Will VBACs make a comeback?
The New York Times wrote a fascinating story looking at the rise and fall of VBACs — or vaginal births after Caesarean section — and how the government would like to bring them back into practice more frequently. It examined the successes at a Navajo hospital in Arizona, where they have lowered their number of Cesareans and increased their number of VBACs, even though the national numbers are just the opposite.
Here is the gist of The New York Time’s very long, but very interesting, story:
In the beginning there used to be a saying “once a Caesarean, always a Caesarean.”
Doctors feared the Caesarean scars on the uterus could rupture during subsequent labors so women were always forced to have Caesareans after their first one.
However in 1980 a panel declared it was safe for many women to deliver vaginally after having a C-section and the VBAC became very popular.
By 1996 VBACs reached their high of 28.3 percent.
Then there were some problems. Ruptures, deaths and of course lawsuits lead to stricter guidelines to perform VBACs and the rate has now dropped to below 10 percent.
So why is that bad? Here’s what the New York Times’ article explains:
“The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that a health care overhaul is supposed to address.”
“Even the American College of Obstetricians and Gynecologists has acknowledged that the operation is overused. Though there is no consensus on what the rate should be, government health agencies and the World Health Organization have suggested 15 percent as a goal in low-risk women.”
“ ‘VBAC’ has become a battle cry, with fierce advocates on both sides—women who insist that they should not be forced into surgery versus doctors and hospitals who insist on repeat Caesareans, citing the risks of labor and concerns about liability and insurance. ”
With that background information, then the article looks at the Tuba City Regional Health Care Corporation. It’s a hospital run by the Navajo Nation in Arizona and many believe is a model of what obstetric care should be like across the nation.
The hospital’s overall Cesarean rate is 13.5 percent which is less than half the national rate of 31.8 percent in 2007.
And last year the hospital had 32 percent of women who previously had Cesareans deliver vaginally. (Remember the national average is below 10 percent.)
Nurse-midwives deliver most of the babies born vaginally. It is believed that the C-section rate is lower because the midwives are trained to coach women through labor and will wait longer to recommend a C-section. Also the midwives are less likely to induce before due dates which can also lead to a C-Section.
(For comparison sake, midwives attend to only 10 percent of vaginal births nationally.)
Besides just the midwives, changes in insurance practices could also help increase VBACs, according to the article.
“Changes in malpractice insurance would also help, so that obstetricians would feel less pressure to perform Caesareans. (The hospital and doctors in Tuba City are insured by the federal government, and therefore insurance companies cannot threaten to increase their premiums or withdraw coverage if they allow vaginal births after Caesarean.) Patients, too, would have to adjust their attitudes about birth and medical care during pregnancy and labor.”
So what do you think? Did you have a VBAC? Would you have chosen a VBAC if you could? Did you feel pressured to have a C-section from your doctor or insurance company?
Do you think it is an important goal to reduce the number of C-section and increase VBACs? Would you be afraid to deliver vaginally after a C-section?
Would this story help you want to have a midwife attend your birth? Would it increase your confidence in asking for a VBAC?
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243 comments Add your comment
Cammi317
March 11th, 2010
11:45 am
Interesting topic, I’ll have to ask my friends and family members who had c-sections. My daughter was delivered vaginally, 8 lbs, and no tearing. Interestingly enough, my sister delivered my niece 4 months before, 8 lbs 4 oz, and her doctor gave her an episiotomy because he claimed women always tear their first time anyway. If not for the fact that he delivered myself and all of my siblings many moons earlier, I would call him a moron. However, since my niece’s birth was his last delivery before he retired, I will simply say he was old and misguided. :0)
Jason
March 11th, 2010
11:50 am
My wife just had a VBAC, and I’m glad that she had the opportunity. All patients should have the right to truthfully assess the benfits and risks concerning any procducres, including VBAC vs. CBAC. A one size fits all approach, such as “We don’t do VBACs. PERIOD.” ignores the potential risks of multiple repeat c-sections.
I do feel that the rate of primary C-sections should be lower, as it is a major surgery that’s unfortunately treated as a routine procedure.
nurse&mother
March 11th, 2010
11:50 am
I hope I didn’t come across like I felt that vag deliveries are alwasy superior to c/s. There are many times where a c/s is necessary.
