A Hospital Explains Why They Ban VBAC
I was sent this letter by a mom from Southern California who wants to VBAC at her local hospital, but can’t since they have a VBAC ban. She wrote a letter to them, which can be found here, and below is what she received in response. She gave me permission to post both letters.
The letter was written on hospital letterhead. I have included the entire letter here and it is typed exactly as it was written except for some identifying information that I have removed for the privacy of the OB who wrote the letter as well as the hospital’s name. Who he is isn’t as important as what he says since he is speaking on behalf of the hospital.
After the letter, I include some commentary clarifying some of the inaccuracies in the doctor’s letter as well as expanding on some of the statements he makes.
March 10, 2008
Dear Ms. B,
I was asked to respond to your letter inquiring about Hospital’s VBAC policy. Your letter is well written and asks some valid questions. I will do my best to answer your questions by giving you a historical perspective as well as direct answers.
[….]Although my primary role involves patient care and administrative duties, I continue to lecture across the country on a variety of obstetrical subjects, with the “Risks and Benefits of Cesarean Section” and “Risks of VBAC” being the two most requested talks I give. I have personally delivered, or supervised the delivery of over 15,000 births, and continue to be involved in over 5,000 patient encounters per year.Historically, when Cesarean sections were being performed 40 years ago they were performed through vertical uterine incisions. These incisions were found to have a uterine rupture rate of 6% in subsequent labors, therefore the standard then was clearly “once a Cesarean, always a Cesarean”. With the advent of transverse uterine incisions, it was found that women presenting in labor prior to their surgery had a much lower uterine rupture rate than previously documented, and hence the VBAC was born. Unfortunately, the new uterine rupture rate was simply not known.In the 70’s, Women’s Right’s groups as well as insurance companies trying to increase profits, pushed the VBAC fury to a point where many institutions began forcing women to VBAC against their wills. Those of us who knew the procedure was not benign complained of inadequate consent for their patients, and women’s loss of autonomy. It was not until almost 20 years later, that good modern VBAC data was available, and that the 1/200 (0.5%) uterine rupture rate was documented.Once the data was available, questions were raised worldwide as to the appropriateness of the procedure. Here at Hospital, our own obstetricians discussed for over 3 years the both the Ethics and logic behind the VBAC controversies. The key question is simply whether or not a 1 in 200 risk of fetal death is “acceptable”, and whether or not a woman has a right to make that decision on behalf of an unborn term fetus. Ultimately, the argument was made that most people would not board an airplane that had a 1 in 200 risk of crashing. Moreover, we do not allow events to transpire that carry a much lower risk. For example, it is illegal for a mother to take her newborn baby home from the hospital without a child protective seat (and most parents would not think of doing such a thing). Yet, the risk of actually being in a car accident on the way home from the hospital is about 100 times less than the risk of a VBAC. Discussion then took place regarding how good we are at saving mothers and babies that have catastrophic events such as uterine ruptures. We concluded that “being good” at dealing with disasters was not a good reason for inviting them. Moreover, in the airline analogy, if we were to invite mom’s to board an airliner that had a 1 in 200 risk of crashing, telling the passengers that only a small percentage of the people onboard would actually die because the hospital and the doctors are good at what they do, is not likely to change their original opinion of declining the flight.
Answering some of your other questions:
I am concerned that if [Hospital] can’t meet the staffing standard for VBACs, that means the hospital doesn’t have the ability to perform an emergency cesarean 23 hors [sic] a day/seven days per week.
[Hospital] is ready to perform emergency cesareans 24×7. In fact, we are remarkably good at it, and can boast about some of the best outcomes in the world. Not meeting some of the recommended requirements for VBAC does not infer a lower standard. Even though we do not have ‘in-house’ anesthesia 24 hours per day, our surgical response time in many cases is better than larger institutions with “in-house” staff. A large University setting may have in-house staff but simply walking from one side of campus to the other may take more time than driving in from home in our small community. Moreover, the volume at some of these large centers and logistic delays often encumber those institutions and negatively impact on their response time, whereas [Hospital] has the ability to mobilize and act quickly when needed. Nevertheless, being good at handling emergencies is not justification for inviting them. There will always be emergencies in medicine that cannot be staffed or prepared for. It is a sad fact of life that some women in labor will have heart attacks, and some will have brain tumors or brain aneurysms, and some will have emboli, but no system can have a Cardiologist, a Neurosurgeon, and a pulmonologist available on site 24 x 7 waiting for these things to occur.We identify these challenges, and we set systems and protocols in place to efficiently handle these emergencies with available resources. These systems work remarkably well, and fortunately in the majority of cases there is enough time for the mobilization of resources to result in the best possible outcome.The cesarean rate in this country has risen well above the World Health Organization’s recommended rate of 10%-15%.. I am concerned that the cesarean rate in [our city] is so high…
The WHO recommended cesarean rate is not based on data. In fact, there are no good published recommendations for cesarean rates that are based on data. That is for a very good reason, and the reason is that the optimal cesarean rate depends on the goal desired. If the goal is to optimize neonatal outcome, one can make a very clear and elegant mathematical argument that the cesarean rate should be almost 100%, and that is not a statement that appeals to many, therefore the issue is left mute. When looking at the morbidity of cesarean sections at term, the majority of complications arise from surgical intervention after failed attempted vaginal delivery. The actual equations get quite complicated, and depend on multiple factors including the health of the mother, and the planned number of Cesarean sections, and timing between pregnancies.
