicians be paid 10% more for performing a VBAC than for a repeat Cesarean, a plan that he said could save more than $134 million a year on medical bills. At least one insurance company already is doing that.
“A doctor, to do a VBAC, means he has to be paid less money, maybe get up at 2 in the morning and be up all night with a woman in labor and not really have any control over when this is going to happen,” said Dr. Bruce Flamm of Kaiser Permanente Medical Center in Riverside, Calif.
“So why should a doctor do a VBAC? A lot of doctors . . . sincerely say, ‘Why not just cut them all?’ The answer to that is, if somebody doesn’t need an operation they don’t need an operation.”
The college’s support for VBAC and a push by insurance companies to reduce costs have helped make vaginal-birth-after-Cesarean routine in some public hospitals. Women who have had one C-section are most likely to have another if they are in a private hospital, research has shown.
“Unless there are contraindications to a VBAC (we don’t) really give a woman a choice whether she’s going to have another C-section,” said Kathy Keleher, nurse-midwife at Medical Center Hospital of Vermont in Burlington. “The decision really is, ‘you need to at least go into labor and we’ll see what happens.’ ”
Recent reports about the worst that can happen caused unnecessary alarm, Flamm said. The June issue of Obstetrics and Gynecology carried reports on 20 cases of uterine rupture over an eight-year period among attempted VBACs at two hospitals.
The rupture risk is remote, doctors agree; estimates run about 1%. And uterine ruptures, which also can happen to a woman who has never had a Cesarean, rarely result in permanent fetal or maternal injury in a hospital setting.
In the journal report, 14 of the 20 babies were fine. Four others died and two had neurological damage. Of the four infants who died, only one was under direct physician observation. Two of them were born at home.
Many such problems could be eliminated if more hospitals and doctors supported VBAC, Flamm said. One insurance study found that vaginal-birth-after-Cesarean was available at fewer than half of U.S. hospitals.
“A lot of people are turning this around and making it sound like those of us who advocate VBAC are saying, ‘Oh, there’s nothing to it. Go try it at home.’ And that’s just simply not true,” he said. “Women are doing VBACs at home because they can’t find a doctor who will allow them to have a normal birth, and they can’t find a hospital where they can have their baby--unless they want an operation.”
Mount Sinai Hospital Medical Center in Chicago reduced its Cesarean rate to 11.5% over two years by, among other steps, requiring women who had previous Cesareans to try labor. Of the 87% who labored, 70% gave birth without surgery.
But at Mount Sinai and across the country, many women request repeat Cesareans, particularly those who suffered through lengthy labors the first time.