It should be a case by case.
I do DISAGREE with a first time mom wanting a C/S (with NO medical indication) “just because”.
Hey, Dian...
March 11th, 2010
12:06 pm
…I didn’t say “VBAC’s are risky based on…claims experience” – what I think is that many who are reading and commenting here missed a very important part of the article – “Even the American College of Obstetricians and Gynecologists has acknowledged that the operation is overused. Though there is no consensus on what the rate should be, government health agencies and the World Health Organization have suggested 15 percent as a goal in LOW RISK WOMEN” (emphasis added).
My point was that in risky situations ALL participants (mainly the mother and her OB/Mid-wife) SHOULD consider the BEST alternative to the potential risk of complication. We all know that MOST births are without problems – we are only concerning ourselves with those known risky pregnancies. And, I maintain, that both the mother AND her OB need to make better INFORMED decisions at the height of the situation at hand, and not prolong (like motherjanegoose’s OB did) the situation. I am not sure what your situation at Grady is, but I can assure you that the OB’s who practice there live dangerously if they adhere strictly to the ACOG recommendations.
KAW
March 11th, 2010
12:45 pm
I had a c-section with my first — 42 weeks and labored for 2 days. She was not progressing and the c-section was the best option for both me and my daughter. After such a horrible labor with my first, I opted for a c-section with my second. Honestly, I was scared to try a VBAC after my first experience. By scheduling my c-section I was able to mentally prepare for the surgery and recovery. For me, recovery from my second c-section was a breeze. I was up, moving around and caring for my baby immediately.
nurse&mother
March 11th, 2010
12:55 pm
I would like to add that VBACS are a better option for moms that request it when: 1. they have already had a vaginal birth (without complications) and 2. When the C/S was for something like fetal distress and NOT for large baby, cephalopelvic disproportion, etc.
Christine
March 11th, 2010
1:01 pm
It doesn’t matter what the c-section was for, if the mom wants to try for a VBAC (even if her chances of success are supposedly low) she should be able to try. The Atlanta ICAN chapter has had many women have VBACs who were supposedly bad candidates.
nurse&mother
March 11th, 2010
1:09 pm
Christine, I would agree with you if the patient signs a waiver (that would actually hold up in court) that she understands the risks and agrees not to sue for complications (should they arise) as a result of the VBAC.
nurse&mother
March 11th, 2010
1:12 pm
One more thing, Christine. I think a doctor should have the right to refuse a service if he/she felt like it was a greater than normal risk to the patient. If the patient insists on delivering VBAC despite huge risks, then she needs to find a doctor that is willing to care for her. You can’t make a doctor do something he/she doesn’t feel is safe because that is a breach of duty. (and I’m not saying that all VBACS are equally unsafe)
Christine
March 11th, 2010
1:15 pm
nurse&mother, all patients have to sign an informed consent that outlines the risks of vaginal and cesarean birth. having a prior c-section for CPD doesn’t mean a vbac is any riskier for you. and women who are more informed about their options and take a bigger part in their own care are LESS likely to sue if something goes wrong.
of course a doctor shouldn’t do something he/she doesn’t feel is safe, but many OBs/Midwives are not practicing evidence based medicine. the studies do not back up the “facts” that they tell women about vbac vs ercs
nurse&mother
March 11th, 2010
1:21 pm
I’ve been a L&D nurse for 12.5 years. Any lawyer will tell you that the informed consents won’t hold water when you present a brain damaged child (whether it is the fault of the practitioner or not). That family can just name their price and the doc will have to just cut them a check. Sad, but true.
Just curious. What is your profession?
Christine
March 11th, 2010
1:26 pm
i’m not saying that fear of being sued doesn’t effect how doctors practice, but I don’t think the answer is to force women into surgeries that they don’t want and present risks of their own. I also don’t think that a family should have to waive their right to protection from malpractice for choosing to try and avoid that surgery.
I am a stay-at-home-mom and a volunteer birth advocate. I am on the Board of Directors of ICAN.
