Arizona Mom Fights VBAC Rules at Local Hospital
By Christine Cupaiuolo — October 15, 2009
An Arizona woman’s dispute with her local hospital over its refusal to allow a VBAC (vaginal birth after cesarean), even though she has already undergone a VBAC at the same hospital, has caught the attention of CNN, which featured the story on its homepage today.
Joy Szabo, 32, told CNN she is grateful for the c-section performed during her second delivery, when doctors feared the baby wasn’t getting enough oxygen, but her third son was a vaginal birth and she thought this delivery would be, too (assuming there were no complications). Page Hospital has since changed its policy and no longer allows VBACs.
VBACs carry a less-than-1-percent increased risk of a uterine rupture, which could cause brain damage in the baby or even death, according to the American College of Obstetrics and Gynecologists. Childbirth Connection, a nonprofit organization that advocates for evidenced-based maternity care, notes that research “suggests that about 1.4 extra babies die due to problems with the scar in every 10,000 VBAC labors, compared with planned c-section deliveries.”
C-section risks to the baby include breathing problems around the time of birth and asthma later in life. The mother is at greater risk for more severe pain and infection. The bottom line, based on the latest research, is that if you “do not have a clear and compelling need for a cesarean in the present pregnancy, having a VBAC rather than a repeat c-section is likely to be safer for you in this pregnancy (and) far safer for you and your babies in any future pregnancies,” according to Childbirth Connection.
“I know there’s a risk with a VBAC, but we think the risks of surgery are worse,” said Joy Szabo. “And I don’t want to have to recover from surgery when I’ll have four children at home, at least not voluntarily.”
After their discussion with their doctor, the Szabos made an appointment to speak with Page Hospital’s CEO, Sandy Haryasz. When the couple told her about their desire for a vaginal birth, they say Haryasz would not budge, even telling them she would get a court order if necessary to ensure Joy delivered via C-section.
“I was a bit flabbergasted, because that seemed rather extreme,” Joy says. “I’d already had a VBAC at Page and it went fine. And if something happened, I know they can do an emergency C-section, because they did one for Michael.”
At issue are ACOG’s recommended guidelines concerning physician and anesthesiologist staffing for VBACs. Banner Health, which owns Page Hospital, released a statement that said ACOG guidelines recommend “24/7 coverage of both physician and anesthesiologist,” and that “two physicians be immediately available during the entire period of labor.” But an ACOG spokesperson disputed that interpretation, noting that physician and anesthesia availability are only two criteria to consider.
Still, ACOG’s guidelines have scared many hospitals away from allowing VBACs (which in turn has inspired suggestions on how to protest a VBAC denial). International Cesarean Awareness Network conducted a survey earlier this year of 3,000 hospitals and found that 821 ban VBACs outright, and and 612 have “de facto” bans, meaning surveyors were unable to identify any doctors practicing at the hospital who would provide VBAC support.
The information gathered led to the creation of a VBAC Policy Database, which can be searched by VBAC policy, or browsed by state.
Another report, Hospitalizations Related to Childbirth, which examined data on childbirths occurring in U.S. community hospitals in 2006, found that childbirths by c-section increased from 21 percent in 1997 to 31.6 percent in 2006, a jump of 51 percent. Meanwhile, there was a 73 percent decline in VBACs, from 35 percent of childbirth-related hospitalizations in women with a previous c-section in 1997 to almost 10 percent in 2006. (Rachel discusses the report here.)
As for the Szabos, rather than agree to a surgical delivery regardless of medical need, Joy Szabo plans on driving 350 miles a week or so before her Nov. 21 due date to be near a hospital in Phoenix that will allow a VBAC. It is unlikely her husband, Jeff, who is staying behind with their three sons, will be able to make it to the hospital for the delivery.
The Szabos’ story was first covered by a local newspaper, the Lake Powell Chronicle (via The Unnecessrean), and has caused an uproar. It’s unlikely we’ve heard the last of this …
For more reading:
In addition to visiting Childbirth Connection, “Our Bodies, Ourselves: Pregnancy and Birth” has a section on VBACs and repeat c-sections. Lamaze International also offers articles on healthy birth practices supported by research studies examining the benefits and risks of maternity care practices.
I’m really glad Joy decided to speak up. This has generated a national discussion about VBAC, women’s right to autonomy, ACTUAL evidence of the safety of VBAC and the rare but real threat of court-ordered cesareans.
2nd what Jill–unnecesarean said in her response here. I’m so so so glad that Joy is following her gut instead of her doctors or others or hospital gut as well. Now, hope others will follow her example here in the US and other countries like US as well.
Since evidence shows that safety is NOT the issue, has anyone done a cost-comparison of VBAC vs C-section? There has to be some motivation for such a policy that so interferes with a patient’s autonomy and wishes.
