By Zoe Lee-Chiong
Women should be able to choose how to deliver their children, with only limited exceptions. Unfortunately, American hospitals often restrict pregnant women from having a vaginal delivery, with harmful consequences.
Take the case of Rinant Dray, who arrived at Staten Island University Hospital in 2011 pregnant with her third child. Although her first two children were delivered by cesarean section (c-section), Dray and her doctors agreed that she’d attempt a vaginal birth this time. Yet, hours later with no evidence of fetal distress, Dray was subjected to a c-section without her consent, badly damaging her bladder.
Dray’s case is an extreme example of the consequences of restricting vaginal birth after a prior c-section (VBAC). Doctors restrict VBAC because they believe doing so leads to better maternal and infant health. But that’s not always the case. Restricting any form of childbirth, including VBAC, is a reminder that women are often prevented from freely choosing their medical and reproductive health care.
While there are cases where c-sections are necessary, up to two-thirds of women who’ve had a c-section may be good candidates for VBAC. In general, VBAC has a lower risk of complications than c-sections, and more than 70 percent of women who choose this option have a successful VBAC. The American College of Gynecologists and Obstetricians (ACOG) states that VBAC is “a safe and appropriate choice for most women who have had a prior cesarean delivery.”
The primary risk associated with VBAC is a tear in the uterus (uterine rupture), usually at the earlier c-section’s incision site. Uterine ruptures require an immediate emergency c-section procedure. They occur in less than one percent of VBACs, however, and the rate decreases if drugs are not used to induce contractions.
In contrast, repeat c-sections carry the risk of serious complications, including injury to the intestines or uterus; infection; and the placenta staying attached to the uterus, causing severe blood loss (placenta accreta). The risks increase with every additional c-section. Pressuring women to have an unwanted c-section can also cause intense psychological distress, which leads to poor maternal and child health outcomes.
Yet, despite the fact that most women are good candidates for them, VBAC are uncommon in the U.S. In fact, it’s becoming hard to find hospitals and physicians who support VBAC. Only 13.3 percent of women who had a previous c-section deliver vaginally. More than 1 million c-sections are performed annually in the U.S, one-third of which (32%) are repeat c-sections. One survey found that nearly half of people pregnant after a previous cesarean wanted to have a VBAC, but 46 percent were not supported in their choice. Of respondents who were not offered a VBAC, more than one-third (39%) could not find a physician or hospital willing to let them have a VBAC. Women may not even be informed that VBAC is an option – while 97 percent of women who had had a prior c-section discussed repeat c-sections with their providers, only 60 percent had been counseled on VBAC.
Women who live in areas where hospitals have VBAC restrictions are left with three options: spend excessive amounts of time looking for a provider willing to perform a VBAC delivery, consent to an “elective” repeat c-section, or deliver at home.
If VBACs are a safe option, why are they so widely discouraged? The reasons are more organizational than medical.
Outdated hospital policies that do not reflect current guidelines are the biggest reason for VBAC restrictions. In 1999, over concerns regarding potentially high rates of uterine rupture during VBAC, ACOG issued guidelines recommending VBACs be performed in settings where an operating room and anesthesia are “immediately available,” in case an emergency c-section had to be done. Many hospitals, particularly smaller and rural hospitals, couldn’t meet those standards, and stopped offering VBAC to their patients. When ACOG updated its VBAC guidelines in 2010 and again in 2017 based on updated research of VBAC risks, it removed the strict recommendation, and ACOG encouraged VBACs in order to curb rising c-section rates. But most hospitals didn’t change their policies to reflect the new guidance. In 2009, the International Cesarean Awareness Network found that more than 800 U.S. hospitals had restrictions against VBAC, either through strict requirements for a VBAC or a lack of availability of providers who are willing to attend VBAC labors.
Medical malpractice concerns are another reason for low VBAC rates. There is a statistically significant association between higher malpractice premiums and lower VBAC rates among providers. Surveys find that nearly one-quarter of providers view litigation as a primary reason not to perform VBAC. Many physicians who offer VBACs impose additional restrictions on women seeking to give birth vaginally.
C-sections may also be more convenient for doctors, since they offer more control over the timing of childbirth. Physicians must be immediately available during a VBAC, in case complications arise. Providers in smaller, rural, and/or private practices note that this is a time constraint that imposes limitations on their lifestyles and clinical practices.
When treatment restrictions are based on outdated policies, fear of being sued, and physician convenience, rather than medical need, patients suffer. VBAC bans result in excessive rates of major medical interventions during childbirth, create adverse health outcomes for both mothers and infants, and hamper reproductive autonomy for women. Pressuring pregnant women to undergo surgery regardless of whether they need or want it contributes to gender-based violence in medicine.
Women deserve evidence-based policies so they can make their own best decisions about how to give birth. We deserve access to VBAC, if desired, regardless of our socio-economic status, geographic location, or insurance carrier. We deserve counseling on all delivery options, with information on their relative risks and benefits. And, we deserve basic respect for women’s ability to decide for ourselves, without force, coercion, or risk of lawsuit.
Rinat Dray eventually sued the hospital over the damage to her bladder, and for being overruled when she refused to have a c-section. In 2018, her appeal was denied on the grounds that the state’s interest in the well-being of a viable fetus was “sufficient to override a mother’s objection to medical treatment, at least where there is a viable full-term fetus and the intervention presents no serious risk to the mother’s well-being.” Our fight for a women’s “right to choose” in all aspects of her reproductive care is far from over.
Zoe Lee-Chiong is a graduate student at Georgetown University’s Health and the Public Interest program.