JATL
March 11th, 2010
1:29 pm
Theresa -dig in and find our missing comments! This keeps happening this week. My comment two days ago was never posted.
In case my post on this one never makes it -I’m ALL for VBAC!
nurse&mother
March 11th, 2010
1:39 pm
This is precisely why many doctors won’t delivery VBAC. They have no protection from a suit prone society. There are a few that will agree to VBAC with the criteria mentioned in one of my previous posts.
Have you ever attended any legal issues regarding labor and delivery?
I’d be willing to bet that if you were a physician and had worked hard (not to mention the DEBT they have incurred during school) to be where these docs are, you would want to protect yourself as well. It only takes one bad outcome to change your world.
I wholeheartedly agree with patients rights. While I agree with VBACing when a patient is LOW risk, I understand that not all women are good candidates. And I respect the doctors that make decisions to refuse to deliver VBAC when the risks are high. Have you ever been present for a uterine rupture and the baby almost died (or ran the risk of being permenantly compromised)? If not, they you are not properly informed.
I can certainly understand why some women would want to VBAC (when it is their choice).
I also understand that not all patients know what is best for them. Take for example, those folks like Michael Jackson who had surgery after surgery after surgery to reconstruct his looks. Did he find a surgeon that would perform the surgeries? Yes. Was it wise on the part of the surgeons? probably not. Just because a patient wants something, doesn’t mean he/she can always look at the bigger picture.
Just my medical opinion. It looks like we probably won’t see eye to eye on this one, so I will try not to comment further.
So, Christine...
March 11th, 2010
1:43 pm
…as a stay at home mom on the board of ICAN you are more qualified to suggest how “safe” a medical procedure is over 1) – a 30+ year medical malpractice expert; and 2) – a 12+ year practicing labor and delivery nurse who is specially trained in handling birth emergencies. And, I do not see where anyone, anywhere, is “forcing” “women into surgeries that they don’t want”.
You are seemingly so caught up in the advocacy of your cause that you are distorting the facts – but hey, don’t let the facts get in the way of a good theory.
SIIHB
March 11th, 2010
1:43 pm
“… I don’t think the answer is to force women into surgeries that they don’t want and present risks of their own.”
Just because a Doctor doesn’t provide a service doesn’t mean that a woman is forced to do anything. You can find another doctor.
This is not something that you decide at the last minute. On your first visit, you can ask the doctor if they are willing to give it a try.
We all have a different risk tolerance. Some women might be willing to try when others would not. If they say, “Well, your chances of complications are 1 in 1000 for c section and 1 in 999 in VBAC, some women might still opt for the c section.
Tonya
March 11th, 2010
1:49 pm
To so many who say “find another doctor”
As someone who believes in natural childbirth, it’s been a real pain to find a doctor (or midwife for that matter) who will go along with something as simple as a med-free birth in Atlanta. Add VBAC to the mix, and you narrow down the possibilities to a handful at best. I’m being honest. I came from FL, whose birth options I took for granted while there, but would give A LOT to get back. Medical care in general here is VERY limited versus other metropolitan areas as far as diversity if concerned.
SIIHB
March 11th, 2010
1:52 pm
There are 50+ OB practices in the metro area.
Tonya is one of those...
March 11th, 2010
1:55 pm
…”macho” women…come he!! or brain damage, she is going to push it out, just as shaggy suggests!?!?!?
Christine
March 11th, 2010
1:57 pm
nurse & mother – I don’t need to have been present at a birth that ended in UR to understand what one is. All births have risks. I am not anti-cesarea. I am against unnecessary cesereans and limiting patient choice (and if you do some checking into how few doctors in the US attend VBACs you will see where the “forcing” comes into it).
“So Christine…” – I never said I was more qualified than anyone. I urge everyone to do the research for yourself. The NIH panel that was just held (that I linked to above) is a great place to start. The National Institute of Health agrees that women are not getting the opportunity to VBAC or the risks of ERCS explained to them.
Michelle Frank
March 11th, 2010
2:00 pm
To SIIHB: there might be over 50 OB practices in the metro Atlanta area, but those that are tried and truly supportive of natural childbirth, including VBACs, there are less than one handful.
