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C-Section or Vaginal Birth? Women Too Often Denied the Choice

5 years ago
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After 36 hours of labor that ended in a cesarean section, I lay in recovery with my baby at my breast; the midwife whispered in my ear, "Don't worry. Next time you can try for a VBAC." What she meant was: At the end of a theoretical next pregnancy, I could try laboring again, and, perhaps, if things progressed differently (or, at least, progressed) have a vaginal birth after cesarean (VBAC). At the time I blanched. With a 30-minute-old babe in arms, who would want to consider another labor?
Plenty of women, it turns out. Because in America, not every woman gets to choose how they give birth. Over the last decade and a half, hewing closely to the old adage "once a cesarean, always a cesarean," hospitals have steadily, and increasingly, pushed women who have birthed once through c-section into surgery again with their next babies. The fear is of uterine rupture; rare, but devastating, that's when the scar from the previous c-section gives way, destroying the mother's uterus and harming, or even killing, the baby or mother. It's a scenario hospitals (and mothers) are obviously loath to contemplate. The tiny percentage of VBACs that go wrong, go terribly, catastrophically wrong. And, as a result, there have been lawsuits.

But uterine rupture only happens in less than 1 percent of cases. Many women, at low-risk for such complications, are desperate to try labor again, rather than "just" schedule a next surgery. That's because cesareans themselves aren't risk free. Major abdominal surgery, c-sections carry, at minimum, a six-week recovery period, as well as chance of hemorrhage, blood clots, infection, and scarring that can cause problems for subsequent pregnancies. There's even a slightly greater risk of maternal death with c-sections than with VBACs. Some evidence suggests that scheduled surgeries can result in a baby being born too early, putting the infant at greater risk for childhood asthma and allergies. Moms who give birth vaginally, on the other hand, have a shorter recovery time and better mental health picture post-partum; an easier birth experience overall. And of women who try for VBAC? Some 74 percent are successful.
Policies that deny women the option to try labor again run up against clinical evidence, cost more than vaginal births, and don't take women's desires into consideration. So why are women dissuaded from trial of labor?
Those were the questions posed at a conference on VBACs held earlier this month at the National Institute of Health, prompted by a dramatic drop in VBACs over the last 15 years. The conference concluded that, rather than risky, trial of labor was often a reasonable, even better, option for many women. The major reason hospitals stopped offering women the chance to labor? Fear of malpractice suits: "American College of Obstetrics and Gynecology members confirm that concern over liability is a main reason they stopped offering [Vaginal Births After C-Sections]," the NIH final draft report explained. "A 2009 ACOG survey revealed that 30 percent of obstetricians stopped . . . performing VBACs because of the risk or fear of professional liability claims or litigation. This is further compounded by 29 percent acknowledging having increased their number of cesarean deliveries and 8 percent having stopped practicing obstetrics altogether. In a recent study of ACOG Fellows, risk of liability was among the primary reasons cited for performing a cesarean delivery/surgeries."
It's one of the same reasons cited for a new, disturbing study that shows the already high rate of c-sections in America climbed in 2007 to 32 percent of all births. Though the World Health Organization believes cesarean-sections should comprise only 15 percent of births in the industrialized world, some hospitals have a near 50 percent c-section rate -- a number fueled by failed pregnancy inductions and fears of malpractice, among other things. With the number of potentially unnecessary primary c-sections rising . . . the number of secondary c-sections has skyrocketed. And clearly not all of those surgeries are warranted.
It's been 14 months since my cesarean, and my external scar is thin, if uneven. I've got a lumpy bit above the right side of the incision where scar tissue appears to have adhered to the soft-tissue underneath. It doesn't look awful, just peculiar. But I see it and I remember the weeks of forced inactivity post-partum, and I can understand not wanting to go through it again, especially not with a toddler running around. And yet, what's amazing to me is that the option to labor depends not just on whether I'm a good candidate for a vaginal birth, but entirely on geography -- living near a provider that allows the chance. Otherwise I won't have an option.
There's a place for c-sections -- countless lives have been saved by the procedure, women who, like myself, might have once faced dire consequences from laboring on and on with no end in sight, or from placenta previa, where the placenta blocks the opening of the cervix, or from breech births where a baby's head, born last, may become stuck in the birth canal, or for any of a number of other emergency reasons to birth surgically. Such procedures recognize and honor all parties at stake -- the mother, the baby, and the doctor, working together as a unit all working to ensure the health of the mother and child is secure.
But mandatory cesareans for low-risk women -- a group that has seen an 89 percent rise in the procedure since 2003 -- privilege the legal concerns of hospitals over mothers, and treat women not as patients -- with rights like any other -- but merely as vessels for a fetus, a fleshy roadblock to a quick and easily scheduled conclusion of a pregnancy. As a result of VBAC bans, women who are determined to avoid a second surgery find themselves on murky legal ground. Much was made at the end of the NIH conference about the "right of refusal" -- that is the right to refuse a cesarean even if a physician insists one is necessary. Effectively banning the procedure in swaths of the country has created militancy, fear, anger, and distrust on both sides.

The irony is that VBACs were not always in such disfavor among doctors. In fact, from the early 1980s to the mid 1990s, ACOG actually encouraged women to try a vaginal birth after c-section. But then in 1999, in response to a rise in litigation, ACOG issued the following: "Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care."

The word "immediately" (revised from "readily") put a scare into hospitals -- from then on, many simply scheduled any pregnant woman who'd had a previous c-section to have another -- without discussion, without reviewing the woman's history, without regard to the wishes of the parent-to-be. Smaller hospitals, especially, said it wasn't feasible to have enough staff on hand to ensure a surgical team could jump on an emergency c-section on a moment's notice, so they took away the option to labor. As a near direct result, the VBAC rate in America dropped from 28.4 percent in the mid-1990s to less than 10 percent today.

In the meantime, women trying to avoid surgery began to seek out providers -- sometimes hundreds of miles from home -- who would agree to allow a trial of labor and a VBAC. Women who, a decade ago, would have been obvious candidates for VBAC but didn't -- and don't -- have access to hospitals that perform VBACs were forced into non-essential surgeries.

Some women have fought back.
Last year, Page, Ariz., resident Joy Szabo spent her entire pregnancy protesting her local hospital's refusal to allow her to try labor after a cesarean, even though Szabo had already had one successful VBAC before the hospital changed its policies. Szabo painted on her van: "Page Hospital: Enter my body without permission, sounds like rape to me." Szabo ended up moving 300 miles away from home to birth in a hospital that did allow VBACs, and ended up with a successful, natural, birth.
The NIH panel urged hospitals not to make women jump through the hoops Szabo ran through, nor to dissuade women from birthing naturally a second time around. For some the issue is an emotional one, tied up in the type of birth they dreamed of, and the means of bringing a child into the world the way mother nature intended.
I'm still enjoying the baby born of that long-road to a c-section in January 2009 too much to even begin thinking of a second pregnancy. But I know plenty of women who spend precious time they should be caring for Baby No.1 worrying about which hospital will allow them the chance to birth differently the second time around.
Filed Under: Woman Up

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