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 United States, 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.; Aspen, Colo.; and elsewhere have announced that they will no longer offer the VBAC option.
Only 16.5 percent of U.S. women with prior Caesarean sections who delivered last year had a vaginal birth, according to the National Center for Health Statistics, a 20 percent drop from the previous year.
Ginger Clinton, a 24-year-old Simi Valley, Calif., 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.
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 percent VBAC deliveries as part of its Healthy People 2010 objectives, up from the 28 percent rate reported in 1998.
But safety, cost, convenience and malpractice concerns have sent the rates plunging.
Policy change
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 percent 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 practice.
"There has been absolutely no change in the underlying scientific background on VBAC," says Dr. John Aiken, a Los Angeles obstetrician. "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."
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, chairman of the obstetrician task force on VBAC. "It's more time-consuming, more worry. And they don't get paid any more for it."
Women who have successful VBACs avoid the much longer recovery time and risks associated with C-sections. For the mother, those risks include infection, hemorrhage, blood clots and exposure to major anesthesia. The risks to the baby from C-sections are higher rates of respiratory disorders, fetal trauma and fetal death.
Few medical experts disagree with the idea that doctors should be on hand during a VBAC patient's labor, but some say women are being misled into thinking that such labor is extraordinarily risky.
"The patient is not being told, 'I don't want to sit with you in the hospital,' " says Ellie Shea, a longtime birth educator in the Los Angeles area. "She hears, 'This is a matter of safety for you; you should really have a Caesarean.' "
To keep the risk low, the American College of Obste- tricians and Gynecologists recommends that women try VBAC only if they've had only one Caesarean via a type of incision called a low transverse (a horizontal incision on the lower part of the uterus). The low transverse scar is much less likely to rupture than other types of Caesarean scars during a VBAC attempt. Candidates should be healthy women who are in their 37th to 40th week of pregnancy.
Once popular
Only a few years ago, health insurers and hospitals were so enamored of VBACs as a cost-cutting measure (vaginal births are less expensive than surgical births) that almost every former Caesarean patient was urged to try it. That practice led to a dramatic increase in uterine ruptures and scores of lawsuits from families who suffered injuries or deaths.
Many of the lawsuits arose from cases in which the patient was not a good candidate for a vaginal birth, said Dr. T. Murphy Goodwin, chief of maternal-fetal medicine at the University of Southern California's Keck School of Medicine.
"We select our patients for VBAC much more carefully now," Goodwin said. "There is a much greater appreciation for who is a good candidate."
Shari Roan is a reporter for the Los Angeles Times, a Tribune Publishing newspaper.