Health experts: Most repeat C-sections unnecessary

February 20, 2010

Health experts: Most repeat C-sections unnecessary

Rate of vaginal births after C-sections plummets amid hospitals’ liability concerns

Michelle Williams is three months' pregnant and determined to experience childbirth the way nature intended. But because her previous baby was delivered through an incision in her abdomen and uterus — a cesarean section — she has to travel more than an hour from her home in Channahon to find an obstetrician willing to let her try for a vaginal birth.

One out of every three pregnant women now has a C-section, the most common surgical procedure in the U.S. The skyrocketing C-section rate has been hotly debated in birthing and medical communities, yet little attention has been paid to one of the consequences: Once a woman has a C-section, she often has to fight to deliver subsequent babies the old-fashioned way, if a hospital or obstetrician allows her to try it at all.

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.

From the early 1980s until 1996, the VBAC rate crept up as doctors — and insurance companies — encouraged C-section veterans to try one. But "Physicians were pressured into offering VBAC to unsuitable candidates," according to ACOG. As more VBACs occurred, the number of highly publicized uterine ruptures rose.

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."

Once a woman undergoes a C-section, the resulting scar tissue is weaker than the uterine muscle. If the scar opens during labor, it would require an emergency C-section. Certain factors — induction of labor, or a vertical (rather than horizontal) incision — can increase the risk of rupture.

In 99.5 percent of the cases, nothing goes awry. But if the scar gives way, results can be catastrophic; the baby has a 10 percent chance of dying or suffering brain damage.

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.

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.

VBAC-tivists say women need true informed consent and a choice.

"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."

C-sections are considered medically necessary when there's a problem with the baby's heart rate, the umbilical cord exits the uterus before the baby does, the mother's pelvis is too small to deliver a large baby, or the baby is in the breech position.

Women also can request the surgery, which influences doctors, said Strassner. A women who had prolonged labor with her first child and ended up with a C-section anyway often does not want to endure another labor without a guarantee that things will be different.

"Why do in 30 hours what you can do in 30 minutes?" said Jean Dalrymple, of Kansas City, whose second child is due March 22. Dalrymple said she has "lobbied early and often for the repeat C-section" even though her doctor offered her a VBAC.

Terrified by the thought of labor, Dalrymple, 38, said she respects women who want to experience a vaginal birth, but is "positive that God created the C-section for chickens like me."

Other women who request C-sections may be afraid of uterine rupture and misinformed about how frequently they occur, said Dr. Sarah Kilpatrick, who heads the department of obstetrics and gynecology at the University of Illinois College of Medicine in Chicago.

"Or they want to plan their delivery or haven't thought about the complication of a repeat section," said Kilpatrick. "Women still think it's like a zipper — you pull the baby out and zip it back up. But surgery is harder the second time. There's an increased chance of injury to the bladder and bowel in the patient and other complications."

To get a VBAC, however, women often have to advocate for it. Some even feel they have to lie.

Chicago's Mariana Patzelt, 27, who had two previous C-sections, planned to drive from her home in Norwood Park to UIC to deliver her third baby. But after laboring too long at home in hopes of reducing her chances of a C-section, she ended up delivering in the emergency room of a nearby hospital.

When doctors there asked whether she had had any previous surgeries, she said no.

"The whole time I was hoping they didn't see the scar," she said. "I knew if I would have said yes, it would have blown my chances and I wouldn't be able to fight hard enough for everything I worked for.

"Hospitals treat birth as a medical condition, a disease they have to fix rather than something natural we've been doing since the beginning of time."

Channahon's Williams, 30, hopes to deliver her baby naturally in August. She plans to drive more than 40 miles to the University of Chicago Medical Center to try for a VBAC to avoid the trauma she experienced with her first child, Sadie.

Williams and Sadie had complications from the cesarean surgery. Sadie was rushed from Joliet's Silver Cross Hospital to Children's Memorial Hospital in Chicago, and Williams felt unable to bond with her baby. Two months later, an infection landed Williams back in the hospital.

But she is realistic about her chances of a VBAC and just wants a healthy baby.

"If the VBAC doesn't go as planned, my husband and I are working on a birth plan to make the next C-section as peaceful and as beautiful as possible," she said. "Little things — like asking the doctor to hold up the baby as soon as it's born so that I can see — can make difference between a traumatic birth and a relaxing one."