The backlash against VBACs.

Health and medicine explained.
Dec. 28 2004 6:00 PM

VBAC Backlash

Why are hospitals forbidding women who have had C-sections the right to have vaginal births?

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A study just released in the New England Journal of Medicine—the largest and most rigorous to date, involving almost 34,000 births at 19 academic hospitals from 2000 to 2003—confirms the VBAC's minimal risk. The study included roughly 18,000 women who chose VBAC and 16,000 who elected a repeat Caesarean. Mishaps struck a small percentage of each group. Of those who chose VBAC, 74 percent delivered vaginally, and the rest had Caesareans. One-hundred-twenty-four VBACers (0.7 percent) experienced uterine ruptures (14 of these were discovered after a vaginal birth, and 110 were discovered during Caesareans that were initiated when labor stalled or a fetal monitor indicated distress); seven of the babies whose mothers' uteruses ruptured (0.04 percent of all the planned VBAC births) suffered hypoxia-related brain damage that was likely caused by these uterine ruptures, and two of those babies (0.01 percent) died. The Caesarean group, meanwhile, saw twice as many maternal deaths (7 versus 3, or 0.04 percent for Caesareans versus 0.02 percent for VBAC). Overall, "adverse events," ranging from minor complications to those dozen deaths, occurred in 5.5 percent of the VBAC births and 3.6 percent of the elective Caesareans. VBACs posed more risk to infants, C-sections to mothers. A woman choosing VBAC over repeat Caesarean, the report study concluded, increased her overall risk of adverse outcome by 0.046 percent­­—a factor of about 1 in 2,000.

These odds make the hospitals' complaints about VBAC's safety sound rather disingenuous. To be sure, the most serious adverse outcomes hold our attention, as well they might; brain-damaged and dead infants and mothers who die, lose their uteruses, or live their lives in pain rank among our worst nightmares. But these horrors attend Caesareans, too. And VBAC carries a risk premium similar to or less than that of numerous elective procedures—or birth in general. Fallopian tube ligation for birth control, for instance, fails in 1 of 200 cases, creating the possibility of a life-threatening ectopic pregnancy. Epidural anesthesia during labor raises the chance of instrument-assisted delivery, stalled or long labor, maternal fever, maternal low blood pressure, and Caesarean—all of which cause further, often grave, dangers. A VBAC goes badly, however, with extreme rarity. Covering a VBAC, says Burgee, is usually quite boring.

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Given his support of VBACs, I was surprised to learn that Burgee himself doesn't perform them. He did for two decades, but he stopped in 1990 when he reduced his practice to half-time while he got a law degree (so far unused). When he resumed his full-time practice, he didn't take them up again. He stopped, he says, partly because his legal education made him see his legal risks more starkly. Managing the cases thus seemed more complicated than ever: The OB in him would be pulling for the VBAC, while the surgeon, lawyer, and potential trial defendant would worry that he should wheel the mother to the O.R. Now he explains to his patients why he doesn't perform VBACs, outlines the odds as well as the arguments for and against, and offers the names of midwives and doctors who will perform the procedure. Burgee's stand, distinctly personal, provides excellent care for his patients while leaving them every option; one can scarcely object.

Likewise, who can question my wife's choice to pursue a VBAC? Given two nearly equal risks she chose the risk she felt most comfortable with.

Both decisions highlight the perversity of hospitals banning VBACs. When a hospital bans the practice, it takes away the right of doctors, midwives, and patients to make such personal choices; it settles by institutional edict a decision that should belong to patient and caretaker. The choice is indeed serious: A Caesarean is major surgery, and a VBAC adds a risk that is tiny but terrible. But choosing between the two options isn't a matter of right or wrong, statistical clarity, or policy imperatives. It's a judgment call—one that a hospital has no business making.

David Dobbs is writing The Orchid and the Dandelion (Crown), a book exploring ideas about how genes and experience shape temperament, behavior, and fate. 

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