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Battle lines drawn over C-sections

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Legal vs. medical risks

For some women, birth has become the latest battleground for reproductive rights.

At a growing number of hospitals, women are being forced to schedule a repeat cesarean section just because they already had one. Doctors and hospitals say they fear lawsuits if they allow a patient to attempt a vaginal birth after a C-section -- called a VBAC -- and something goes awry.

"We think the risk is more of a legal risk than a medical risk," acknowledges Bob Wentz, CEO of California's Oroville Hospital, which banned VBACs two years ago.

As the overall C-section rate in the USA continues to climb, so will the proportion of pregnant women who have already had one. C-sections hit an all-time high of 27.6% in 2003, the most recent year for which information is available.

Though VBACs practically were unheard of before the 1980s, the overall C-section rate was so low that relatively few women cared. But today, some pregnant women regard VBAC bans as an intolerable attack on personal autonomy. They view VBACs' risks -- mainly, the chance that the uterine scar from their previous C-section will tear -- as a reasonable trade-off for the chance to experience a vaginal birth and avoid abdominal surgery, which carries its own risks.

"My uterus, my choice," read one placard at a rally in late July at St. Joseph Medical Center in Tacoma, Wash. On Aug. 1, the hospital began requiring that all pregnant women who had had a C-section schedule a repeat cesarean for their next delivery.

In large chunks of the USA, no hospital or doctor will allow women to attempt a VBAC:

*In Flagstaff, Ariz., an obstetrician/gynecologist says she was reprimanded by her colleagues for arranging to do what her own patients could not: have a VBAC at her own hospital.

*In North Platte, Neb., a mother of five delivered baby No. 6 at home after the local hospital suggested that because she had had one C-section, she temporarily relocate to Denver or Omaha -- each nearly 300 miles away -- if she wanted to deliver vaginally.

*In Oklahoma, most OB/GYNs won't allow patients to attempt a VBAC because their malpractice insurance no longer will cover claims resulting from such births.

The VBAC rate peaked at 28.3% in 1996. By 2003, it had dropped to 10.6%, less than a third of the 37% goal set by the U.S. Department of Health and Human Services' Healthy People 2010 report. The report viewed unnecessary C-sections as a heavy toll on pregnant women and health care resources.

More recent data are not yet available, but all signs indicate that the VBAC rate has slid into the single digits. In other words, more than 90% of pregnant women who have had a C-section will have another. "I think VBAC is dead," says Gary Hankins, chairman of the American College of Obstetricians and Gynecologists' committee on obstetrics practice.

Small change, big effect

If that's the case, hospital CEO Wentz and many of his colleagues would cite Hankins' organization as the cause of death. In 1999, a one-word change in the obstetricians group's guidelines spurred community hospitals to begin prohibiting VBACs.

Previously, the group had recommended that only hospitals with a "readily available" surgical team -- interpreted as no more than a half-hour drive away -- allow VBACs. The revised guidelines call for an "immediately available" surgical team in case a uterine rupture necessitates an emergency C-section.

Many hospitals have interpreted that to mean they must have an anesthesiologist and operating room standing by whenever a patient attempts a VBAC, a luxury they say they can't afford. If they can't meet the guidelines, they argue, they're opening themselves up to lawsuits should mother or baby be injured during a VBAC attempt.

The contractions of normal labor can cause a C-section scar to rupture. At worst, uterine ruptures lead to blood transfusions or a hysterectomy and possibly fatal brain damage in the baby. But such catastrophes are uncommon.

In the most definitive study, published in December in The New England Journal of Medicine, about 75% of 18,000 women who attempted a VBAC were successful. The National Institutes of Health study found that ruptures occurred in fewer than 1% -- or 124 -- of those who tried to have a VBAC.

In most cases, mother and baby did fine. Of the babies born to the VBAC group, there were 12 cases of brain damage that appeared to have resulted from a lack of oxygen caused by maternal complications, such as a rupture. Seven of the 12, two of them fatal to the babies, were linked to uterine rupture.

The VBAC rupture complication rate may seem quite low, says Hankins, chief of obstetrics and maternal-fetal medicine at the University of Texas Medical Branch at Galveston, but "it's damn high if you're the one."

Only about 1 in 5 of his patients who have had a C-section opt to try for a VBAC, Hankins says, adding, "I truly believe in letting the women have the choice."

Increasingly, though, only women who deliver at large teaching hospitals can choose a VBAC.

In Oklahoma, women who want a hospital VBAC must go to academic medical centers in Oklahoma City or Tulsa, says Carl Hook, CEO of the state's Physicians Liability and Insurance Co. One reason: On Jan. 1, the company stopped covering claims arising from VBACs because of large awards in suits related to such births, Hook says.

The insurer covers about 75% of Oklahoma doctors who deliver babies, Hook says. "The vast majority of our obstetrician physicians, they were pleased" with the decision to drop VBAC coverage.

Mark Landon, the Ohio State University OB/GYN who led the National Institutes of Health study on VBACs, isn't surprised. "There is a group of obstetricians who probably are just as happy not to offer this service inasmuch as it simplifies things for them. There is no doubt that conducting a VBAC is clearly more labor-intensive than doing another C-section."

