Special deliveries

Cost and convenience to doctors are among factors reducing vaginal births after Caesareans.
By SHARI ROAN
LOS ANGELES TIMES
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 (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, Iowa; 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.
Finding support
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. "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 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, not increasing.
Revised requirements
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 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 in Los Angeles. "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 (Calif.) 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."
Comparing the risks
The risk of infant death because of uterine rupture during a VBAC is about 1 in 1,000, twice the rate among other laboring women, according to studies. Uterine ruptures can cause permanent injuries in babies and lead to hysterectomies.
But 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, injuries to other organs 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.'"
Shea is also a doula, a person trained to provide emotional support and comfort during labor.
Standing firm
Juliet Babros, a Redondo Beach, Calif., public-relations executive, was resolute about wanting to try a VBAC for her second child. She delivered the baby vaginally, without incident, recently. "I had a slow recovery with the Caesarean," she says. "I didn't feel like I could respond to my baby as quickly. Now I have a 2-year-old, and I want to bounce back quicker. I want to get home quicker."
She explained her reasoning to her obstetrician, who was so unenthusiastic that Babros decided to find a new doctor. Her second doctor supported her wishes but warned that she would be subjected to numerous restrictions during labor, and that another Caesarean was still a possibility.
"They treat you as this high-risk person," Babros says. "When you talk to doctors about it, you get so fearful because they are fearful. They tell you the worst-case scenarios and maybe none of the benefits."
To keep the risk low, the American College of Obstetricians 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, studies show. Candidates should be healthy women, carrying babies in a head-down position, who are in their 37th to 40th week of pregnancy.
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 nationwide 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, where dozens of VBAC-related lawsuits in the 1990s led to payouts totaling $24 million.
"We select our patients for VBAC much more carefully now," Dr. Goodwin said. "There is a much greater appreciation for who is a good candidate."