Birth, Babies, and Beyond

Pregnancy, birth, and parenting

A Push to Encourage Vaginal Births After C-Sections

Experts Encourage Vaginal Births after C-sections

In 1933, when the rate of cesarean sections in New York City hit 2.2 percent, public health experts were appalled. They declared an epidemic of C-sections that needed to be staunched. Nowadays, doctors think they're doing a good job if fewer than one in three women giving birth in hospitals has a surgical delivery. One in three. I mean, what's going on here?

Have our bodies changed so dramatically in the past few generations? At the turn-of-the-20th century, Dr. Franklin S. Newell, a Harvard doctor said that civilized ladies did not have the wherewithal to push out babies so he proposed that they all get elective c-sections. He described his notions in a scientific article called, "The Effect of Overcivilization on Maternity."

To be sure, sometimes c-sections are necessary to save the lives of both mothers and babies. But the odd thing is that while c-section rates have steadily increased in the past few decades, it has not coincided with a steady decline in maternal mortality. If anything, it's just the opposite. According to the latest government statistics collected in 2006, for every 100,000 women giving birth in the U.S. about 13.3 died, up from 6.6 in 1987. That does not prove a cause and effect, or even an association between mortality and c-sections. But it does show that increasing c-sections are not dramatically saving lives either.

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But there is a reason for optimism. This March, a panel of expert advisors to the National Institutes of Health encouraged doctors and hospitals to stop the ban against vaginal births after cesarean sections. Currently about a third of hospitals do not even offer women who have had c-sections the option of trying for a vaginal delivery because they believe they do not have proper backup should anything go wrong.

The history of childbirth is chock full of all kinds of maternity advice based more on culture or fear-of-lawsuits than scientific studies. The recent advice encouraging vaginal births should come as a wake-up call to both women and their doctors who have been worried about letting a woman try to go through labor after she has had a prior c-section. The panel said about three-quarters of women who try to have a vaginal delivery after a c-section (called VBAC and pronounced veeback) are able to do so. The rest need an emergency c-section. They also said that studies suggest that about one percent of women suffer from uterine rupture when they try to have a vaginal birth-which may seem really low to some women and a risk not worth taking for others. 

For the past century or so, the dogma has been "once a c-section, always a c-section," -based on a statement made by a prominent obstetrician in the early 1900s. In the 1960s, studies began to reveal that many women with low incisions from c-sections could safely deliver their next baby vaginally. That prompted a rise in so-called VBACs, peaking in 1996. Since then the rate has dwindled. Some say it's due to a fear of lawsuits. Others say it has to do with a 1999 statement by The American College of Obstetricians and Gynecologists. They recommended that instead of encouraging VBACs, that women should only be offered the option of trying to go through labor if the hospital is equipped to respond to emergencies.

The NIH panel made some key points. They worry that decisions are made based on fear of litigation rather than what's in the best interest of the mother. (Most doctors feel that you are unlikely to get sued for doing a c-section but more likely to get sued for not doing one--should anything go wrong.) They also say that more research is needed to figure out which woman who has had a c-section is likely to suffer from the rare but terrible consequence of uterine rupture.

The panel of experts in this new NIH report include obgyns, pediatricians, nurses and experts in maternal-fetal medicine. As they conclude, "given the available evidence TOL (trial of labor) is a reasonable option for many pregnant women with a prior low transverse uterine incision (the bikini cut)." They also suggest that all health care providers (meaning hospitals, doctors, insurers) work together to minimize any barriers to allowing a woman to try for a vaginal birth. 

The good news is that the experts are telling providers to inform women of their birthing options. The not-so-good news is the lack of hard-core science to help women make the safest choice. Maybe this report will encourage this much-needed research so pregnant women can have more information to make informed choices.

Randi Hutter Epstein, M.D., is the author of Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank.

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