Natural Birth Post Cesareans: Why Docs Lag Science

It's hard to imagine being fired by your doctor, especially just before giving birth. But that's what Debbie Fields says happened to her last December when her desire for a vaginal birth after Caesarean (VBAC) was quashed by her obstetrician. Fields wanted to go into labor naturally; her OB insisted on scheduling a planned C-section one week before her due date. When Fields, whose first child was born by C-section in 2006, insisted on sticking to her plan, she was told to "find a new doctor." She went home, had a good cry, then scrambled to track one down. Two days before Christmas, she went into labor and delivered a healthy baby boy. Despite her successful VBAC, Fields still bristles at what she endured to have the birth she wanted. "You feel like a beggar with your hat in your hands," she says.

Back in the VBAC heyday of the 1980s, vaginal birth after a prior C-section was routine. But as the number of VBACs increased, so did reports about risks, including uterine rupture. In 1999, the American College of Obstetricians and Gynecologists (ACOG) issued guidelines stating that medical specialists be "immediately available" during a VBAC to treat a potential emergency—a standard that does not exist for routine labor. Many hospitals can't afford round-the-clock anesthesiologists, and their OBs are busy attending to more than one patient. As a result, hospitals that didn't have the resources to comply, and feared being sued if a birth went bad, stopped offering VBACs altogether. End result: the rate of VBACs dropped from a peak of 28 percent in 1996 to less than 10 percent today. C-sections, meanwhile, continued to shoot up. A new government report out this week says Caesarean rates increased by 53 percent between 1997 and 2007. Today, C-sections account for almost one third of all births in the U.S.—an all-time high.

The problem: the VBAC trend doesn't make medical sense. Earlier this month, after poring over data at the National Institutes of Health, a panel of experts concluded that VBAC is a reasonable option for many women and urged professional organizations to revisit current guidelines, including the recommendation for "immediately available" emergency care. Uterine rupture is highly uncommon, occurring in less than 1 percent of patients. Women who have multiple C-sections, on the other hand, are at significantly higher risk of developing placental complications that can cause hemorrhaging and, in rare instances, maternal death. A "trial of labor," as its known in medical jargon, is successful in nearly 75 percent of cases. What is clear, says Dr. Cathy Spong, chief of NIH's Pregnancy and Perinatology Branch, is that VBACs are safe in the majority of women. Despite the scary-sounding risks, most mothers and babies do well, no matter how the babies are born.

VBAC advocates hope that health-care reform, with its emphasis on evidence-based medicine, might help turn the tide on VBACs. The VBAC stigma among doctors and hospitals, based more on fears about multi-million-dollar lawsuits than on data, has forced many women to switch providers, often traveling out of their way to find a supportive OB or midwife and a willing hospital. Since 1996, one third of hospitals and half of physicians no longer allow women to have a VBAC.

When she was pregnant with her second child, Allison Denenberg signed on with one of northern Virginia's VBAC go-to doctors to avoid another C-section. Denenberg didn't want to have to recover from abdominal surgery while taking care of a toddler and a new baby. She wanted to breastfeed, which can be more challenging after a C-section (positioning a baby to nurse can be uncomfortable and many women find that their milk takes several days to come in). She wanted her baby to pick his or her own birthday. And she wanted a positive birthing experience; after her first C-section, Denenberg worried that she hadn't pushed effectively and blamed herself.

This time, Denenberg wanted to bond with her baby uninterrupted after birth without a surgical curtain in the way and she wanted to care for her baby "without having to call somebody for help," she says. A Virginia chapter leader for the International Cesarean Awareness Network (ICAN), an advocacy group that supports VBACs, Denenberg feared that if she didn't try to deliver her second baby vaginally, she might suffer postpartum depression. In the end—after a 24-hour labor, including three and half hours of pushing—Denenberg underwent a repeat C-section because her baby wasn't budging. It wasn't the outcome she wanted, but it was "awesome," says Denenberg, because she was in control, and her OB cheerleaded her efforts. "It's a woman's right," she says.

Often overlooked is a woman's fundamental and primal desire to undergo the birthing rite of passage, to have a baby the way babies have been born from the beginning of humankind, complete with the roller coaster of emotional and physical experiences—pain, joy, power, and, ultimately, an overwhelming sense of accomplishment. That desire, and women's frustration over the lack of support and accessibility, has led ICAN's Barbara Stratton, based in Baltimore, to organize protest rallies at hospitals with "VBAC bans." Their signs get right to the point: THANKS, BUT ONCE WAS ENOUGH and CHOOSY MOMS CHOOSE VBAC.

Choice, the ultimate imperative, has been lost for many women. When malpractice insurers refuse to cover VBACs and hospitals fear litigation, doctors can't offer them and women can't have them, says Dr. Howard Minkoff, chair of obstetrics and gynecology at Maimonides Medical Center in Brooklyn, N.Y. Now it's up to ACOG, which sets professional standards, to respond to NIH's call. What women need are doctors and hospitals that support VBACs, complete information about risks and benefits, and a medical provider who works with them in tandem. "Women are not irrational crazy creatures," says ICAN president Desirre Andrews. They're capable of making well-informed decisions for themselves and their babies. Having a VBAC should be one of them.

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