Women who have had a caesarean section often want to deliver their next child vaginally--and many are physically capable of doing so. But across the nation, they're increasingly denied that option.
Vaginal birth after caesarean--known as VBAC--a childbirth practice heralded only a few years ago as a way to spare women from another surgery, has fallen so far out of favor that women now say they have to fight for it.
This year, hospitals in upstate New York; central Ohio; Spokane, Wash.; Des Moines; Aspen, Colo.; and elsewhere have announced that they will no longer offer the VBAC option.
Only 16.5% of U.S. women with prior caesarean sections had a vaginal birth last year, according to the National Center for Health Statistics, a 20% drop from the previous year. California's rate, at 14.5%, is among the lowest in the nation, and some local hospitals report current rates of less than 5%. In Southern California, where few hospitals forbid vaginal births after a caesarean, many women nevertheless say their obstetricians actively discourage the option.
Ginger Clinton, a 24-year-old Simi Valley woman, sought a vaginal birth earlier this year because of a difficult recovery after the caesarean birth of her first child. Although doctors said she was a good candidate for a vaginal delivery, she had to change physicians twice before finding one who supported her request.
"I was at the end of my second trimester when I went to the third doctor, and then my insurance company almost didn't let me switch doctors," said Clinton, who had a successful vaginal delivery in July. "It was worth the battle, but, golly, it was a lot of work."
Women's health experts agree that VBAC can be a reasonably safe--even preferable--option. The American Academy of Obstetricians and Gynecologists concluded in a 2000 report that the benefits of a vaginal birth after a caesarean outweigh the risks for many women. And the federal government has set a goal of 37% VBAC deliveries as part of its Healthy People 2010 objectives, up from the 28% rate reported in 1998.
But safety, cost, convenience and malpractice concerns have sent the rates plunging, not increasing.
The decline started in 1999 when the American College of Obstetricians and Gynecologists recommended that a doctor and an anesthesiologist be "immediately available" when a VBAC patient is in labor. Before 1999, a doctor and surgical team were advised to be "readily available," widely interpreted to mean that they be within 30 minutes of the hospital.
The policy change addressed a complication of VBAC, called uterine rupture, in which the caesarean scar from a previous birth ruptures. Such an event occurs in an estimated 1% of VBAC patients, and both the mother and baby can die or be seriously harmed.
Although the revision was designed simply to ensure women's safety, it began to drive the procedure from everyday practice.
"There has been absolutely no change in the underlying scientific background on VBAC," says Dr. John Aiken, an obstetrician at Northridge Hospital Medical Center. "But because of this ... requirement, the physician has to be on site. A lot of physicians don't come in to the hospital until their patient is fully dilated [ready to give birth]. So they can't meet the criteria."
Both hospital administrators and doctors say it's too costly and inconvenient for a doctor to sit with a patient in labor (which may last many hours).
"There really isn't any incentive for the physician to do VBACs," said Dr. Roger K. Freeman, an obstetrician at Long Beach Memorial Medical Center and chairman of the obstetricians task force on VBAC. "It's more time-consuming, more worry. And they don't get paid any more for it."
Clinton's doctors were blunt in denying her VBAC attempt. "One doctor said he wouldn't be willing to wait during my labor. The other doctor said even if he was [available], the chance of having the rest of the team there isn't very good," she said.
Some women, patient advocates and doctors are upset that nonmedical issues may lead to unnecessary surgery that has attendant risks of its own. One patient advocacy group, International Cesarean Awareness Network, plans to petition the obstetricians group, the American Hospital Assn. and insurance groups, protesting the increasing loss of VBAC as an option.
"It's all about money," says ICAN's president, Anita Woods of Kansas City, Mo. "It has nothing to do with safety. We are being railroaded by money concerns."
Decisions to forbid VBACs have divided doctors and health executives in many cities. Ridgecrest Regional Hospital, a Mojave Desert hospital about 150 miles from Los Angeles, for example, voted earlier this year to drop VBACs because it could not supply round-the-clock doctor and anesthesiology services, says Tina Wallum, administrator of patient care services.