When attempted vaginal deliveries are removed from the equation, such as in elective cesarean deliveries at term without labor, the outcomes are much better for the newborns than in vaginal deliveries and the morbidity to the mother can be equivalent or even lower than in attempted vaginal deliveries. Although we do not consent women for vaginal deliveries, the risks of attempting a vaginal delivery are actually quite high, and carry many of the same risks, if not more, than cesarean sections. Realize that Cesarean delivery virtually eliminates the risk of birth trauma. The numbers you quote for fetal injury during Cesarean section are not accurate. I can tell you the rates you report for newborn injury from Cesarean delivery would not be tolerated and would certainly be identified by quality assurance measures.
You quote statistics in this part of your letter, which are not accurate. The complication rates for Cesarean sections in the last 20 years have dropped to levels that now are arguably safer than vaginal delivery, and although retained neonatal lung fluid is a very real increased morbidity to the newborns, it carries no long term sequelae in the absence of prematurity, and is more than compensated for by the benefits.
Delivering premature babies, whether by cesarean or vaginal delivery, both have the long-term implications you suggest but are not associated with the route of delivery.
I am concerned that [Hospital] is understating the risks of primary or subsequent cesarean surgeries yet exaggerating the risks of VBAC
The risks of VBAC are very real. The 1 in 200 risk is an average risk of “catastrophic” uterine rupture taken from many studies across the country. They do not count smaller ruptures whereupon the baby has not “fallen out” of the uterus yet, as these are often called “windows”. This leads to the variations in the reporting of uterine rupture. Those of us who provide care on a regular basis can tell you we see these ruptures frequently, even in the absence of VBACs. I have seen 3 in the last 6 months at [Hospital]. All were handled well and had good outcomes, but even when trying to minimize these events they happen due to factors beyond our control. The national death rate from Cesarean sections is less than 1 per 100,000 in most studies. Unavoidable death due to pregnancy complications unrelated to route of delivery is 1 in 10,000. When comparing these risks of uterine rupture in VBAC of 1 in 200, you see that the equation very much supports our decision to take the safest route and discourage these procedures.
In summary, the physicians at [Hospital] are very much aware of the dichotomy between what is safest for the unborn fetus and maternal preferences and autonomy. These controversies are often complicated by lack of data, poorly understood data, and strong emotional components.
I can assure you that we strive to provide the safest medical environment while supporting as much of the autonomy and patient desires as possible. Nevertheless, we ultimately have to be true to ourselves, and do what science tells us is best for our patients, even if sometimes we cannot please 100% of the clients.
You may find it interesting that since our decision to not offer VBACs, the majority of our patients responded very favorable, with a majority of women reporting a feeling of freedom in not having to justify to others their desire to not VBAC. Although we expected a backlash of unhappy patients, we were pleasantly surprised to find the majority of women understanding the rationale and supporting our decision. I now receive less than 2 complaints per year on our decision to not offer VBACs at [Hospital.]
In fact, the greatest increase in our Cesarean section rate the last few years has come from women demanding a Cesarean delivery and refusing vaginal delivery. The acceptance of women’s autonomy and right to choose their mode of delivery has led to a significant number of women simply choosing Cesarean as the preferred mode of delivery.
If you continue to have strong desires to VBAC despite the risks involved, I am sure your obstetrical provider can help refer you to a University Center where the procedure is still being offered. Although the risks may not be lower there, they may have chosen to offer the service both for patients and for training of their residents.
Ok, Jen here…
When we consider why hospitals create policy, including VBAC bans, it’s important to examine their thought process. That’s what I’m going to do here.
First, can we just look at the names of his two most requested topics: “The Risks and Benefits of Cesarean Section” and “The Risk of VBACs?” It is glaring to me how only cesareans have benefits… VBACs only have risks. Did anyone else catch that?
He says, “Historically, when Cesarean sections were being performed 40 years ago they were performed through vertical uterine incisions. These incisions were found to have a uterine rupture rate of 6% in subsequent labors, therefore the standard then was clearly ‘once a Cesarean, always a Cesarean’.”
Yet, that phrase, when coined 92 years ago, was not an anti-VBAC statement. Here is the history of that phrase from ACOG themselves (Obstet Gynecol 1997;90:312-5. c 1997 by The American College of Obstetricians and Gynecologists):
The phrase, “once a cesarean, always a cesarean” dates back to an article by Edwin Cragin entitled “Conservatism in Obstetrics” published in 1916. Although cesarean delivery rarely was performed in that era, Cragin’s purpose was to urge physicians to avoid unnecessary cesareans. He termed the cesarean operation “radical obstetric surgery” and urged his colleagues to practice sound obstetrics to avoid having to resort to it. The famous “once a cesarean, always a cesarean” phrase came in the final paragraph of the article and clearly was meant to emphasize that one of the risks of a primary cesarean is that repeat operations might be required. Interestingly, the author went on to point out that there are many exceptions to this rule and that one of his own patients had 3 vaginal births after cesarean without difficulty. This is remarkable given that vertical uterine incisions were standard at that time. The low transverse uterine incision would be championed by Kerr a decade later.
He correctly cites the uterine rupture rate at around 1 in 200 and yet he incorrectly states that uterine rupture has a 100% perinatal mortality rate. Landon 2004 stated, “Overall, our data suggest a risk of an adverse perinatal outcome at term among women with a previous cesarean delivery of approximately 1 in 2000 trials of labor (0.46 per 1000), a risk that is quantitatively small but greater than that associated with elective repeated cesarean delivery.”
In other words, while the rate of uterine rupture in a spontaneous labor with one prior cesarean is approximately 1 in 240 (0.4%), 1 in 2000 (0.05%) VBAC babies will have a bad outcome including death or brain damage.
The OB who wrote our letter above then says, “The key question is simply whether or not a 1 in 200 risk of fetal death is ‘acceptable.'” As the risk of fetal death is not 1 in 200, we do not need to debate whether that is acceptable.
He says, “We concluded that ‘being good’ at dealing with disasters was not a good reason for inviting them.”
Offering VBAC is not “inviting disaster” anymore than supporting a first time mother in labor. The risk of uterine rupture is similar to other obstetrical complications that can present in a first time mother and require an emergency cesarean.
Repeat cesareans can also result in “disaster” through increased risk of placenta accreta. The truth is, both VBAC and repeat cesarean have risks and benefits and it is the parent’s right to choose which set of risks and benefits are tolerable them.
To ban VBAC completely negates the patient’s voice which violates everything doctors are supposed to honor in terms of patient autonomy.
He says, “The WHO recommended cesarean rate is not based on data.” Yet, he did not offer any medical studies that show that women and babies are benefiting from the USA’s 31% cesarean rate. He only states that he believes babies would benefit from an almost 100% cesarean rate.
I think the burden of proof lies with the person wishing to impose surgery. Show us the evidence.
A quick google search led me to this commentary from the medical Journal Epidemiology published in July 2007 which states:
Twenty years ago, the World Health Organization recommended that no more than 15% of deliveries should be delivered by C-section, pending evidence that higher levels benefit either mothers or their offspring. Of 60 medium- and high-income countries reviewed in a recent study, the majority (62%) had national rates of C-section above 15%. If we assume, based on the World Health Organization recommendations, that C-section rates above 15% lack medical justification, then there are 3.5 million medically unjustified interventions performed among these countries yearly.
This article cited World Health Organization. Appropriate technology for birth. Lancet. 1985;2:436-437 as the source of the WHO recommended 15% cesarean rate.
The commentary continues: (emphasis mine)
What are the consequences of these trends for the health of women and babies? To the extent that high rates of C-sections are not medically indicated [this includes repeat cesareans], they unnecessarily expose the mother and child to consequences that are not fully understood. In such procedures, the mother and her partner have no active participation in the birth of their child. The costs and benefits of this elective procedure, both physical and emotional, should be seriously explored before accepting the liberalization of its use.
Elective caesarean section may provide some benefits. A systematic review of 79 studies of elective C-sections versus vaginal deliveries, including observational and randomized trials, has shown that women with C-section have decreased urinary incontinence at 3 months and decreased perineal pain in comparison with those having a vaginal delivery. On the other hand, C-section was associated with a higher risk of maternal mortality, hysterectomy, ureteral tract and vesical injury, abdominal pain, neonatal respiratory morbidity, fetal death, placenta previa, and uterine rupture in future pregnancies. One limitation of observational studies is that the associations with poor outcomes could be due to the conditions that trigger the C-section rather than the C-section itself, despite statistical efforts to adjust for these confounders. Consequently, the strength of this evidence should be considered with caution.
Two recent reviews of observational or ecological studies have examined the association of C-section rates with maternal and neonatal mortality and morbidity. One is the study mentioned above, using data on 60 medium- and high-income countries of all regions, and the other is based on data from Latin American countries. Both reviews found no evidence for reductions in maternal and neonatal mortality and morbidity with increases in C-section rates to above 10%. In fact, higher rates of C-section were associated with higher rates of maternal and neonatal mortality and morbidity. For example, Barros et al showed that, between 1982 and 2004, the C-section rate in one city in southern Brazil increased from 28% to 43%, whereas the preterm birth rate has increased from 6% to 16%. The increase in preterm births occurred despite improvements in socioeconomic and nutritional conditions in the population. The increase in C-section rates and also an increase in elective induction of labor contributed to this trend.
Our doctor from the hospital then discusses recent uterine ruptures. “Those of us who provide care on a regular basis can tell you we see these ruptures frequently, even in the absence of VBACs. I have seen 3 in the last 6 months at [Hospital.]” This is very odd.
Since the hospital does not ‘perform’ VBACs, we can imply that these 3 ruptures occurred to women without a prior cesarean. If you look at this post of mine, you will see that Dr. Marsden Wagner states that the risk of uterine rupture in an unscarred uterus is 1 in 33,000.
We know from medical studies that inducing, especially with Cytotec, results in higher rates of rupture. In VBACing women, the use of Cytotec to induce increases rupture rates to 1 in 20. This hospital had 2800 births annually.
Using those numbers, approximately 1400 women gave birth during those 6 months. If he has seen 3 uterine ruptures in the last 6 months, that means 1 in 467 unscarred, non-VBACing women are rupturing at this hospital. That is an extremely high number – over 80 times greater than the 1 in 33,000 rate. While it’s absolutely possible to have 3 ruptures in a small sample population, how does that contribute to this conversation about uterine rupture in VBACing parents?
“You may find it interesting that since our decision to not offer VBACs, the majority of our patients responded very favorable, with a majority of women reporting a feeling of freedom in not having to justify to others their desire to not VBAC. Although we expected a backlash of unhappy patients, we were pleasantly surprised to find the majority of women understanding the rationale and supporting our decision. I now receive less than 2 complaints per year on our decision to not offer VBACs.”
This is no surprise. Many women do not know that VBAC is a safe and reasonable option per ACOG. They believe that VBAC is dangerous. And when their doctor tells them that VBAC is so dangerous that their hospital doesn’t “allow” them, that seals the deal.
However, I know the women in this community. And there are a lot more than just 2 who would love to have a hospital VBAC. Instead, they plan home VBACs. They drive long distances to birth at other hospitals that support VBAC. These women are still perusing their right to have a VBAC. They just aren’t using their pregnant energy to fight this ban.
“In fact, the greatest increase in our Cesarean section rate the last few years has come from women demanding a Cesarean delivery and refusing vaginal delivery. The acceptance of women’s autonomy and right to choose their mode of delivery has led to a significant number of women simply choosing Cesarean as the preferred mode of delivery.”
Women have the autonomy and right to choose their mode of delivery at this hospital as long as it is not a VBAC. They don’t have that right.
Reading letters like this is tough. It’s tough because it feels like an insurmountable fight.
But here is the truth: the evidence is on the side of VBAC. The ethics of medicine is on the side of patients making their own medical decisions – not hospital policy. And yes, it can feel overwhelming. But VBAC bans have been reversed all over the country.
Seeing this letter gives you a peek into why hospitals ban VBAC. The only way they are overturned is by having advocates who are clear on why VBAC matters, who know the facts, have a plan, and are persistent. Don’t give up. You can increase VBAC access in your community.
What do you think?
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What do you think? Leave a comment.
As a nationally recognized consumer advocate and Founder of VBAC Facts®, Jen helps perinatal professionals, and cesarean parents, achieve clarity on vaginal birth after cesarean (VBAC) through her educational courses for parents, online membership for professionals, continuing education trainings, and consulting services. She speaks at conferences across the country, presents Grand Rounds at hospitals, advises advocates seeking legislative change in their state, and serves as a expert witness in legal proceedings. She envisions a time when every pregnant person seeking VBAC has access to unbiased information, respectful providers, and community support, so they can plan the birth of their choosing in the setting they desire.