© 2003 by Henci Goer
More and more women who want a vaginal birth after cesarean (VBAC, "vee-back") are discovering that it is difficult or impossible to obtain one. Doctors and hospitals offer the rationales that elective repeat cesarean surgery is safer for the baby and that the hospital lacks the ability to handle the need for emergency cesarean should the uterine scar give way during labor. The validity of those arguments depends on the answers to three questions:
• First, is planned repeat cesarean surgery safer than planned vaginal birth? The answer is "no." Dozens of studies totaling tens of thousands of women have conclusively shown that elective repeat cesarean is more hazardous for the woman, no safer for the baby, and poses serious risks to the woman's future reproductive life. What is more, with appropriate care, 7 out of 10 women or more will give birth vaginally thus ending their exposure to the hazards of cesarean surgery.
• Second, is it reasonable for hospitals to refuse VBAC based on the argument that they don't have the staff or equipment to deal with potential emergencies? Again, the answer is "no." Emergencies occur in non-VBAC labors, and there are other situations that increase the chances of needing an emergency cesarean where hospitals don't make special exceptions such as induction of labor and epidural analgesia. If a hospital isn't safe for a VBAC labor, it isn't safe for any woman to labor there.
• Finally, should doctors and hospitals have the right to refuse VBAC on the grounds that cesarean surgery is safer for the baby? The answer is "no" here as well. Even if cesarean delivery were safer, which it is not, VBAC denial violates a woman's right to informed refusal, a right explicitly guaranteed her by the American College of Obstetricians and Gynecologists (ACOG).[1] In addition, medical ethics and human rights forbid coercing or forcing a person to undergo a medical procedure of any kind--let alone major surgery--in order to benefit another person. And that includes when the beneficiary will otherwise surely die, which is hardly the case with VBAC.
ACOG's current VBAC guidelines openly admit the real reason for refusing VBAC, as do many obstetricians: the desire to avoid malpractice suits arising from VBAC labors.[2] The guidelines set standards for VBAC management, standards, it should be noted, that establish the standard of care and will be used in malpractice litigation. They include recommendations that a physician be "immediately available" throughout active labor and that there be "availability of anesthesia and personnel for emergency cesarean delivery." The former unduly burdens busy physicians, and the latter cannot be met by most community hospitals. The guidelines themselves acknowledge that no research supports these recommendations. They are based on "consensus and expert opinion." In other words, the recommendations provide seemingly compelling reasons to deny VBAC and have the authoritative weight of ACOG behind them, but, in fact, they were devised by a group of physicians with a strong, self-interested motivation to suppress VBAC and with no scientific evidence to back them up. ACOG's Code of Professional Ethics enjoins obstetricians to resolve conflicts of interest according to what is best for the patient, a principle that obstetricians clearly have abandoned in this case.
A fact sheet on the hazards of cesarean section published by the Coalition for Improving Maternity Services can be downloaded at www.motherfriendly.org/resources.
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1. ACOG. Informed refusal. Committee Opinion No 237, June 2000.
"Once a patient has been informed of the material risks and benefits involved with a treatment, test, or procedure, that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test, or procedure or whether to make a choice among a variety of treatments, tests, or procedures. In the exercise of that autonomy, the informed patient also has the right to refuse to undergo any of these treatments, tests, or procedures. . . . Performing an operative procedure on a patient without the patient's permission can constitute 'battery' under common law. In most circumstances this is a criminal act. . . . Such a refusal [of consent] may be based on religious beliefs, personal preference, or comfort."
2. ACOG. Vaginal birth after previous cesarean delivery. Practice Bulletin No. 5, 1999.
