It would seem perfectly natural that a woman could give birth naturally if she wants to. Guess what? She can't.
An increasing number of hospitals in this country are refusing to offer women the option of delivering the way nature intended, if she had a cesarean section the first time around (and guess what -- chances are she has because the 31% of all births are now C-sections -- up 50% in 10 years).
I wrote an article in this week's issue of Time magazine called "The Trouble With Repeat Cesareans" on the subject of women's diminishing patient's rights. I won't repeat the story here, since you can link to it here, but will give some of the back story for those who want more:
This was a story I've been wanting to write for a long time. The short version is, doctors and hospitals are no longer allowing many women to have a vaginal birth after cesarean (or VBAC, pronounced "vee-back") because the "medicolegal" costs are too high. Or, as one ob-gyn put it when I asked why she and other doctors no longer allow VBACs, ""It's a numbers thing. It is financially unsustainable for doctors, hospitals and insurers to engage in a practice when the cost of doing business way exceeds the payback. You don't get sued for doing a C-section; you get sued for not doing a C-section."
Now, I think most of us realize that many hospitals are for-profit institutions and that doctors need to make money too, increasingly hard in this era of managed care. It is nonetheless tough to hear a physician talk about medical care in such bare-bones financial terms. So, um, we can't get the most appropriate care because it costs too much? What's especially galling is that VBACs are actually a much less expensive "procedure" (if childbirth can be termed that way) than cesarean sections, which are major abdominal surgery and require days more in the hospital. The costs the doctor is referring to are the malpractice insurance costs passed on to doctors. And those costs aren't even reasonable, but are largely in response to a few high-profile cases of VBACs gone awry dating back 10 years, many of which involved a labor-induction drug called Cytotec, which is no longer used during vaginal births after cesarean.
Meanwhile, according to the International Cesarean Awareness Network (ICAN), out of 2,849 hospitals with labor and delivery wards nationwide, 28% have total outright bans on VBAC and an additional 21% have de facto bans in that they say they'll do it but none of the doctors on staff will do it. That's half of American hospitals, but the numbers are probably much worse. Many of the rest will allow what's often termed "Cinderella VBACs" (a term coined by Henci Goer ) -- "yes, you can have a VBAC as long as you have it Monday - Friday, between 8 am and 5pm and you aren't over 40 weeks and we don't think your baby is too big".
Moreover, even if the hospital allows VBACs, it doesn't mean that all the doctors there are willing or eager to perform them. Take my own case. After I had a cesarean with my first child, I made a point to find a new practice that was VBAC-friendly. (I would have stayed with my first doctor, but my insurance switched, a whole other story). The practice I eventually signed up was very encouraging, telling me that VBACS had a 60-80% success rate and that their particular practiced boasted a 75% success rate. All good. Right?
Except, when I hit the 6 month point, my doctor said to me casually, "OK, let's schedule your C-section now."
"Excuse me?"
"Oh," he said, "You know, you only have a 13% chance of success with your VBAC." He went on to explain that since I had reached the "pushing" phase of my first labor, my chances of a successful VBAC were dismally low and therefore it made no sense to attempt one.
Furious at the bait-and-switch (doctors love, love, love C-sections -- in and out in an hour! No messy labor! No pesky doulas or family members hanging around!), I asked him to produce the study that said so. It turns out that the study, which dated back to 1999, was contradicted by several later studies, all of which showed a significantly higher rate of success -- between 40-60%. One study showed no difference in success rates at all, no matter where the first labor ran into trouble.
The doctor on call when I ended up giving birth on Thanksgiving weekend, was, needless to say, very much put out by my inconveniencing him. His revenge? He refused to talk to me while I was in labor, and didn't answer his pager when I was ready to push. So that's an example of a hospital that allows VBAC and supposedly pro-VBAC doctors for you. The truth is, doctors who are truly VBAC-friendly are few and far between. The good news is, I gave birth, via VBAC, to a perfectly healthy little boy and had a much quicker, easier recovery than I did with my C-section (which was hell, but another story).
I'll end with this story, much more dramatic than mine: After giving birth to her first child via cesarean, Alexandra Orchard, a CPA in Colorado Springs, was told her second baby measured too large to be delivered vaginally. "My doctor said, 'You're not only risking her life, you're going to break her collarbone when you push her out,'" Orchard recalls. Through tears, she scheduled a second cesarean. "I was in so much pain after each surgery that I don't even remember when I met my children." With her third child, Orchard was determined to get a VBAC, but her doctor refused. Orchard researched the risks and with the help of a midwife, labored for 30 hours and gave birth at home to a daughter, now almost two years old. Orchard is apprenticing to become a midwife because, she says, "I don't want my daughter to have to fight like I did."
I'm glad to see articles such as this drawing attention to the plight of women in this country who aren't so lucky to have access to a supportive OB/hospital. In my state, until recently it was illegal for midwives of any kind to attend home births (not the only state where this is the case), so if a woman couldn't find support for a VBAC in her area, she basically had to go "underground " to have that option. Hopefully, articles like this will bring attention to the VBAC issue and help women in the future to have that choice, no matter where they live or choose to give birth. Thank you, Paula!
There are still many risks in giving birth, both to baby and to mother. People are taking a big chance doing this at home, IMO.
In the end the safest place to give birth is the place where you feel safest. If someone is in the small group of the truly high risk, then yes, they should definitely be in a hospital. Any homebirth midwife who saw such a situation would tell that person to go to a hospital.
I think the best model of care is midwives for almost everyone (in the hospital or at home) and OBs stick with the folks who really need that level of expertise. You don’t go to a neurosurgeon for a headache, right? This is how most of Europe does it and they have much better maternal/fetal outcomes then we do.
Staying home can help avoid many complications caused by these unnecessay interventions.
Of course you can't predict WHAT will happen in childbirth, but the chances of winding up with a C-section are greatly reduced when you make those choices. The majority of women I know who chose an epidural wound up with a C-section. Of course they were ALL medical emergencies.
Women are so terribly afraid of birth and pain that they are completely sold on having epidurals and C-sections. OBs are stressed and frightened as well. Not a good combination.
Go to midwiferytoday.com for more info. It will be an excellent conference.
One big problem is that women do not know how to move their bodies in order to facilitate the descent and rotation of the baby. Middle Eastern Dance was originally designed to teach women to do just that. Unfortunately, it was eroticized and its original intent was lost. If women danced their way to birth there would not be so many c-sections. Good luck with that tho when you're hooked up to an epidural !
I recently had a colleague who lost a case in which a woman who was VBAC-ing ruptured her uterus and lost her baby. The doctor was sued because she was at another hospital attending to another patient. A staff doctor attended to the patient who was VBAC-ing, was able to get her to the OR and the baby out in under 7 minutes, but the baby died anyway. No better care could have been provided to this woman. My colleague settled for millions, and the hospital now requires doctors who have patients who are VBAC-ing to be in-house. This is impossible for most ob/gyns, who practice at several hospitals.
The malpractice industry is now determining how care is provided in this country. Frivolous lawsuits that settle rather than going to court drive up the costs of insurance. Bad outcomes are rare, but they are costly on an economic and emotional level.
This is a much more complicated issue than what is presented here. Yes, there are doctors who like to work less and get paid more. But there are also many who simply want what is best for their patients and are unable to provide it due to systemic constraints. I, frankly, am tired of the adversarial nature of medicine in this day and age.
Another issue I see prevailing is something you mentioned here: your colleague being busy with another patient at another facility while they had another patient in labor elsewhere. OBs work long, hard hours- I respect the amount of time that goes into the job. But many OBs have themselves stretched too thin. I understand that even with only a few patients, some are inevitably going to go into labor at the same time. . . but when it gets to the point where an OB is constantly needing to cancel appointments & juggle multiple women in labor at the same time, then obviously they've taken on more than they can safely handle. More than they can safely handle in terms of what's safe for their patients, & more than they can safely handle in terms of what's safe for their business & liability.
Those who want what's best for their patients should not have so many patients to care for at once in order to give the patients that they do have the time & care they need & deserve. This is something that is in line with the midwifery model of care, & you'll see midwives getting sued less than OBs because they don't guarantee perfect outcomes. They don't take on so many clients that they don't have the time to explain the risks & benefits to them
I am an emergency physician in an inner-city ER that serves mostly uninsured and MediCal patients, 60% Spanish-only population. I am also a strong believer in home/natural births, midwifery, and am alarmed by the low prevalence of breast feeding as well as support for immediate breast feeding by obstetricians and L&D staff.
That said, I must take issue with several of your assertions in a number of your posts. First of all, how can you just assert that "OB's take on too many patients"? I think you are living in a dream world. Where are these inner city patients to go? What midwife is available to them? For that matter, what OB? If I have a 17 weeker come in with bleeding, an empty uterus with a beta if 220,000 and an adnexal mass, much less an 8 weeker with no problems who just needs an outpatient prenatal care referral, I have to move several mountains to even find an available OB. OB's see the volume they do because they HAVE TO.
What are YOU doing to affect policy, to change insurance coverages to include midwifery, to get midwifery on hospital referral panels, to actually provide on-call coverage of ER's like mine, so I can refer my uninsured/underinsured patients to you from the ER?
(Continued)
Believe me, if I could get a lactation consult or prenatal consult on all these women dumping cow protein into their babies and ticking along in week 11 without a single prenatal check, I'd do it in a heartbeat, and I'd surely recommend a midwife if I had one to recommend.
Dr. Russo works in a clinic for underserved women. I assure you, she is not making big $$, and no one in this field picks up more patients for the money anymore. Not when you work with underserved populations. That is a thing of the past. Most underserved/Medi-Cal care is a money-losing affair and is subsidized by government or foundation funds etc... These OB's are covering multiple hospitals because they HAVE TO. Furthermore, I am confused by your assertion on the one hand that an OB is not needed at all for most deliveries, yet on the other hand saying they should be available all the time?
Try to get off your midwifery high horse. Not all physicians are opposed to holistic healthcare.
One final comment, there was a discussion back a bit about sexism, and weather or not people delivering babies should only be "Those who have the ability to do so themselves". All sides of that argument seemed sexist to me; You should not assume that all women have, will, are able to, or want to bear their own children.
I had a great VBAC at home. Recovery was a breeze. Pain from childbirth was nothing like recovering from a cesarean. It was totally manageable. To be drug-free and fully aware and present when my baby was born was priceless. To have him drug-free and fully aware was amazing. To eat and drink immediately after labor ... was so satisfying after all that hard work!
Why I VBACed: http://vbacfacts.com/vbac
Why I had a homebirth: http://vbacfacts.com/hbac
My birth story: http://vbacfacts.com/hbacbirth
Home birth vs hospital birth for the number cruncher: http://vbacfacts.com/2008/09/06/homebirth-vs-hospital-birth-for-the-number-cruncher/
For women seeking VBAC, this article is a good start: http://vbacfacts.com/2009/01/15/im-pregnant-and-want-a-vbac-what-do-i-do/
Ladies, you can do it! You can birth that baby! :)
Best,
Jen from vbacfacts.com
I too had a safe successful homebirth VBAC. I had two previous cesareans. I agree that the hospital *should* be the safest place to have a baby, but it's not. I learned that the hard way when I had my second child- a traumatic, unnecessary repeat cesarean due to the attitude about VBACs. It was very traumatizing, but it led me to start researching & I'm thankful that I was able to learn & make changes to the care I was seeking before something worse happened.
Jill-- www.unnecesarean.com
Fortunately, I was raised by a strong woman who didn't scare me with stories of the pain and suffering of childbirth. She portrayed it as a rite of passage and something empowering. To her, it was pain that was manageable and temporary and happy. I can't say that I wasn't scared of giving birth when I became pregnant, but I was more scared of a needle in my back or a doctor pulling my baby out of my abdomen.
Our family is a large one, many of the women are nurses. Not a one ever used epidurals or had a C-section and everyone breastfed.
I wish more women had faith in their bodies and the process of birth. For me, it was the most important thing I've ever gone through. I feel that I gained a confidence and power. I wish that for more women.
Women aren't broken. The system is. It's costing some families the lives of their babies &/or mothers, & the rest of the consumers countless dollars.
If OBs didn't take on too many patients, there wouldn't be as many issues & they wouldn't feel so rushed or bothered. They'd be able to spend more time with women prenatally, focusing on good health, nutrition & education, & this would decrease interventions & complications during birth.
Yes, it's not a 9 to 5 job. Nor should it be made into one with the over-scheduling of births to the detriment of women's health. And it's not a male-female issue as NWReader suggests. A surgeon is a surgeon.
Back to the VBAC discussion...
If you're endorsing the midwives model of care, that's a separate issue.
http://www.slate.com/id/2111499/
Thank you for telling my story so well.
Alexandra Orchard
A few years ago, I started offering a workshop for women who have had traumatic births. I am passionately driven to help women heal from the emotional trauma of having all your choices stripped away, of being utterly violated, of being disempowered as a mother, all the while being told it's ok or necessary because the baby is healthy. I don't think that it's too much to ask that we also have moms who are healthy, both physically, AND emotionally. In a culture that respects birth as normal, that can happen. And I am going to everything in my power in my lifetime to work toward that goal.
Thank you again for writing these pieces. May it begin a tidal wave of true change!
If it is truly about too much risk then why do hospitals allow a completely elective procedure that carries small but potentially catastrophic risks such as liposuction? Hmmmm, let me see. Yes, it's about money and bans on VBAC are also about money....and fear. Doctors who don't fight for the rights of patients to have choices have been beaten down by the system and given up. All economic forces are against the VBAC option. Hospital administrators prefer revenue producing c/sections as financial loss is the norm in most obstetric units. The crusade against VBAC defies evidenced based medicine, defies ACOGs tenets about the sanctity of a woman's right of informed consent and refusal and defies a basic right of self determination when it comes to our bodies.
Ultimately, it will take major reforms in the medical-legal tort system to bring most doctors and VBAC banning hospitals back to common sense. Can Washington work on that please?!!
It’s interesting to see the nearly century old analogy given a 2009 update by adding choice rhetoric and assigning the right of refusal to THE DOCTOR while saying nothing of the woman’s right to INFORMED REFUSAL of a repeat Cesarean section. Choice indeed!
More than 7000 elective repeat Cesareans would need to be performed to prevent ONE perinatal death caused by uterine rupture. Many women are being denied the reasonable choice to not be one of those that takes a cut for the team and, as featured in Pamela Paul’s Time Magazine article, are finding themselves having to drive hours in labor to give birth vaginally in a hospital. Others just stay home.
It's ridiculous that the excuses we're given for not being able to access evidence-based health care options & support in choosing how we birth is that 'it's too expensive.' This is the United States- we spend more on maternity care than any other country in the world! Yet, our outcomes are the worst out of all industrialized countries. . .
If it was truly about needing to save money, there wouldn't be such restricted access to midwives. The midwifery model of care has better outcomes for mom & baby than the typical OB/hospital model of care & costs considerably less. It's time that consumers start demanding evidence-based care instead of convenience & fear-based treatment.