Panel: Vaginal Birth After Cesarean Not Common

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Cesarean birth rates are steadily rising and still less than 10 percent of women have successful vaginal births after cesareans. A National Institutes of Health panel has been examining the clinical risks and benefits of vaginal births after cesareans — as well as legal, ethical and economic considerations.

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For women who've given birth by cesarean section, there's news today that might change their next birth. Yesterday, a National Institutes of Health panel examined the decline in vaginal birth after cesarean in the United States, and they concluded the main reason for the decline is not medical.

NPR's Brenda Wilson reports.

BRENDA WILSON: It used to be a given, if a woman had one cesarean, any children she had after that would have to be delivered by cesarean. It's now understood that that is not medically necessary. It's estimated that up to 75 percent of women would have no problem having a vaginal birth after cesarean or a VBAC.

In the 1980s, the U.S. rate for VBACs was around 30 percent. It's now down to less than 10 percent - and overall, cesareans are increasing. Some women are afraid to go through labor after having had a cesarean, or they may be reluctant to second-guess the doctor. Others, many of whom made their way to NIH this week, are ready to do battle with doctors, hospitals and a medical system they say deprives women of the experience of having babies the way women were meant to have babies.

Ms. SHANNON MITCHELL (VBAC activist, Florida): This is a human rights issue. I am being cut open because obstetricians have decided that I need to be. I have the right to say no just as much as they do.

WILSON: Shannon Mitchell is a VBAC activist from Florida who says the state now has the worst cesarean rate in the country.

Ms. MITCHELL: In my state, there's a statute that says women have the right to refuse any procedure, but we are being told we cannot refuse caesareans. The two hospitals in my county, actually, if you show up in labor, will cut you anyway - or they'll tell you to go to the closest hospital, two hours away.

WILSON: The NIH consensus panel, made up of obstetricians and other medical doctors and academics, did debate whether women had the absolute right to refuse, but decided that that was not part of their charge. The panel's main finding was that there was no evidence indicating a greater risk to women and children from VBACs.

Panel Chair, Dr. Gary Cunningham, of the University of Texas, Southwestern Medical Center, said they concluded the main reason for the decline in VBACs is not medical. Instead, it's because of a joint recommendation by the American College of Obstetricians and Gynecologists, and the American Society of Anesthesiologists, that a surgical team has to be on hand if a woman attempts labor after a cesarean.

Dr. GARY CUNNINGHAM (Chairman, Consensus Development Panel): We urge the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists to reassess this requirement, relative to other obstetrical complications of comparable risk, and in light of limited physician and nursing resources.

WILSON: The greatest complication from VBACs is uterine rupture. But there are few studies to show who's most at risk. On the other hand, women who undergo repeated cesareans have a higher risk of death with each cesarean.

Recent surveys of hospitals indicate that nearly a third say they don't allow vaginal birth after cesareans. Fear of lawsuits appears to be the main factor.

The panel recommended that studies be conducted to determine what impact fear of litigation had on the willingness of physicians and hospitals, to allow women who've had cesareans to attempt labor.

For the current president of the American College of Obstetricians and Gynecologists, Dr. Gerry Joseph, that didn't go far enough. He thought stronger action was needed to begin to protect physicians and hospitals against lawsuits in the rare instance something does go wrong.

Brenda Wilson, NPR News.

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