Mamatoga Guest Blogger: Finding Support for Childbirth after a Cesarean: Part I

Why is VBAC support so hard to come by?

By Melinda Kane

I met a woman from Saratoga last month who was interested in exploring the idea of a vaginal birth after cesarean (VBAC), but she couldn’t find anyone to talk to about it.  She asked family and friends, and friends of friends, and so on.  And turned up nothing.  Nada.  No one she knew or they knew had had a VBAC.  She asked around in all kinds of local places, and eventually asked the author of this blog.  Which is how she got to me.

Now this is Saratoga, a place that seems rather cosmopolitan, has an educated and seemingly well-connected populace, and that has an abundance of alternative health care options.  Is it really that hard to get local information about VBAC, and to find options for planning one?  For me, as someone who deals with pregnancy and birth all the time and who talks to people about VBAC on a near-daily basis, this was eye-opening.  I knew it was bad, but it is really that bad?

In some ways, the answer is a resounding YES, but also a big-as-your-pregnant-belly NO.  Part I of this series will cover the ‘yes’ – why it is that VBAC is so hard to come by and find support for, especially in the Saratoga area and points north.  Part II will talk about the ‘no’ and all the options that women living in this area DO have.

First, the “yes”.  If you live in Saratoga, or Glens Falls, or one of any number of counties between here and the Canadian border and have had a cesarean delivery in the past, chances are you’ll have another surgical delivery if you have another baby.  Why?  Because you have to get to Plattsburgh before you encounter another hospital that doesn’t have an explicit hospital policy prohibiting VBACs.  Traveling east or west doesn’t yield much of a change, especially for women in the Saratoga or Glens Falls area, as VBACs are also banned at Southern Vermont Medical Center in Bennington, VT and at hospitals in Amsterdam and Gloversville, NY.

Why should it be so hard to find a hospital or a provider willing to go along with a VBAC plan?  To answer this you have to understand some things about the American College of Obstetricians and Gynecologists and how their recommended protocols for dealing with VBACs influence hospital policies.

In the early to mid-1990s (which for you and me and many other women of current childbearing age meant middle school or high school or perhaps our undergrad college years and hence not a time we expected to become mothers) VBACs were relatively common.  In fact VBAC rates hit a national high of about 28% in 1996, although locally a woman in the Capital District at about the same time had a much greater success rate.  In 1998 VBAC rates for residents of all four Capital/Saratoga region counties were between 40 and 50 percent!

But the ACOG VBAC practice guidelines issued in 1999 contained two statements that chilled the overall climate for VBACs, as described by the NIH Consensus Conference on Vaginal Birth After Cesarean.  First, ACOG changed its earlier recommendation of “encouraging” VBAC to a recommendation that women should be “offered” trial of labor if there are no contraindications. Second, the guideline also stated that VBAC (also termed a “trial of labor” or TOL) should only be offered in institutions equipped to respond to obstetric emergencies and in settings where physicians capable of performing a cesarean delivery are “immediately available” to provide emergency care.  Not all institutions were able to comply with this new standard, which in turn led some to cease offering trial of labor and therefore VBAC altogether.  According to that 2010 National Institutes of Health (NIH) consensus conference report, 30% of hospitals ceased offering VBAC as an option in order to comply with the guideline.  A look at the Vital Statistics on the NYS Department of Health website reveals that Saratoga County’s VBAC rate (for residents of Saratoga County, not just Saratoga Hospital) dropped from 41 percent to 12.2 percent in just five years.

Hospitals weren’t the only ones to stop offering trials of labor.  According to the same NIH report, 30% of obstetricians stopped offering TOL, 29% acknowledged increasing their number of cesarean deliveries and 8% stopped practicing obstetrics altogether because of the risk or fear of professional liability.  Not only did hospitals draw the line, but even within hospitals that offered VBACs, physicians became less willing to offer the option to their patients.  The research about the safety of VBAC had not substantially changed, but the way physicians and hospitals practiced, and their tolerance for risk and for professional liability concerns caused them to practice more conservatively.

Fast forward to 2012 and there is little that has changed in practice.  VBAC bans are common, especially in rural areas and at smaller community hospitals, while VBAC rates at area hospitals that offer VBAC as an option are abysmally low.  According to a 2010 Public Citizen report, out of 138 New York State hospitals offering VBACs in 2010, one hundred of them had VBAC rates of 10% or less (reported as the number of vaginal deliveries by women with a previous surgical delivery).  And no hospital has reversed its decision to cease offering VBACs, even as evidence continues to mount about the risks associated with multiple cesarean deliveries, and despite a recommendation by the NIH expert panel that ACOG reevaluate the “immediately available” guideline and other barriers to VBAC access.

So there you have it – the somewhat depressing side of how it came to be that, in certain places, women have been denied a choice about how to deliver their own babies.  In part II, we’ll talk about options that do exist for moms seeking a VBAC in the Capital/Saratoga region.

Melinda Kane is a birth doula and chapter leader of ICAN of the Capital District