If If ACOG and hospitals consider VBACs “too risky,” then they should work to reduce the primary c-section rate, which is the beginning of the VBAC cycle. If there were fewer primary c-sections (risky surgery) then the issue of VBACs would not be such an issue. Perhaps ACOG would like to comment on the increase in primary c-sections from 25% to 31% when the recommended rate from the World Health Organization is 10% to 15%. While I think Joy and her family are courageous for standing up for their health care choices, the real issue is getting the OBs to reduce the primary c-section rate. While c-sections were intended, and have in fact saved the lives, of the 10% to 15% of high risk pregnant women and their babies, the current rate goes way beyond the average for the population. In fact it is to the point where one has to wonder if OBs and hospitals are really concerned with the best health care for the mom and baby, or whether they are more concerne with their annual income.
in response to JoshuasGrandma…
While economics may not be ALL of the problem, hospitals and physicians do stand to gain economically from performing more cesarean sections, and planned cesareans (as are typical when VBAC is denied) are the best economically speaking. Planned cesarean sections are very efficient and predictable for space and staffing, and there are many add-on charges that are paid for by insurance; in contrast, letting labor start and proceed on its own time frame requires unpredictable use of space and staff with fewer complications and interventions, while the hospital will usually be paid only a set “global fee” for the birth. The article “Effects of Hospital Economics on Maternity Care”on the Citizens for Midwifery website explains some of the basic economics that drives interventive maternity care. Under our current system, the more interventions and the more complications requiring treatment, the more income for physicians and hospitals, but letting labor begin and continue on its own time frame (including for VBACs) results in less income for the hospital and physician, even though the outcomes are better for mothers and babies.
In response to Susan,
Sorry, for posting this, but just sharing you how I feel on this. You got to be kidding me on this because most of them are being performed nowadays in non emergent situations. Then being performed in emergent situations which they were intended for. At the same time I’m with others (Jill–Unnecesarean, JoshuasGrandma, Pamela, my previous response here).
Good for her to stand up and get the public involved. I had similar issues when I wanted to have my second child. The area hospital, Everett, WA, considered me high-risk, virtually would not allow an attempt at natural labor, etc all because I had a C-Section with my first because he was breech. I fired my OB, found a mid-wife who would do homebirth VBAC, and had a beautiful, safe homebirth. I didn’t even bother going to an OB for my third, and again had a beautiful, peaceful water birth at home. We need more women in the USA to stand up for their rights to birth, the natural way!
Here is the article Susan mentioned (thanks!) from Citizens for Midwifery:
Childbirth Connection also has good data on incentives and costs: http://www.childbirthconnection.org/article.asp?ck=10285
Generally speaking, a vaginal birth without complications is least expensive; followed by a vaginal birth with complications; a c-section without complications; and finally, the most expensive, a c-section with complications.
An earlier post by Rachel on liability issues is also relevant:
What a mirror image for my personal story. On my first delivery I had, what I now know, was a “failure to progress in labor” c-section which the doctors (off the record) told me was “celphalopelvic disproportion” ( baby is too big- was 8# 4 oz). A friend told me I could have a VBAC the next time, but doctors wouldn’t let me. I switched to the high risk delivery doctor at the largest hospital in the area and had a very successful vaginal delivery of an even larger baby. (8# 11 oz) I went on to deliver 2 more children of similar size the natural way as well. On #4 we did have to negotiate a bit as they gave me too much epidural and put me to sleep. My husband, bless his heart, made sure my body was allowed to do what it does naturally and avoided a c-section again in spite of the situation. I also found it ironic, that I never needed an episiotomy during all 3 natural deliveries. Recovering from a c-section while caring for and nursing an infant was very painful and I wish I had known from the beginning how to avoid a c-section unless it is a true emergency. I had my last child 10 years ago and can see it has only gotten worse since then. OBGYN’s are in a tough position due to their high malpractice costs and the best advice may be to educate for avoidance of unnecessary c-sections before a woman’s first delivery.
I agree that the problem begins with our high c-section rate, but there is more to this problem. It’s true that VBAC moms have difficulty finding an OB and a hospital that will allow a VBAC. Although, when one is found, we are often required to submit to certain procedures or policies that have little or no justification. I am currently pregnant and intend to deliver my baby at a local hospital that allows women to deliver in inflatable pools of water. However, the hospital policy states that women attempting a VBAC can only labor in the water. At the actual moment of birth, the VBAC mom must stand up in the pool to deliver the baby and then she can sit back down in the water. Standing in water during delivery doesn’t sound safe and there are no medical reasons why a VBAC cannot occur in the water. In fact, many women attempting a VBAC have water births at home under the supervision of a midwife with no problems. Hospitals are not the only problem. In many communities there are no midwives available to attend a home birth, or free standing birth centers to accommodate laboring women. Due to restrictions from some insurance companies (including Medicaid in my area) home birth or birth centers are not an option for every woman. Why is it that a woman has a right to choose whether or not to abort her child, but has little choice regarding a child’s birth?
The reason the hospitals do this is due to people suing them in the first place ! What is everybody carrying on about ? Why would you want to selfishly put a baby through a long, traumatic, arduous labour just so you can experience “natural birth”. For heaven’s sake. The hospitals are damed if they do and damned if they don’t with this society. If her natural birth went badly I bet she’d be the first one to sue the pants off her Ob and hospital for ‘negligence’. As a mother of two, I am pro choice, and I hate being judged and bullied by the politically correct, natural birth banshees. I chose to have ceasareans and my children were delivered safely and without any distress. Most of my friends have had natural birth and I applaud them equally with caesarean mothers. How many mothers in history who lost babies or died with their babies during childbirth would have been grateful for such a thing as a modern caesarean. It is an insult to the women’s movement to condem the advancement of caesarean.
And remember …. Birth is the easy part … it’s the next 20 years that is the proof of motherhood.