Tonya
March 11th, 2010
2:02 pm
Seriously…macho because I choose natural childbirth? Because I don’t hold my ultimate faith in my OB/GYN and would never consider suing for a delivery-related birth defect (birth is an uncertain process with NO guarantees). But I also believe that a birth experience exists, and having had a butthole for an OB who delivered my son. No, a c-section is NOT an option for me unless all other options are exhausted.
But since I’ve done this twice and am pregnant with a 3rd, it’s a subject I might know something about…
Tonya
March 11th, 2010
2:06 pm
SIIBB:
You’re right..and over 75% are VERY medicalized. Numbers mean nothing about options, as I have quickly come to realize since living here. So many are trained in the same schools with the same conceptions about birthing, that anything against the ‘norm’ is not viewed positively. In fact, I am currently seeing a great CNM who was basically my only choice within a 20-mile radius for the care I expect and the birth experience I desire.
How’s that for choice?
nurse&mother
March 11th, 2010
2:08 pm
Christine I am not convinced that you are not “anti-cesarea” (and certainly you are entitled to your opinion). So when do you feel that a doctor should tell a patient he/she refuses to let a patient VBAC?
Tonya
March 11th, 2010
2:13 pm
nurse&mother:
Can I answer that last one…at the 1st prenatal appointment. I would prefer to know my doctor’s philosophy on birth from the ‘jump’. A website would be even better. For those like me that are NCBers, and those desiring a VBAC, it would save us time and frustration.
And don’t “bait-and-switch”…offering a birth experience or procedure you don’t plan on providing. We’re adults, and can handle the truth accordingly. I respect a doctor’s right not to do something they are not comfortable with, as long as he respects my right to search out a provider who may share his/her views.
Tonya
March 11th, 2010
2:13 pm
That was MAY NOT share his/her views.
nurse&mother
March 11th, 2010
2:15 pm
As a mother of two, I also preferred vaginal deliveries. And I don’t think a mother is being “macho” to want a vaginal delivery. If I had different situations with my deliveries, I certainly would have been open to other alternatives.
Patricia
March 11th, 2010
2:17 pm
“This is not something that you decide at the last minute. On your first visit, you can ask the doctor if they are willing to give it a try.”
Well, I did ask, at the first visit, and at several subsequent visits, as I met the different OBs in the practice. And they were all “Oh yes, we are *very” VBAC supportive,” until my third trimester, when all the “ifs” and “buts” and various (non-evidence-based) cracks began to show in their alleged “support.” And the more they doubted and discouraged, the more I talked about research and statistics — and the less patient and friendly and “supportive” they became. And they forced me to be put on their surgical schedule for the week of my due date – and yes, I do mean, forced me to be scheduled, because they scheduled me without my knowledge or consent. I was not consulted as far as the date, time, nor the doctor(s) who would do the surgery.
I pointed out that there was no EVIDENCE to suggest I could not go past my due date and go into labor naturally, and I did not want to be scheduled before 42 weeks. So they did it anyway, and then pointed to their sign that said they would charge me a fee of several hundred dollars if I canceled the surgery.
Bait and switch… it happens all the time. I found a new doctor who *does* practice evidence-based medicine, and, thankfully, was willing/able to take me on as a patient, at 37 and a half weeks, and had a VBAC one week later.
nurse&mother
March 11th, 2010
2:18 pm
Tonya, I can’t vouch for what doctors do in their offices (and certainly doctors in ATL or elsewshere). I live in rural north Georgia. The doctors in our area are up front from the “get go”. And yes, I still see an occasional VBAC (usually when they fit the criteria mentioned above).
Christine
March 11th, 2010
2:19 pm
N&M, thanks for quoting my typo there ;)
When used judiciously a cesarean is a lifesaving procedure. I am certainly NOT anti-cesarean.
I do not think that a patient should ever be forced into surgery. The risk of maternal death is almost 4 times higher in a cesarean than in a vbac. That risk is not something that anyone should choose for the mother.
As I said before, I also do not think that a physician should be forced to attend to a patient that they are not comfortable attending if they feel the risk is too high. But how to reconcile the two?
