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?

Illustration by Robert Neubecker

Our first child, head askew, had to be delivered by Caesarean. We loved the obstetrical surgeon who extracted him: Dr. Burgee worked fast, made us laugh, and left almost no scar. He saved the lives of my wife and son. I thanked my stars we lived in a Caesarean world.

But the operation hit Alice hard. Her legs ballooned with fluid, stranding her in bed; her incision hurt every time she moved or nursed; and her milk production faltered, stunting Nick's growth so that herequired hospitalization. Mother and baby both took months to recover. So, two years later, when Alice got pregnant again, the first thing she said to our midwife, Martha, was, "Please tell me I don't have to have another Caesarean."

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Martha obliged her, explaining that a normal vaginal delivery after C-section did carry extra risk, but that it was minimal. The best studies found that choosing a vaginal birth after having had a Caesarean (also known as VBAC) instead of a repeat C-section, roughly doubled the risk of uterine rupture, bringing it up from 0.3 percent-0.5 percent to around 0.6 percent-1 percent. And though a serious rupture can require an emergency Caesarean, these rarely occur and seldom cause lasting harm if a surgical team is in-house (as is the case at our birthing center in tiny Gifford Hospital in Randolph, Vt.). Roughly 75 percent of all VBACs go routinely, and those that don't usually end up as non-emergency Caesareans. This means that if a woman accepts a 1-in-200 chance of a rupture and emergency Caesarean, she has a 75 percent chance of avoiding another C-section altogether. Perhaps due to the recognition of these favorable odds, the rate of VBACs among mothers with previous Caesareans increased from 3 percent to 28 percent between 1981 and 1996. The change from the old "once a Caesarean, always a Caesarean" rule that had held for most of the 20th century had spared millions of women unnecessary surgery.

So, our daughter Linnea was born by vaginal delivery. Alice felt better after four hours than she had after four months following the Caesarean. We thanked our stars we lived in a VBAC world.

Unfortunately, during the past decade, more than 300 hospitals have stopped performing VBACs—and more do so monthly. The VBAC rate fell from 28 percent in 1996 to 12.7 percent in 2002, with double-digit drops in 2001 and 2002; repeat Caesareans now account for 13 percent of all births. The drop in VBACs accounts for most of the rise in overall Caesareans, from 20 percent in 1996 to 2002's record high of 27 percent. Many of these mothers who undergo Caesareans want VBACs but are denied that option by hospital bans that run counter to medicine's growing emphasis on patient autonomy and informed consent.

Why the turnabout?

Hospitals usually claim they're trying to protect mothers and babies from harm. But the truth is that hospitals ban VBACs for legal and business reasons, not medical ones. Several mothers have sued in recent years when VBACs led to uterine ruptures and damage to mother or baby. Some of these women won awards in the millions, usually because the emergency C-section had taken too long or the doctor hadn't warned them of increased risk. A key issue in such suits is a 1999 American College of Obstetricians and Gynecologists guideline calling for "immediate" availability of O.R. teams to support VBACs. Immediate, on-site availability of such teams thus quickly became a de facto legal standard.

Hospitals can sharply reduce their legal exposure by having such teams on call. But staffing these teams creates its own problem, which our Dr. Burgee calls "the harmony on the ship issue." Some hospital staffs rebel at the request to remain in-house while a mother attempts a VBAC. Hospitals with round-the-clock staffs might already have all the people needed—a surgeon or OB, anesthesiologist, operating room crew, pediatrician, assistant surgeon—on the premises. But at other hospitals, particularly smaller ones, those people might have to make special trips to the hospital to stand by during a VBAC for as long as the labor takes. Such hospitals may have to choose between VBACs and a happy surgical unit.

As it happens, Burgee and the rest of the Gifford staff support the hospital's VBAC commitment, even though the hospital (15 beds in the main unit, another eight in the birthing center) is the sort of small operation considered unsuitable for VBACs. The staff is unusually cohesive, and the birthing center—the first such center in Vermont, established in 1977—has long supported a team of midwives who work with the hospital's obstetricians with unusual collegiality and ease. In short, the hospital leans toward patient choice and a noninterventionist approach.

Gifford's staff and administration were also influenced by the findings of the Vermont/New Hampshire VBAC Project, which from 2000 to 2002 enlisted OBs, midwives, and birthing-center and obstetrical staffs from the region's hospitals to draw on the scientific literature and their own experience to create sensible VBAC policies. The resulting guidelines offer both small hospitals like Gifford and big academic centers like Dartmouth advice on how to provide VBACs safely and economically. (The guidelines outline how to assess the risk level of each patient—low, medium, or high—and set staffing levels and availability accordingly; they also remind hospitals to fully review risks and possible procedures with the patient.) That the project involved staff from so many hospitals has helped give it broad support in the two states, where almost all the large hospitals and many smaller ones continue to offer VBACs. The results are encouraging. Gifford's birthing center, for instance, hosts some 12 to 15 attempted VBACs a year—hundreds over the past three decades. About 1 in 5 of these women ended up having a Caesarean, but none has ruptured or gone to emergency Caesareans.

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