Medical Examiner

VBAC Backlash

Why are hospitals forbidding women who have had C-sections the right to have vaginal births?

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.”

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.

A study just released in the New England Journal of Medicine—the largest and most rigorous to date, involving almost 34,000 births at 19 academic hospitals from 2000 to 2003—confirms the VBAC’s minimal risk. The study included roughly 18,000 women who chose VBAC and 16,000 who elected a repeat Caesarean. Mishaps struck a small percentage of each group. Of those who chose VBAC, 74 percent delivered vaginally, and the rest had Caesareans. One-hundred-twenty-four VBACers (0.7 percent) experienced uterine ruptures (14 of these were discovered after a vaginal birth, and 110 were discovered during Caesareans that were initiated when labor stalled or a fetal monitor indicated distress); seven of the babies whose mothers’ uteruses ruptured (0.04 percent of all the planned VBAC births) suffered hypoxia-related brain damage that was likely caused by these uterine ruptures, and two of those babies (0.01 percent) died. The Caesarean group, meanwhile, saw twice as many maternal deaths (7 versus 3, or 0.04 percent for Caesareans versus 0.02 percent for VBAC). Overall, “adverse events,” ranging from minor complications to those dozen deaths, occurred in 5.5 percent of the VBAC births and 3.6 percent of the elective Caesareans. VBACs posed more risk to infants, C-sections to mothers. A woman choosing VBAC over repeat Caesarean, the report study concluded, increased her overall risk of adverse outcome by 0.046 percent­­—a factor of about 1 in 2,000.

These odds make the hospitals’ complaints about VBAC’s safety sound rather disingenuous. To be sure, the most serious adverse outcomes hold our attention, as well they might; brain-damaged and dead infants and mothers who die, lose their uteruses, or live their lives in pain rank among our worst nightmares. But these horrors attend Caesareans, too. And VBAC carries a risk premium similar to or less than that of numerous elective procedures—or birth in general. Fallopian tube ligation for birth control, for instance, fails in 1 of 200 cases, creating the possibility of a life-threatening ectopic pregnancy. Epidural anesthesia during labor raises the chance of instrument-assisted delivery, stalled or long labor, maternal fever, maternal low blood pressure, and Caesarean—all of which cause further, often grave, dangers. A VBAC goes badly, however, with extreme rarity. Covering a VBAC, says Burgee, is usually quite boring.

Given his support of VBACs, I was surprised to learn that Burgee himself doesn’t perform them. He did for two decades, but he stopped in 1990 when he reduced his practice to half-time while he got a law degree (so far unused). When he resumed his full-time practice, he didn’t take them up again. He stopped, he says, partly because his legal education made him see his legal risks more starkly. Managing the cases thus seemed more complicated than ever: The OB in him would be pulling for the VBAC, while the surgeon, lawyer, and potential trial defendant would worry that he should wheel the mother to the O.R. Now he explains to his patients why he doesn’t perform VBACs, outlines the odds as well as the arguments for and against, and offers the names of midwives and doctors who will perform the procedure. Burgee’s stand, distinctly personal, provides excellent care for his patients while leaving them every option; one can scarcely object.

Likewise, who can question my wife’s choice to pursue a VBAC? Given two nearly equal risks she chose the risk she felt most comfortable with.

Both decisions highlight the perversity of hospitals banning VBACs. When a hospital bans the practice, it takes away the right of doctors, midwives, and patients to make such personal choices; it settles by institutional edict a decision that should belong to patient and caretaker. The choice is indeed serious: A Caesarean is major surgery, and a VBAC adds a risk that is tiny but terrible. But choosing between the two options isn’t a matter of right or wrong, statistical clarity, or policy imperatives. It’s a judgment call—one that a hospital has no business making.