One thing I know is true – if we can reduce the primary cesarean rate in the US, far fewer women and doctors will be faced with this conundrum.
Tonya
March 11th, 2010
2:21 pm
N&M:
The ‘country’ doctors are actually my 1st choice. With them…it is what it is. I respect the honesty.
pws
March 11th, 2010
2:22 pm
Every woman needs to work with her doctor to make the right decision for her and her baby. My doctor never forced me into having 3 C-Sections, he just gave me all the facts involved, both pro and con with having VBAC after having the first C Section. Part of that information is evaluating why you had the first C Section, and whether those risks of VBAC are still present with the second pregency or not. Both my “premium” babies are now 25 and 21, and I am very thankful that the technology for C-Section is now available. I wouldn’t have both of these beautiful, intelligent women in my life had it not been for C-Section delivery. Too long to explain why the first child was still born, and why my doctor chose to deliver them 3 weeks early on purpose, but I’m glad he did. Not only did we make that decision together, but he provided excellent prenatal care for someone whom at the time was considered “high risk”. But part of that was because I was involved with my care as well, it was my responsiblity to ask questions, each person needs to be involved in their own prenatal care.
nurse&mother
March 11th, 2010
2:25 pm
Now THAT, Christine, I will agree with ;-) (reduce the primary c/s rate).
"macho woman"...
March 11th, 2010
2:33 pm
…is defined, by me, as a woman who is going to have that baby “naturally” no matter what the OB is recommending, no matter what the fetal heart monitor shows, and no matter how mnay red flags are staring her in the face regarding the delivery of her child. Then, when the problems exxacerbate, she still won’t give in, and when the child is compromised she claims that the OB / labor nurses failed to inform her of all the problems and it is THEIR fault.
Tonya, you may not fit this description to a T, and you may THINK you will not sue the OB, yet until you have that compromised child, you do not know what you will do…
Jamie
March 11th, 2010
2:39 pm
N&M I am having a bit of a hard time following you because you can agree with reducing the primary c-section rate but you believe that very few women qualify for a VBAC because their initial c-sections were necessary (This seems to be the tone of what you are saying). I just don’t understand how that logic follows if most women don’t qualify for a VBAC because of their *necessary* c-sections how then are we do reduce the rate?
Patricia
March 11th, 2010
2:42 pm
“Tonya, you may not fit this description to a T, and you may THINK you will not sue the OB, yet until you have that compromised child, you do not know what you will do…”
Good thing she has YOU, who obviously knows best, and can predict what her theoretical response to a statistically unlikely outcome will be.
fact finder
March 11th, 2010
2:43 pm
Look at the facts. Every current study done points to the safety of VBACs. The risks of UR (uterine rupture) are less than 1%, while the risk of developing an infection from a c/s (cesarean) are 15% with 3% of those leading to the mother’s death. But do the research for yourself. Ultimately it’s your body and your child. You have the right, and your child deserves for you to make a fully informed decision. Look at other counties with lower c/s rate, they also have lower maternal/infant death rates, it’s not a coincidence. Empower yourself.
That's the point, Patricia...
March 11th, 2010
2:50 pm
…”the theoretcal response to a statistically unlikely outcome” is not known until it is known – and by then, if you have made the choice that is “statistically unlikely” to happen, and it happens because the was adamant in being “macho”, the more likely she is to try to look for blame outside her own head…
hey, fact finder...
March 11th, 2010
2:52 pm
…what is the c/s rate in China – oh, that’s right, they throw out female babies with the bath water – DOH.
nurse&mother
March 11th, 2010
2:52 pm
Ok, Jamie, it’s not rocket science. If you try to encourage more women to deliver vaginally with the first delivery (when POSSIBLE-remember fetal distress, placenta previas, breech babies just to name a few don’t qualify) instead of a c/s, then you are automatically going to reduce the number of c/s. To be put simpler: If you have a mother who has a c/s (and maybe the doctor rushed to the c/s conclusion) then she is most likely going to have a repeat c/s. BUT if you give women more time to try to delivery vaginally (when possible), you will probably have some who will deliver vaginally rather than c/s. I have seen a few midwife patients who ended up delivering vaginally where the doctor had already recommended a c/s. That said, there are still going to be many women who couldn’t deliver vaginally if you let them labor for a week. Do you understand what I am saying now?
