March 10, 2009

The War Against VBACs

Over the last week or so, many childbirth education blogs and articles have focused on Pamela Paul’s latest article in TIME magazine, The Trouble With Repeat Cesareans. It is so wonderful that this important subject is receiving some attention. Paul, who happens to be a third time student at the Prenatal Yoga Center, also expanded on the story in the Huffington Post in Childbirth Without Choice. In this lengthier version, Paul goes on to detail her own personal experience with a VBAC (Vaginal Birth After Cesarean) backlash.

The current trend in our country is that one third of pregnant women will give birth via cesarean section. Within that population, 9 out of 10 women will have c-sections for any subsequent births. For some women it is a choice, and the c-section will be scheduled; others who may want a VBAC will find themselves restricted by the lack of hospitals or doctors willing to provide the service.

Paul’s article focuses on the obstacles women who want to try a VBAC face. Many hospitals are moving away from offering VBACs to their patients altogether. A recent study from the International Cesarean Awareness Network shows 821 hospitals formally banning VBAC, and 612 with a “de facto” ban. There seem to be three main factors contributing to this decision: financing, scheduling and medical risk. Financially speaking, many doctors and hospitals are not willing to risk either the chance of litigation or higher insurance premiums. In a 2006 ACOG (American College of Obstetrics and Gynecology) survey of 10,659 ob-gyns nationwide, 26% said they had given up on VBACs because insurance was unaffordable or unavailable, while 33% said they had dropped VBACs out of fear of litigation. There is also the personnel cost to take into consideration. In order for a hospital to provide a VBAC, they are required to have an anesthesiologist and surgeon on call in case something goes awry and an emergency c-section is needed. This is both costly and time consuming. However, Ms. Paul highlights a comment from Dr. Mark Landon, a maternal-fetal-medicine specialist at the Ohio State University Medical Center and lead investigator of the NIH’s largest prospective VBAC study: “How can a hospital say it can handle an emergency C-section due to fetal distress yet not be able to do a VBAC?”

Hospital staff scheduling is also a factor. A cesarean takes an hour while a labor undertaken “the old fashion way” is unpredictable and can last many hours. I often joke with my students when they are scheduling their c-sections or inductions that they will never go in on a Friday, Saturday or Sunday night. Monday through Thursday is the prime time in the Labor and Delivery unit.

As Paul boldly points out, the medical risk of a VBAC is real. Once the uterus is cut, the strength of its muscle tissue is compromised. In the case of a uterine rupture, the results can be fatal to both mom and baby. Because there is a higher risk of uterine rupture for a VBAC candidate, there are stricter protocols about induction and monitoring to assure the safety of both mother and child. A rupture, however, occurs in just 0.7% of cases. That’s not an insignificant statistic, but the number of catastrophic cases is low – only 1 in 2,000 babies die or suffer brain damage as a result of oxygen deprivation. While that number may seem frightening, especially to a mother-to-be who wants nothing but a healthy baby, it is important to remember that there are also significant risks associated with cesarean births.

Neither a VBAC nor a planned cesarean can guarantee a complication-free experience. Both options offer benefits and serious risks that need to be taken into account. But doesn’t an expectant mom who understands all the relevant factors deserve access to both? Dialogue on both sides of the VBAC argument is crucial, especially when we’re seeing the prevailing attitude toward VBACs robbing so many expectant moms of the choice of how to birth their babies.

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