Giving Birth Their Way
Women who have had a caesarean section often want to deliver their next child vaginally--and many are physically capable of doing so. But across the nation, they’re increasingly denied that option.
Vaginal birth after caesarean--known as VBAC--a childbirth practice heralded only a few years ago as a way to spare women from another surgery, has fallen so far out of favor that women now say they have to fight for it.
This year, hospitals in upstate New York; central Ohio; Spokane, Wash.; Des Moines; Aspen, Colo.; and elsewhere have announced that they will no longer offer the VBAC option.
Only 16.5% of U.S. women with prior caesarean sections had a vaginal birth last year, according to the National Center for Health Statistics, a 20% drop from the previous year. California’s rate, at 14.5%, is among the lowest in the nation, and some local hospitals report current rates of less than 5%. In Southern California, where few hospitals forbid vaginal births after a caesarean, many women nevertheless say their obstetricians actively discourage the option.
Ginger Clinton, a 24-year-old Simi Valley woman, sought a vaginal birth earlier this year because of a difficult recovery after the caesarean birth of her first child. Although doctors said she was a good candidate for a vaginal delivery, she had to change physicians twice before finding one who supported her request.
“I was at the end of my second trimester when I went to the third doctor, and then my insurance company almost didn’t let me switch doctors,” said Clinton, who had a successful vaginal delivery in July. “It was worth the battle, but, golly, it was a lot of work.”
Women’s health experts agree that VBAC can be a reasonably safe--even preferable--option. The American Academy of Obstetricians and Gynecologists concluded in a 2000 report that the benefits of a vaginal birth after a caesarean outweigh the risks for many women. And the federal government has set a goal of 37% VBAC deliveries as part of its Healthy People 2010 objectives, up from the 28% rate reported in 1998.
But safety, cost, convenience and malpractice concerns have sent the rates plunging, not increasing.
The decline started in 1999 when the American College of Obstetricians and Gynecologists recommended that a doctor and an anesthesiologist be “immediately available” when a VBAC patient is in labor. Before 1999, a doctor and surgical team were advised to be “readily available,” widely interpreted to mean that they be within 30 minutes of the hospital.
The policy change addressed a complication of VBAC, called uterine rupture, in which the caesarean scar from a previous birth ruptures. Such an event occurs in an estimated 1% of VBAC patients, and both the mother and baby can die or be seriously harmed.
Although the revision was designed simply to ensure women’s safety, it began to drive the procedure from everyday practice.
“There has been absolutely no change in the underlying scientific background on VBAC,” says Dr. John Aiken, an obstetrician at Northridge Hospital Medical Center. “But because of this ... requirement, the physician has to be on site. A lot of physicians don’t come in to the hospital until their patient is fully dilated [ready to give birth]. So they can’t meet the criteria.”
Both hospital administrators and doctors say it’s too costly and inconvenient for a doctor to sit with a patient in labor (which may last many hours).
“There really isn’t any incentive for the physician to do VBACs,” said Dr. Roger K. Freeman, an obstetrician at Long Beach Memorial Medical Center and chairman of the obstetricians task force on VBAC. “It’s more time-consuming, more worry. And they don’t get paid any more for it.”
Clinton’s doctors were blunt in denying her VBAC attempt. “One doctor said he wouldn’t be willing to wait during my labor. The other doctor said even if he was [available], the chance of having the rest of the team there isn’t very good,” she said.
Some women, patient advocates and doctors are upset that nonmedical issues may lead to unnecessary surgery that has attendant risks of its own. One patient advocacy group, International Cesarean Awareness Network, plans to petition the obstetricians group, the American Hospital Assn. and insurance groups, protesting the increasing loss of VBAC as an option.
“It’s all about money,” says ICAN’s president, Anita Woods of Kansas City, Mo. “It has nothing to do with safety. We are being railroaded by money concerns.”
Decisions to forbid VBACs have divided doctors and health executives in many cities. Ridgecrest Regional Hospital, a Mojave Desert hospital about 150 miles from Los Angeles, for example, voted earlier this year to drop VBACs because it could not supply round-the-clock doctor and anesthesiology services, says Tina Wallum, administrator of patient care services.
“This caused a lot of discussion among our medical staff,” Wallum says. But, she adds: “It’s not that we’re opposed to VBAC, but we believe it should be attempted in a setting that can provide that.”
The new policy means that women who want the option will need to travel 90 miles to a hospital in Lancaster, Wallum says.