Even doctors at large urban medical centers are getting nervous. In Columbus, Ohio, a group of about 60 self-insured OB/GYNs is considering getting out of the VBAC business because of liability concerns, says Tammy Backenstoe, executive director of risk services for MaternOhio Management Services, which manages their practices.

"We've got some practices, if you have a patient who wants a VBAC, each partner in the practice has to sign off before they'll do it," she says.

If any patient could be fully informed about VBAC's risks, one would think Beth Claxton would be. After all, Claxton is a board-certified OB/GYN in Flagstaff.

Her firstborn was breech, or not in the optimal head-down position for delivery. Few doctors will deliver a breech baby vaginally, so Claxton tried everything to get her daughter to flip in utero.

"I thought the recovery would have been faster with a vaginal birth," she explains. "I also wanted to experience natural childbirth."

But the baby wouldn't budge, so Claxton delivered Eliza via a planned C-section in August 2003.

When she became pregnant again, Claxton assumed she would have to schedule a C-section. Although Flagstaff Medical Center didn't have a formal VBAC policy, she says, anesthesiologists refused to stand by while women attempting one were in labor. Flagstaff residents who wanted a VBAC had to drive two hours to Phoenix or Page.

But at her first prenatal visit, her OB/GYN asked whether she wanted a VBAC.

"I was dumbfounded," recalls Claxton, 38. "I said, 'Sure.'"

According to obstetricians groups' guidelines, Claxton was an excellent VBAC candidate: She had only one previous C-section, and it was for a reason unlikely to recur. Plus, her uterine scar was low and horizontal, less likely to rupture than a vertical scar.

Her OB, an anesthesiologist friend and a labor-and-delivery nurse all agreed to meet Claxton at the hospital whenever she arrived in labor. Claxton delivered Meg vaginally on April 16.

On July 8, she received a "letter of concern for failing to comply with the hospital and departmental guidelines regarding an elective VBAC." It came from the hospital's medical executive committee, Claxton says; her OB and anesthesiologist received similar letters.

Copies of the letters were placed in their credentialing files at the hospital, Claxton says. She's not sure what, if any, effect they'll have.

The hospital's Janet Dean says the medical staff leadership frowned upon a physician arranging to do what her own patients could not. "For approximately the past three years, we had had a working understanding between the hospital and our medical staff that the hospital did not provide elective VBAC," Dean says. "The decision not to offer elective VBACs needs to be applied equally to all expectant mothers."

Because few pregnant women have the kind of connections Claxton has, VBAC bans are driving some of them to labor at home, arriving at the hospital only when they are about to deliver and hoping it is too late to have a C-section.

"Some women think they can show up in active labor and just refuse" a C-section, says San Diego resident Tonya Jamois, president of the International Cesarean Awareness Network, a pro-VBAC group. "It's hard to be Rosa Parks when your contractions are just two minutes apart."

And some women, such as Barbara Roebuck, never bother going to the hospital. Roebuck, 37, delivered four babies vaginally before requiring a C-section for her fifth, who was breech. Pregnant with her sixth, she says she saw four doctors in a futile search for one who would let her try a VBAC.

"Every one of them said: 'Hospital policy. You don't have a choice,'" Roebuck recalls.

"Oh, yeah?" she replied. "If I don't need one, I'm not having one. You want me to recover from major surgery while taking care of an infant or toddlers?"

Her own solution

A letter to Roebuck May 27 from Cindy Bradley, CEO of Great Plains Regional Medical Center in North Platte, explained that the hospital has banned VBACs since 2002 because it cannot ensure immediate surgical support recommended by the obstetricians' group. Failure to meet those guidelines makes the hospital vulnerable to rupture-related lawsuits, Bradley wrote.

She suggested that Roebuck schedule a C-section or temporarily relocate to a town with a hospital that meets those guidelines. In an interview, Bradley said that the closest hospitals that allow VBACs are in Omaha and Denver, each about 280 miles away.

Moving four hours from her family was out of the question, Roebuck says. So was scheduling a C-section. So, on June 29, Roebuck delivered 9-pound, 13-ounce Shane at home with only friends and family in attendance.

The thought of laboring or delivering at home after a C-section, without electronic fetal monitoring and an operating room close by in case of a uterine rupture, sends chills down Bruce Flamm's spine.

"It sounds like it is kind of spreading, which is just a disaster," says Flamm, a Kaiser Permanente OB/GYN in Riverside, Calif., who has written extensively about VBACs.

Roebuck was lucky; her home VBAC went smoothly, Flamm says. But it's only a matter of time before one goes wrong and a baby dies because a C-section could not be performed quickly enough, he says.

Flamm urges women to "search for the middle ground. Talk to the doctor, see if they would just be willing to stick around the hospital that one day they're in labor."

"Unfortunately," Flamm says, "nobody wants to do the middle ground."

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© Copyright 2004 USA TODAY, a division of Gannett Co. Inc.

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