For Those Who Deny That VBAC is a Vital Option

For Those Who Deny That VBAC is a Vital Option


In anticipation of next week’s NIH Consensus Development Conference on VBAC, and in response to ICAN’s first blog carnival, many birth advocates, birth professionals, mothers, and general supporters of VBAC are taking to their keyboards this week to write in defense of the vitality (and viability) of VBAC.

I, for one, believe that VBAC is a vital option.

I believe this passionately, and I’ve written about it extensively.

But instead of examining and defending why VBAC is a vital option, I’d instead like to address those who deny that VBAC is a vital option–especially those whose decision effectively prevents women from having VBAC as one of their birthing options.

More specifically, I think that care providers who deny women the opportunity to have a VBAC–whether because of medical philosophy, malpractice insurance policies, hospital guidelines, or even personal preference–should be under some sort of real (even regulatory) pressure to limit the number of primary cesareans that they perform.

If they do not want to or are ill-equipped to offer the relatively safe (and, yes, vital) option of VBAC, then they should take painstaking care to limit–and even eliminate–the number of unnecessary scars they put on first-time birthers.

And I think that they need some good old fashioned “motivating” incentives to make these sorts of changes.

And that’s because I’m not sure that the evidence supporting the relative safety of VBAC–and all of the eloquent and persuasive arguments based on that evidence–is enough to convince care providers to change their opinions of and practices regarding VBAC.

As much as medical professionals and others may disagree with me, it seems that the history of VBAC in the United States (and potentially elsewhere) is largely  a history of shifting opinions based primarily on financial and medico-legal concerns and pressures, and secondarily on evidence-based medicine and the rights and autonomy of women.  For like most human beings, it is the tangible incentives that change hearts and minds–not the intangible, philosophical ones.

(Case in point: was it overwhelming evidence or insurance incentives to reduce maternity costs that contributed to the increase in VBACs in the early to mid-90s?  And was it overwhelming evidence or malpractice insurance policies and lots of [induction-related] uterine rupture lawsuits in the late-90s that led to the sharp decrease in VBACs at the end of the 90s and up to today?)

It’s sad.  Disappointing.  Even atrocious in some cases.

And this doesn’t mean that VBACtivists (and birth advocates in general) should give up fighting vehemently in support of a woman’s right to bodily autonomy and integrity when it comes to the birth of her child(ren).  It doesn’t even mean that we should give up writing eloquently phrased, persuasive, and evidence-based arguments in support of VBAC!

But it does mean that VBAC advocates might want to consider (or continue considering) the following questions and concerns when discussing and formulating VBAC policy:

  • If a care provider refuses to attend VBACs–or if a hospital refuses to allow VBACs–shouldn’t they be expected to maintain an especially (yet safely) low primary cesarean rate?  (And I mean “expectation” in the most concrete sort of way–with standards, incentives, repercussions, investigations, etc.)  The “problem” or “issue” of VBAC is not as much of a problem or issue if fewer women have scars on their uteri.
  • Who can, or should (or even would) create such standards of care? ACOG?  The AMA?  Insurance companies?  Hospitals?  (The issue becomes increasingly complex, however, when one considers the financial benefits that many hospitals reap from higher c-section rates.  This, of course, might give them an implicit incentive not to pressure doctors to decrease the c-section rate.)
  • Instead of denying coverage to women with prior cesarean sections, why don’t insurance companies raise premiums for OB/GYNs with inordinately high c-section rates?  C-sections cost thousands more than most vaginal deliveries, and lowering the c-section rate (and, correlatively, increasing the VBAC rate) would thus save a substantial amount of money each year on maternity costs.
  • Can consumer groups advocate for these sorts of insurance practices?  Does media attention (on the increasing risks and costs of repeat cesareans, for instance) ever affect the way that insurance companies operate?  (Am I hoping for the impossible here?)
  • (This is my bottom-of-the-barrel thought.)  Many care providers cite the fear of a lawsuit as one of their reasons for refusing to attend VBACs.  This is not entirely unreasonable, especially given those law firms devoted to  seeking out uterine rupture cases indiscriminately.  But…has any woman who has 1) been explicitly denied a VBAC (against her wishes) yet 2) lost her uterus (or, devastatingly, her life) as the result of placenta accreta (one of the risks associated with repeat cesareans) ever sued her care provider, partly on the basis of the denied VBAC?  (Put more flippantly–seriously, does it have to come down to a slew of placenta accreta lawsuits before care providers start changing their tune about VBAC?!)

What do you think?

Is the VBAC-supporting evidence enough to change hearts and minds?

Or do we need some of these (and other) incentives to convince care providers in the United States and elsewhere that VBAC is a vital option?

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  1. Eliza

    Excellent, fantastic and wonderful ideas! How do we implement these ideas?????????

    • BirthingBeautifulIdeas

      @Eliza – That’s the million dollar question. :-) I fear that getting an insurance company to see our point of view is far more difficult than getting ACOG to see our point of view!

      Maybe it’s just worth pointing out to OB/GYNs the simple fact that we need evidence (and not insurance companies) to dictate maternity care decisions!

  2. VBAC Blog Carnival: Why is VBAC a Vital Option? | ICAN Blog
    VBAC Blog Carnival: Why is VBAC a Vital Option? | ICAN Blog03-08-2010

    […] is not persuasive enough, perhaps providers and hospitals that refuse to support VBAC should face regulatory pressure or incentives to severely limit the number of primary cesareans they […]

  3. Anna

    Excellent post (and blog as a whole). By no means an expert on any aspect of the health insurance side of this, I just wanted to chime in and say our insurance was delighted that we picked an HBAC the second time around as it saved them money too. As I delve deeper into the birthing lit. and media (re)presentations of the conundrum at hand (Sky high RCS vs VBAC options), then I’m struck by how often “the hospital” is held responsible rather than individual docs. Last I checked a building could not yield a knife….. I firmly believe that a big part of this battle could by won by making the midwifery model of care more widely accessible and making it part of overall health care reform. Maternal/fetal medicine is a HUGE cash cow in the US, yet most of society remains blissfully ignorant of the high stakes until childbearing hits home. (It saddens me to no end that money should have to lead the way in making VBAC/HBAC more accessible but you are definitely on to something here – incentives speak!).

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