Weighing the Risks
The risk of infant death due to a uterine rupture during a VBAC is about 1 in 1,000, twice the rate among other laboring women, according to studies. Uterine ruptures can cause permanent injuries in babies and lead to hysterectomies.
But women who have successful VBACs avoid the much longer recovery time and risks associated with C-sections. For the mother, those risks include infection, hemorrhage, blood clots, injuries to other organs and exposure to major anesthesia. The risks to the baby from C-sections are higher rates of respiratory disorders, fetal trauma and fetal death.
Few medical experts disagree with the idea that doctors should be on hand during a VBAC patient’s labor, but some say women are being misled into thinking that such labor is extraordinarily risky.
“The patient is not being told, ‘I don’t want to sit with you in the hospital,’ ” says Ellie Shea, a longtime birth educator in the South Bay. “She hears, ‘This is a matter of safety for you; you should really have a caesarean.’ It’s hard for women to sort out whether they should pursue a VBAC and whether they are endangering their babies if they do so.” Shea is also a doula, a person trained to provide emotional support and comfort during labor.
Juliet Babros, a Redondo Beach public relations executive, was resolute about wanting to try a VBAC for her second child. She delivered the baby vaginally, without incident, last week. “I had a slow recovery with the caesarean,” she says. “I didn’t feel like I could respond to my baby as quickly. Now I have a 2-year-old, and I want to bounce back quicker. I want to get home quicker.”
She explained her reasoning to her obstetrician, who was so unenthusiastic that Babros decided to find a new doctor. Her second doctor supported her wishes but warned that she would be subjected to numerous restrictions during labor, and that another caesarean was still a possibility.
Statistics show that VBACs are successful in 80% of women who are considered good candidates for the procedure.
“They treat you as this high-risk person,” Babros says. “When you talk to doctors about it, you get so fearful because they are fearful. They tell you the worst-case scenarios and maybe none of the benefits.”
Cedars-Sinai Medical Center offers a class to help pregnant women reach a decision, says Dr. Kimberly Gregory, director of maternal-fetal medicine. “The class is an opportunity to get a perspective about the risks and benefits in a more objective way,” Gregory says. “VBAC is fairly safe if you’re willing to accept that 1% [uterine rupture] complication rate.”
To keep the risk low, the American College of Obstetricians and Gynecologists recommends that women try VBAC only if they’ve had only one caesarean via a type of incision called a low transverse (a horizontal incision on the lower part of the uterus). The low transverse scar is much less likely to rupture than other types of caesarean scars during a VBAC attempt, studies show. Candidates should be healthy women, carrying babies in a head-down position, who are in their 37th to 40th week of pregnancy.
Coming Full Circle
Only a few years ago, health insurers and hospitals were so enamored of VBACs as a cost-cutting measure (vaginal births are less expensive than surgical births) that almost every former caesarean patient was urged to try it. That practice led to a dramatic increase in uterine ruptures and scores of lawsuits from families nationwide who suffered injuries or deaths.
Jacqueline Gang, a San Pedro woman who is expecting her second child, was surprised when her obstetrician balked at her request to try a vaginal birth.
“He came right out and said it was for liability reasons,” says Gang, who has hired a doula to help advocate for her during her labor. “Part of me was a little offended at his honesty.... I want my doctor to do what is in my best interest.”
Many of the lawsuits arose from cases in which the patient was not a good candidate for a vaginal birth, said Dr. T. Murphy Goodwin, chief of maternal-fetal medicine at USC’s Keck School of Medicine, where dozens of VBAC-related lawsuits in the 1990s led to payouts totalling $24 million.
“We select our patients for VBAC much more carefully now,” Goodwin said. “There is a much greater appreciation for who is a good candidate.”
To reduce possible complications, the American College of Obstetricians and Gynecologists recently admonished doctors to avoid using drugs that start or speed up labor in VBAC deliveries. Use of labor-inducing drugs, called prostaglandins, have doubled in the last decade (from 9.3% of all deliveries in 1990 to almost 20% in 2000). But the drugs dramatically increase the risk of a uterine rupture during VBAC, according to a study published last year in the New England Journal of Medicine.
A quicker physician response time, better selection of patients and disuse of labor-inducing drugs should reduce the risk of complications from VBAC, experts say. But not many women stand to benefit from the changes, says Shea, the birth educator.
“If women know to ask some questions or understand what is happening behind the scenes, they are more likely to get a VBAC,” she says. “But it’s hard for the average woman to advocate for herself.”