Michelle Frank
March 11th, 2010
2:52 pm
Local Atlanta hospitals have c-section rates well into the mid to higher 30%s. Do all of you anti-VBACers on here really believe that 1 out of every 3 women underwent a necessary c-section?
Jamie
March 11th, 2010
3:01 pm
N&M I see what you are saying perfectly fine but it does not follow suit with what you are saying about VBACs. Yes more women should be given more time to deliver vaginally but many OBs won’t do this for fear of lawsuit if a bad outcome occurs (just like with VBACS and you have already said that doctors should not be forced to practice a way that will put them in danger of lawsuit). And you are saying you believe too many intial c-sections occur well then how does it follow to say very few people qualify for a VBAC (if as you said many c-sections are being done unnecessarily)? I’m saying your two different points make sense but the two points are not in line with each other.
Tonya
March 11th, 2010
3:05 pm
Uhhh, I have a child with Autism. I don’t blame vaccines nor have I ever. I don’t blame my OB, my Ped, or God. At this point, it is what it is. I KNOW what I would do because I believe in personal responsibility and education. If I make the final call, I can live with the outcome (positive or negative). If that makes me macho, great.
N&M, I get what you’re saying. A lot of repeat c-secs can be attributed to questionable primary c-secs. By lowering the rate of the latter, more VBAC options may open up.
Tonya
March 11th, 2010
3:08 pm
“macho woman” sounds like a grady nurse I know…which is why I will NEVER trust my care to Grady. You don’t know what’s best for me, and doctors don’t always either. I make sure I’m an educated consumer. Period.
nurse&mother
March 11th, 2010
3:08 pm
Where is the happy medium? Does everything have to be black and white? I truly think this is a gray area. It should be a case by case situation.
Just a word of advice to anyone who really wants to convince another person (and this applies to society in general-not just in the delivery room). You kill more flies with honey than with vinegar. I would recommend good communication and respectful honesty. Those who speak up with a “chip” on their shoulder usually seem to alienate others (does this make it right? no, it’s just the way it usually is). Be willing to listen to the other side as well.
Please don’t come into the delivery room with an attitude. This usually only creates tension where you really don’t want tension. I have many patients who have ideals and opinions, but are not so hateful. I ALWAYS try to be respectful of my patient and her wishes (not to mention safety) even when the she or the family is disrespectful. And I have a few (very rare, though) that are downright hateful. There is just a way to go about it;-)
Peace out! LOVE healthy discussions.
Uh, Tonya...
March 11th, 2010
3:15 pm
…NEVER say never – if you are in a knife fight, get shot, get 3rd degree burns, or in a really bad auto accident, the only ER in the Atlanta area to be taken is Grady if you really want the best care for traumatic injuries…
Blair
March 11th, 2010
3:17 pm
If you think that women who seek VBACs are trying to be “macho women” then you are totally missing the point. I know for me one of the reasons I chose to VBAC was that it was safer for me and my child. I was aware of the (small) risk of uterine rupture and I was also aware of the risk of repeat c-section for me and my baby.
nurse&mother
March 11th, 2010
3:17 pm
Jamie that is because VBAC’s are different than a laboring patient in a first time mom. Yes, I think that there are some C/S that are done unnecessarily. Are all done unncessarily? Of course not (common sense).
Once a c/s has been done (whether it was done unnecessarily or not is completely irrelevant at this point) there are risks to VBACing (once again read my previous posts). Some women are in the low risk catagory (see above posts) and others who are at high risk. Sheesh!! I refuse to carry on a battle of wits with an unarmed person.
Uh, Blair...
March 11th, 2010
3:18 pm
…please re-read the definition…
Christine
March 11th, 2010
3:22 pm
N&M, I think the “high risk” part may be where you are losing some people. You haven’t really illustrated who you think is too high risk to vbac or statistics to show why you think so.
I really don’t see how personally attacking people is catching more flies with honey than with vinegar though.