VBAC Scare Tactics (8): The MD trump card
Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in the U.S. have faced some sort of opposition from their care providers when they have expressed their desire to VBAC. Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”
The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean. (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)
And if you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be hurling phrases like “catastrophic uterine rupture” and “dead baby” your way.
If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way. And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.
I encourage all mothers who read this post (and others in my “VBAC Scare Tactics Series”) to take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother’s interests and plans for the birth of her child.
Scare tactic #8: Look, I’m the one who has earned the medical degree and I am telling you that you cannot attempt a VBAC. Your only choice is a repeat cesarean. Period.
Questions to ask in response:
- I appreciate all of your hard work! So could you please share with me your medical, evidence-based reasons for why I cannot attempt a VBAC?
- Are you suggesting that you will ignore any questions I ask you regarding my desires for this birth or about the comparative risks of VBAC and repeat cesarean?
- Does your malpractice insurance company prohibit you from attending VBACs? Are there any other bureaucratic or administrative (i.e. non-medical) reasons that force you to deny your patients the opportunity to attempt a VBAC?
- Where is the nearest exit?
A more nuanced analysis:
It is worth noting first and foremost that VBAC has been shown to be a relatively safe option for most women who attempt it. The medical literature consistently shows uterine rupture–the main risk specifically associated with VBAC–to occur in less than 1% of all VBAC attempts. The American College of Obstetrics and Gynecology (or “ACOG,” OB-GYNs’ organizational body) claims that VBAC is not only “a safe option for many women” but is also a way to help reduce the United States’ skyrocketing cesarean rate. What’s more, even though the risk of uterine rupture is lower (though not eliminated) if one chooses an elective repeat cesarean instead of a VBAC, there are still risks specifically associated with repeat cesarean that are not necessarily associated with VBAC.
Thus, there is absolutely no reason for any care provider to quash any and all discussion about VBAC by injecting the “MD trump card” into a conversation.
That being said, the reasons as to why a care provider might use the “MD trump card” are varied.
Occasionally, it might be that the care provider’s malpractice insurance refuses to cover VBACs. And perhaps s/he then hides behind the “MD trump card” because s/he is too embarrassed or even frustrated to admit that s/he must make medical decisions not based on the evidence but based on what insurance companies dictate. This is certainly an instance of the sorry state of the current relationship between insurance companies and medical care in the United States–especially when it comes to obstetricians.
Nonetheless, if you are a woman wanting to attempt a VBAC, and your care provider’s malpractice insurance does not cover VBACs, then it is certainly a wise idea to begin seeking a new care provider.
More often than not, however, it seems that the “MD trump card” arises after a woman has posed various questions challenging other scare tactics that the care provider might have uttered.
To use an example, suppose that a woman’s care provider tells a her that VBAC is synonymous with placing a child in a car without a carseat or safety belt. (I know of multiple women who have reported hearing this sort of comment during their prenatal appointments.) But since this mom has done her research on the relative risks of VBAC and repeat cesarean, she reminds her care provider that the risk of uterine rupture is approximately .7% for all moms attempting VBAC and that the risk of catastrophic uterine rupture is approximately .04-.255%. Perhaps she even cites this study or this study from the New England Journal of Medicine from which she discovered these statistics! And perhaps she declares that she has made the informed decision to take on the risks (and benefits) of VBAC rather than to take on the risks of repeat cesarean!
And in response, the care provider claims that s/he is the one with the medical degree and that s/he will decide what is best for this mom and her baby.
This response is unquestionably problematic. For one, it fails to engage the mother’s responsible decision to research her plans for her child’s birth. And even if the care provider suspects that a patient has misinterpreted medical research, it is the care provider’s responsibility to rectify this misinterpretation.
What’s more, using the “MD trump card” often illustrates a care provider’s possible (and perhaps probable) arrogance. For even if some care providers do not know about the recent studies on VBAC and uterine rupture, or even if their teachers or mentors during medical school or residency explicitly (and incorrectly) taught that VBAC was inordinately dangerous, and even if they are embarrassed about being challenged by their patients, this does not mean that they should obscure their (perhaps innocent) lack of knowledge about the facts of VBAC and uterine rupture by using their medical degree to trump any questions that their patients may have.
In other words, if they don’t know the answer to the questions their patients are asking, then they should inform their patients that they need some time to perform additional research.
If their patients cite research that differs drastically from the research with which they are familiar, then they should ask their patients for a couple of days to review that research in more detail.
These responses respect true informed consent. These responses honor patient autonomy. And these responses support the sort of participatory medicine that midwife Amy Romano talks about in her recent article on e-Patients.net.
For what it’s worth, my MD dad always tells me that if a doctor refuses to answer your questions, then it’s time to find a new doctor! We should want care providers who who engage with us and who listen to us (both of which are good tools for diagnosis, I might add).
So instead of heeding entirely to your care provider’s “MD trump card” or even to well-meaning friends or family members who tell you that, “Your doctor is the one who went to medical school, so S/HE knows best,” consider taking a participatory role in your medical care. Find a care provider who is willing to discuss VBAC and repeat cesarean with you–who is willing to offer transparent information about both options, who does not use the “MD trump card” when you ask questions, and who will support you in whichever decision you make for your baby’s birth.
You will be participating in the decisions regarding your baby’s health for the rest of his or her life. Why not begin by finding a care provider who supports you in actively participating in the way you bring that baby into the world?