(WOMENSENEWS)--"Choice" is an American catchword.
We are constantly making choices about how to lead our lives. We wage political and economic battles over what kinds of choices citizens should be allowed to make--from school vouchers to having an abortion--with the recognition that each choice entails conflict.
But one choice you don't hear so much about is that of certain maternity patients to choose their birthing method. That's because, in this case, little choice is left.
Mainly I work as a journalist. But in my sideline work as a doula, or nonmedical birth assistant, I come across many women desiring the security of hospital facilities "just in case" who can still attempt a natural birth with a hospital-based midwife or doctor.
No similar choice exists for many who have had a Caesarean section and would like to try a vaginal delivery referred to as a VBAC, vaginal birth after C-section.
If such women are not comfortable with giving birth at home, they are often unable to find a doctor to agree to attempt a vaginal birth in a hospital. One woman I spoke to worked with seven care providers in her part of Maryland, never finding a doctor to support her, while another, in Brooklyn, transferred three times before she found a VBAC-friendly practice. At that point she was 32 weeks along.
During the last 10 to 15 years, many hospitals have banned VBAC and obstetricians have stopped offering it in favor of elective repeat Caesarean sections, mainly due to liability concerns.
VBAC Safety Studied
At the same time, recent studies from health authorities such as the National Institutes of Health and the Agency for Health Quality and Research have shown that VBAC can be safe, often safer for the mother than a repeat Caesarean. There is a fraction of a percent chance that labor contractions will cause the old scar to separate. Meanwhile, repeat Caesarean sections carry a comparable risk of hemorrhage, infection and other complications, increasing with each subsequent surgery.
Mothers seek VBACs because they want to have more children, to avoid the complications of major surgery, and, as a college classmate of mine Angela Martinez, says, "I just want to go through normal birth. I feel like I cheated the first time around."
Consider Martinez's choices as she searches for a care provider for her second child in her home state of New Mexico. Since her first baby was born via Caesarean section due to fetal distress, there are no lingering physical abnormalities preventing her from attempting a VBAC.
There is one midwife-run birth center within an hour's drive from her rural home, which is rare, as most U.S. birth centers have shut down. But she isn't sure if she is comfortable giving birth outside a hospital.
In her town, most obstetric practices told her that they only performed scheduled repeat Caesarean sections, but she found one that offered VBAC services.
That practice had certain restrictions: If she did not go into labor before her doctor's estimated due date, or if labor failed to progress at a brisk enough pace, she would agree to an immediate Caesarean, even if no emergency existed. She would be required to have an epidural catheter placed and at least one dose administered in order to test the efficacy of the placement. She asked for the practice's VBAC success rates but did not manage to obtain them. When she told one of the doctors she was interested in a natural birth, the doctor responded, "There's nothing natural about VBAC."
Lone Doctor Overbooked
She decided to look further afield and found one obstetrician who claimed to have high success with VBACs. However, he has so many patients that now, in her sixth month, she still has only met the nurses and doesn't know much about his practice standards or how he calculates his high success rate. In addition, she has to drive for about an hour to reach the clinic. "That worries me a little bit," she says; nevertheless, he appears to be her only choice for a hospital-based VBAC attempt. Martinez is due in February.
More than half of American women looking for a VBAC could not find a doctor or midwife offering that service, according to a 2006 report by the Childbirth Connection, a New York non-profit focused on maternity care.
Lead author Eugene Declercq, professor of maternal and child health at Boston University School of Public Health, says the situation may have worsened since then.
VBAC rates have plummeted to less than 10 percent in 2008 from 28 percent in 1996, while Caesarean section rates have steadily risen to 32 percent from around 20 percent in the same time period.
Caesarean sections are the most commonly performed surgical procedure in U.S. hospitals, according to a 2006 study of childbirth statistics sponsored by the Agency for Healthcare Research and Quality.
As fewer doctors offer VBAC, Declercq worries that repeat Caesareans are becoming "all they [mothers] can envision."
Ellie Miller, who works as a doula in New York, decided to have a home birth VBAC; she had a Caesarean with her first baby after a prolonged pushing stage. She opted to stay at home because after having given birth in a hospital, she knew staying home would give her more choices about how to labor. As a doula, she sees her clients' labor process managed by doctors who "only want to do what they know."
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Hana Askren became a doula after growing up with her father's stories about delivering babies in a birth center. A Los Angeles native, she now lives in New York, where she works as an editor on a financial publication and also coaches high school girls' wrestling with Beat the Streets Wrestling.
For more information:
Listening to Mothers, Survey 2006:
NIH, Vaginal Birth After Caesarean:
U.S. Govt: Vaginal Birth After Caesarean: