The NIH Consensus Conference on Vaginal Birth After Cesarean has just released its findings offering strong support for a far more liberal policy regarding vaginal birth after C-section (VBAC).
The NIH conference on VBAC was convened because doctors, patients, and policy makers believe that the current VBAC policy is misguided and potentially harmful. As the statement explains:
Vaginal birth after cesarean (VBAC) describes vaginal delivery by a woman who has had a previous cesarean delivery... In 1980, a National Institutes of Health (NIH) Consensus Development Conference Panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered. The option for a woman with a previous cesarean delivery to attempt a trial of labor (TOL) was offered and exercised more often in the 1980s through 1996. Beginning in 1996, however, the number of VBACs has declined, contributing to the overall increase in cesarean delivery ...
Although the number of women ... faced with the question of whether to attempt TOL has markedly increased, there has been a concurrent, dramatic drop in VBAC. Yet cesarean and VBAC rates are identified as quality indicators for maternal health by policymakers, insurance providers, and health care quality monitoring groups. Success of TOL is consistently high (60 to 80 percent), whereas the risk of uterine rupture is low (less than 1 percent)...
In other words, in 1980, after reviewing the scientific literature, an NIH panel recommended offering a trial of labor to women who had had a previous C-section. As a result, VBAC became popular. Many women had successful vaginal deliveries. Only a very small proportion of women had serious complications, almost exactly what was predicted. Yet the VBAC rate peaked in 1997 and has declined precipitously since the, as the following graph shows.
Why did VBACs decline despite the fact that the benefits and risks were exactly as predicted? The answer can be summed up in one word: lawsuits. Although women offered VBAC were counseled about the small risk of uterine rupture (opening of the uterine scar during labor) and the attendant risk that the baby might die in the event of a rupture. Nonetheless, when a baby died after a uterine rupture, many mothers sued, and claimed that they had not "understood" the risks even though those risks were clearly explained. Juries were moved by these emotional appeals, and large judgments were paid out.
What did everyone learn from these lawsuits? Doctors learned that patients maintained that they could not "understand" risks no matter how carefully explained, patients learned that they did not have to take responsibility for their decisions, and lawyers learned that VBAC complications represented a bonanza.
The American College of Obstetricians (ACOG) stepped into the breach and, attempting to make things better, made them far worse. ACOG likes to remind its members that doctors have never lost a lawsuit in which they followed ACOG guidelines. Therefore, ACOG decided to promulgate guidelines that doctors could use in their legal defense. Unfortunately, the ACOG guidelines were so strict (unreasonably strict in the eyes of most obstetricians) that most obstetricians could not meet them. ACOG mandated that VBAC should only be attempted when both an anesthesiologist and obstetrician were present so that anyone who experienced a uterine rupture could be treated immediately. Most medium sized and small hospitals cannot afford to have an anesthesiologist in the hospital around the clock. Most obstetricians cannot afford to sit for hours while a patient labors. Therefore, many hospitals and anesthesiologists stopped offering VBAC.
Simply put, lawyers have sharply restricted the availability of VBAC.
The latest NIH panel reviewed the scientific literature and confirmed their earlier stance. VBAC should be offered to eligible women because the chance of success is high and the risk of complications is low. Furthermore, the conference report urged ACOG to re-evaluate their VBAC guidelines, presumably to eliminate the need for continuous presence of both anesthesiologist and obstetricians. In addition, the panel recommended that policy makers review the medico-legal strictures on VBAC, since liability concerns are driving the restriction of VBACs.
So doctors, patients and NIH are in agreement that VBAC should be offered to many more women. Too bad the lawyers don't agree, since they seem to be in charge of making the decision, and they recommend C-section.
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Comments
It is unfortunate that people are not willing to take responsibility for their own choices, it makes life so much more complicated and filled with paperwork for the rest of us.
I am in the mental health field and ultimately decided against marriage counseling because couples (who are seeking counseling for marital problems to begin with) can each individually sue the therapist if their marriage does not work. That is a sad state of affairs.
Thanks again, very interesting!
Stephanie
I agree. It is also demeaning to women because it is based on the assumption is that women are not capable of giving informed consent to anything that involves increased risk.
Thanks for this.
Quite a few. I don't understand how insurance companies are allowed to tell doctors what procedures they can and cannot perform.
If Dr's and their patients were allowed to make the these choices (instead of doing only what they were "approved" to do) everyone would benefit. What will it take for hospitals to change their policies?
The world seems divided between busy career women (or just anti vag) who schedule a c-section like a haircut, to the opposite, women who are so committed to delivering a baby vaginally that anything less is considered a failure. Of course within these extremes there are many permutations, myths, truths, and self serving directed information.
The childbirth model, as it now exists in the United States of America (like almost every other aspect of the health system in the USA) is unsatisfactory, without exception, on every level. Infants and mothers die too often, they get sick too often, and most who remain relatively healthy did not have a positive experience.
