ICAN President Desirre Andrews was quoted today in the Chicago Tribune. The article discusses VBAC bans in Illinois and the overuse of repeat cesareans (ERCS).
Repeat C-sections have become so routine that 90 percent of pregnant women who have the surgery give birth that way again. That is a concern to health experts, who say vaginal births after a cesarean, or VBACs, should be far more common.
Successful VBACs result in better health outcomes for the mother and the baby and cost several thousand dollars less than cesarean deliveries, according to the American Congress of Obstetricians and Gynecologists, or ACOG. The organization recommends that VBACs be offered in low-risk cases.
Experts point out that although the attempt carries a risk of uterine rupture, the chance it will happen is relatively low: 0.5 percent. Meanwhile, C-sections carry all the risks of a major surgery. Compared with having a vaginal birth, a woman delivering by C-section experiences more physical problems, longer recovery and more emotional issues on average, studies show. Research also has found babies born by cesarean are less likely to be breastfed and more likely to experience breathing problems at birth and asthma as they get older.
Yet the VBAC rate, 9.2 percent, is a far cry from the objective set by the Centers for Disease Control and Prevention: 37 percent. In Illinois, the rate was 11 percent in 2008, down from 38.6 percent a decade earlier.
In the rural parts of the state, the dictum “once a cesarean, always a cesarean” rings particularly true: In northwest Illinois, the VBAC rate is as low as 3.9 percent, according to the Illinois Department of Public Health. Twenty-two percent of Illinois hospitals don’t offer the procedure, according to a survey by the International Cesarean Awareness Network, a grass-roots group that works to lower the rate of unnecessary cesarean sections.
The article points to liability issues as one of the driving factors of ERCS over VBAC:
Safety fears, however, were just one factor. Legal pressures, professional guidelines, and patient and physician preferences also created a VBAC backlash. In March, the National Institutes of Health will hold its first-ever VBAC conference to explore why the rate continues to fall, even though 73 percent of the women who try VBACs are successful.
“The liability issue is huge,” said Dr. Joseph Pavese, chairman of the obstetrics department at Advocate Christ Medical Center in Oak Lawn, where 97 percent of pregnant women with a previous C-section have another one. “Parents expect good outcomes, and physicians are reluctant to try difficult deliveries. If the baby is not perfect, there is possible litigation.”
Risk adversity feeds into this dynamic as well:
Over the years, “The risk of uterine rupture has not changed,” said Dr. Howard Strassner, director of maternal and fetal medicine at Rush University Medical Center. “What has changed is individual tolerance for risk. It reached the point where no one wants to be associated with an adverse outcome.”
In the 1990s, research that suggested VBACs were dangerous — and a pro-cesarean editorial — published in the New England Journal of Medicine immediately affected practice, said Gene Declercq, a professor of community sciences at the Boston University School of Public Health. But more recent and balanced research showing VBACs are as safe — if not safer — than repeat C-sections hasn’t had the same effect, said DeClercq, who researches maternity care practice and policy in the U.S. and abroad.
The result has been an increase in VBAC bans in hospitals across in country, including Illinois.
What crippled the idea of a VBAC, however, was a simple word change. In 1998, ACOG advised that physicians should be “readily available” to provide emergency care because of the dangers of a uterine rupture. Eight months later, the American Congress of Obstetricians and Gynecologists changed the wording to “immediately available,” and many small hospitals in rural areas stopped doing VBACs.
Katherine Shaw Bethea Hospital in Dixon, which handles about 365 deliveries a year, was one of more than a dozen Illinois hospitals that subsequently dropped VBACs because an on-site anesthesiologist wasn’t always immediately available.
VBACs are also banned at Blessing Hospital in Quincy, which touts itself as “the largest and most sophisticated medical center in a 100-mile radius.” Hospital officials declined to explain why.
Desirre comments on this trend:
“It’s illegal to enforce a ban on how our bodies are designed,” said doula and childbirth educator Desiree Andrews, of Colorado Springs, president of the International Cesarean Awareness Network. “But evidence-based practice has been crowded out of the hospital setting in favor of defensive medicine. As a result, too many women are subject to coerced cesareans because hospitals have banned VBACs.”