Health Law

Elective Caesarean versus VBAC

Now here is an interesting article that weighs the risk assumed by mothers as compared to letting them have a vaginal birth after C-Section (VBAC).

Great little synopsis from the blog where I found it.  The True Face of Birth

I recently came across an article titled Cost-Effectiveness of Elective Cesarean Delivery After One Prior Low Transverse Cesarean. The title isn't that interesting, but the article certainly is. The authors calculated the hypothetical overall cost and relative risks of a policy of ERCS (elective repeat cesarean section) versus VBAC (vaginal birth after cesarean). Some of the findings:

• In order to prevent one major adverse neonatal outcome (death or cerebral palsy) due to a VBAC, doctors would need to perform 1,591 cesarean sections and incur a cost of $2.4 million.
• For every five babies' lives saved due to ERCS, one mother will die and many others will be injured.
• "Elective repeat cesarean delivery in 100,000 women whose first birth was a cesarean through a low transverse incision will prevent 37 cases of cerebral palsy and 37 neonatal deaths. To achieve this health benefit requires an excess of 117,748 cesarean deliveries, seven maternal deaths, and 5500 maternal morbid events."

Hundreds of hospitals have banned VBACs since 1999, when ACOG revised its recommendations on VBAC and stated that it “should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”[1] In practice, this translated into 24-hour in-house anesthesia and OB coverage, a requirement that often only large, tertiary hospitals could guarantee. Despite the fact that ACOG’s 1999 recommendation was not evidence-based [2], obstetricians and hospital administrators are under heavy pressure to comply with the recommendations. (The American Academy of Family Physicians has developed VBAC guidelines that are evidence-based; they recommend that VBAC "should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes.") As a result of ACOG’s new position on VBAC, hundreds of smaller hospitals have instituted a no-VBAC policy, requiring women to have mandatory repeat cesareans or to travel elsewhere—sometimes very long distances--to give birth. Some states also do not allow home birth midwives to attend VBACs, which further limits women's options.

This article's findings show that a policy of ERCS comes with a weighty set of costs and risks. VBAC bans force women to assume those risks, rather than allowing each woman to decide for herself whether to have a VBAC or schedule a repeat cesarean. A no-VBAC policy is paternalism at its worst; it takes away women's right to bodily integrity and to informed decision-making.

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[1] ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section.” According to the International Cesarean Awareness Network (ICAN), over 300 hospitals have banned VBACs since 1999. ICAN is currently compiling a comprehensive list of the status of VBAC in every U.S. hospital. See ICAN's VBAC Policy Database.

[2] McMahon, M. (1996). Comparison of a trial of labor with an elective second cesarean section. New Eng J Med 335 (10): 689-695.

Full post as published by Cerebral Palsy Law Blog on April 05, 2008 (boomark / email).