It is true, the USA still remains a leader in scientific research and treatments, but the utilization of these are confined to those with a lot of money and/or political importance, or an insurance policy that hasn't had it's limit sucked out yet. That 80/20 thing might have sounded doable when you signed up, but even minor prostate cancer can shoot that 20% nut into the six figures. Pay close attention to that maximum payout award too, less than ten million forget about it.
I wish that were the case, but I'm afraid that healthcare reform is not going to involve meaningful reform of the malpractice system. I suspect that it will require direct action by Congress on tort reform to change this situation.
Says who? According to the Listening to Mothers II Survey conducted by the Childbirth Connection, the vast majority of American women are quite satisfied with the care they received during childbirth.
Moreover, that has nothing to do with the issue at hand: the fact that courts have ruled that women are incapable of "understanding" the risks of VBAC and therefore can't give informed consent.
Your post humanizes the doctors in this situation and the difficult decisions they have to make when deciding to recommend a VBAC. Getting sued by your own patient, that you're trying to help, is itself a form of harm, and doctors who recommend VBAC, knowing full well they could get sued as a result, are heroes to me. The rest are just reasonable humans put in a hostile situation.
Like you stated in the post, when a malpractice suit goes to court, what matters is the emotional state of the jury, not science or rationality. That is why doctors tend to be so mistrustful of the legal system - all the Post-Enlightenment advancements of humankind in Reason and science go out the door. Instead, doctors are forced to sit through a Medieval witch-hunt, where the only thing that matters is who makes the jury cry more.
Thanks again for your thoughtful post.
We all know that "tort reform" is touted as something that could wring some of the obscene cost out of the healthcare system by some opponents of insurance reform. However, the percentage of cost attributable to lawsuit abuse is less than 2% overall from what I understand.
VBAC vs C-Section could certainly be an instance where there are disproportionately high cost related to lawsuits. However, could choices made by medical providers/ insurers also have something to do with the fact that C Sections are more expensive than vaginal birth, allowing higher billings? And they are more conveninent for doctors, allowing them to schedule births around other events and comittments. In other words, I'm not sure I buy "the lawyers made me do it".
I find this topic very intriguing and would like more information. Perhaps you could point us to the links you used when researching?
Thanks for posting on this interesting issue.
I'm 35 weeks pregnant, so I need to decide soon. My previous c-section was after a long and failed induction (I didn't dilate at all). I was induced at 38 weeks due to pre-eclampsia. After the c-section I developed HELLP and had severe bleeding requiring several transfusions. This all happened 18 months ago. So to say I am a bit nervous about my upcoming delivery is an understatement.
Right now I have PIH, but not pre-e (knock on wood). I have a scheduled section at 39 weeks but I may go into labor on my own before then. (I've been having a lot of contractions lately.) My doctor said it is up to me if I want to try to deliver vaginally if labor happens before 39 weeks.
I so so so wish there were clear guidelines on this. It may sound like I am trying to carelessly let someone else make the decision for me - but I would love to have clear guidelines. How much of a risk is a VBAC for someone with PIH, for example? I'm on a hefty dose of methydopa, but my blood pressure is still usually around 140/90. I wish I had data for something like that, but I don't believe such data exists.
So I am left wondering and worrying about what the best decision is - and wishing my doctor would give me a push one way or the other. But, I can imagine she has a lot of pressures placed on her to NOT push me one way or the other for liability reasons. So me, the non-expert, needs to wade through any information I can find and try to come to a decision... FAST! :)
http://www.ahrq.gov/clinic/tp/vbacuptp.htm
It's the evidence used by NIH in their "deliberations". I believe there to be a numeric typo in the abstract (it says "The rate of uterine rupture for all women with prior cesarean is 300 per 1,000" which is way, way off the data in the full document - no one would ever get pregnant after a C-section if they had a 1 in 3 chance of rupturing, and that's not just the TOL group they are talking about), but the full document in pdf form is an informative review of the scientific literature (397 pages!).
2% of an atronomical number (th cost of healthcare) is a very big number. Moreover, there are tremendous costs beyond direct costs. At the moment, tens of thousands of women are undergoing unnecessary C-sections because of legal concerns about VBAC. That's a large cost, both financial and personal and that should also be taken into account.
i look like the type that could be working in the fields, have the baby, and get back to work. but x-rays showed that bone structure is too small to let babies over about 2lbs even enter the birth canal. i carried both of mine right in my diaphragm. they had to use forceps on caitie during the section, for pete's sake.
maybe they just knew what a tough world it was out here and wanted to stay as long as they could. or they were part bat and were holding onto my ribs with their tiny toes.
i agree that VBAC needs to be an option for those who want it and are safe to have it. it really needs to be a decision between a woman and her doctor. (r)
I guess my question was, what are you basing that on? Your personal feelings as a doctor or is there a study somewhere you could link to?
Judge for yourself; the link is: http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml
The truly discouraging fact is that the law has lost its lustre as a realm attached to justice, fair play and looking out for the little guy. My grandfather ( my father's father) was a Superior Court judge and went into law because he admired Abraham Lincoln and had high principles. My father went into law, seemingly to "game" the principles, and believing in nothing. I think there is a big cultural shift between the days –– say, for instance, 1939 when filmmaker John Ford, made YOUNG MR. LINCOLN–- and presumably no one–– or few ––scoffed at Lincoln's ideals ––and today. Yet we are yearning for a sense of moral compass... are we not?
By Jennifer Block Friday, Mar. 12, 2010
Amnesty International may be best known to American audiences for bringing to light horror stories overseas such as the disappearance of political activists in Argentina or the abysmal conditions inside South African prisons under apartheid. But in a new report on pregnancy and childbirth care in the U.S., Amnesty details the maternal health care crisis in this country as part of a systemic violation of women's rights.
The report, titled "Deadly Delivery," notes that the likelihood of a woman dying in childbirth in the U.S. is five times greater than in Greece, four times greater than in Germany, and three times greater than in Spain. Every day in the U.S., more than two women die of pregnancy-related causes, with the maternal mortality ratio doubling from 6.6 deaths per 100,000 births in 1987 to 13.3 deaths per 100,000 births in 2006. (And as shocking as these figures are, Amnesty notes that the actual number of maternal deaths in the U.S. may be a lot higher since there are no federal requirements to report these outcomes and since data collection at the state and local levels needs to be improved.) "In the U.S., we spend more than any country on health care, yet American women are at greater risk of dying from pregnancy-related causes than in 40 other countries," says Nan Strauss, the report's co-author, who spent two years investigating the issue of maternal mortality worldwide. "We thought that was scandalous."
According to Amnesty, which gathered data from many sources including the CDC, approximately half of the pregnancy-related deaths in the U.S. are preventable, the result of systemic failures including barriers to accessing care; inadequate, neglectful, or discriminatory care; and overuse of risky interventions like inducing labor and delivering via cesarean section. "Women are not dying from complex, mysterious causes that we don't know how to treat," says Strauss. "Women are dying because it's a fragmented system, and they are not getting the comprehensive services that they need."
The report notes that black women in the U.S. are nearly four times more likely to die from pregnancy-related causes than white women, although they are no more likely to suffer certain complications like hemorrhage.
The Amnesty report comes on the heels of an investigation in California that found maternal deaths have tripled there in recent years as well as a maternal-mortality alert issued in January by the Joint Commission, a group that accredits hospitals and other medical organizations, which noted that common preventable errors included failure to control blood pressure in hypertensive women and failure to pay attention to vital signs following c-sections. And just this week, a panel of medical experts at a conference held by the National Institutes of Health recommended that physicians' organizations revisit policies that prevent women from having vaginal births after having had a cesarean. Such policies, designed in part to protect against litigation, have contributed to the U.S. cesarean rate rising to nearly 32% in 2007, the most recent year for which data is available.
The Amnesty report spotlights numerous barriers women face in accessing care, even among those who are insured or qualify for Medicaid. Poverty is a major factor, but all women are put at risk by overuse of obstetrical intervention and barriers in access to more woman-centered, physiologic care provided by family-practice physicians and midwives.
Amnesty is calling on Obama to create an Office of Maternal Health within the Department of Health and Human Services to improve outcomes and reduce disparities, among other recommendations. The report also calls on the government to address the shortage of maternal-care providers.
"Access is only one factor," cautions Maureen Corry, executive director of Childbirth Connection, a research and advocacy organziation that recently convened more than 100 stakeholders, including members of the American College of Obstetricians and Gynecologists and the NIH, in a large symposium on transforming maternity care. "We need to make sure that we reduce the overuse of interventions that are not always necessary, like C-sections, and increase access to the care that we know is good for mothers and babies, like labor support."
Read more: http://www.time.com/time/health/article/0,8599,1971633,00.html?hpt=Sbin#ixzz0hzEuVupy
First, it is a political report, concerned primarily with issues of access, such as poverty, immigration status, insurance coverage, and racial discrimination. It is based on interviews with focus groups consisting primarily of patients.
Of the 138 pages of the report, only 3 pages considered the issue of obstetric interventions. The primary recommendation? An additional intervention: increased use of blood thinners to prevent blood clots.
Maternal mortality is part of a larger problem of healthcare access in the US. The primary purpose of the report is to chastise the US government for failing to provide access to healthcare for all of its citizens. The report is not about obstetric interventions and the issue is mentioned only in passing.
Maternal mortality as a result of lack of access to medical care is a very serious problem. It's a tragedy that should not be co-opted by "natural" childbirth advocates to advance their own, narrow aims.
http://www.amnestyusa.org/dignity/pdf/DeadlyDelivery.pdf