Tuesday, April 01, 2008

Risk Calculus of VBAC and ERCS

I recently came across an article titled Cost-Effectiveness of Elective Cesarean Delivery After One Prior Low Transverse Cesarean. The title isn't that interesting, but the article certainly is. The authors calculated the hypothetical overall cost and relative risks of a policy of ERCS (elective repeat cesarean section) versus VBAC (vaginal birth after cesarean). Some of the findings:
  • In order to prevent one major adverse neonatal outcome (death or cerebral palsy) due to a VBAC, doctors would need to perform 1,591 cesarean sections and incur a cost of $2.4 million.
  • For every five babies' lives saved due to ERCS, one mother will die and many others will be injured.
  • "Elective repeat cesarean delivery in 100,000 women whose first birth was a cesarean through a low transverse incision will prevent 37 cases of cerebral palsy and 37 neonatal deaths. To achieve this health benefit requires an excess of 117,748 cesarean deliveries, seven maternal deaths, and 5500 maternal morbid events."
Hundreds of hospitals have banned VBACs since 1999, when ACOG revised its recommendations on VBAC and stated that it “should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”[1] In practice, this translated into 24-hour in-house anesthesia and OB coverage, a requirement that often only large, tertiary hospitals could guarantee. Despite the fact that ACOG’s 1999 recommendation was not evidence-based [2], obstetricians and hospital administrators are under heavy pressure to comply with the recommendations. (The American Academy of Family Physicians has developed VBAC guidelines that are evidence-based; they recommend that VBAC "should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes.") As a result of ACOG’s new position on VBAC, hundreds of smaller hospitals have instituted a no-VBAC policy, requiring women to have mandatory repeat cesareans or to travel elsewhere—sometimes very long distances--to give birth. Some states also do not allow home birth midwives to attend VBACs, which further limits women's options.

This article's findings show that a policy of ERCS comes with a weighty set of costs and risks. VBAC bans force women to assume those risks, rather than allowing each woman to decide for herself whether to have a VBAC or schedule a repeat cesarean. A no-VBAC policy is paternalism at its worst; it takes away women's right to bodily integrity and to informed decision-making.


[1] ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section.” According to the International Cesarean Awareness Network (ICAN), over 300 hospitals have banned VBACs since 1999. ICAN is currently compiling a comprehensive list of the status of VBAC in every U.S. hospital. See ICAN's VBAC Policy Database.

[2] McMahon, M. (1996). Comparison of a trial of labor with an elective second cesarean section. New Eng J Med 335 (10): 689-695.


  1. This is an easier theoretical discussion to have if you have not had a high risk birth. Note I didn't say high risk pregnancy. My pregnancy was going well until pre-e hit and then HELLP from an undiagnosed clotting disorder.

    It is easier to say *only* 37 cases of cerebral palsy and *only* 37 neonatal deaths when you have not been the mother whose child faced both very real possibilities.

    And from somebody who almost died in childbirth, I would gladly have died myself or suffered injury before having my baby die. So the stat about 5 babies lives=one maternal death. I would take it.

  2. This is more in response to 'aidan's mom'...I believe that the point of the article/blog is NOT simply to state risks, but to show that all the risks are not being properly represented and that we as birthing mothers are having our hands forced, and that we are not being 'allowed' to make our own decisions.

    I for one feel like I am capable of researching ALL the risks and so called 'sides of the stories', and therefore am the best one to make decisions for myself and on behalf of my unborn child.

    PS I almost died too, from my epidural...a risk that I wasn't properly informed about...I wouldn't have needed the epidural if they hadn't induced me...I was induced for being post-dates, and for no other reason. I was also unaware I had a right to refuse induction....

  3. Anon:

    I guess whether or not the risks are properly presented to you really depends on the care provider you choose. My care provider does show me risks. He knows me. He knows the way I think. He knows that almost no decision is made by me until I have seen good data.

    I am sorry you had a bad experience with your epidural. Anything bad that occurs in childbirth is hard to deal with. The point I was making is that when you have not been in the position to have the death of your child looming imminently or a huge chance of cerebral palsy from prematurity, it is difficult to comprehend that all the statistics in the world mean very little to you when your one child represents your 100%.

    I talk to mothers every day on the preemie board I am on who have lost children during delivery or shortly thereafter. There are many mothers on the board who have children with varying degrees of cp.

    I am saying that when faced with a very real possibility of one of these outcomes, it is not hard to imagine why a mother would put her own body on the line.

  4. My baby did die. In my arms, 45 minutes after she was born, as they were closing my uterus from the cesarean.

    I don't think it is fair to say that all mothers who have experienced loss would "gladly" choose to have an elective repeat cesarean.

    I choose to VBAC, at my home, because this was the safest option for BOTH myself and my second baby. I did not have this option at my local hospital. I am happy with the choice I made to VBAC, although it was far less than a "choice" than it could be.

    Please note that Rixa's post is not about primary cesareans, but the choice to VBAC or not. People who promote elective repeats do not accurately portray the TOTAL risk to both the mother and child, and instead focus on the risk of adverse events during an attempted VBAC on the infant.

    Informed choice is all about being presented the entire story, then making the best decision for you and your family. Having this taken away by policy or politics is unfair.

  5. And this is why I love you, you find all this stuff that I can't (read: finishing a degree and way too lazy) find.

    When it comes down to it this, and all procedures (medical or otherwise) need to be about *informed* choice and *informed* consent. Two things that are somehow lacking in most modern North American medicine.

  6. Interesting. I am not opposed to Vbacs. WHy not at least try to Vbac. Maybe it will be an easy delivery. And if it is not, then get a c-section.

    I work in a hospital that does Vbacs. We have 24hour ob and anesthesia coverage. I think, laboring women should only birth in places with these are in place. Why? Because I cannot tell who is going to need them in advance.

    However, if you are not going to go to a tertiary care center and you are going to Smallville Hospital, you may as well birth at home. However, if you birth at home, I would advise you do it near a tertiary care center. If you run into problems give them a call and tell them you are en route. They will then open the OR. At least if you call me, I will open the OR.

    Everythinig in Labor and Delivery has a cost benefit analysis. I often confuse the crap out of folks because I try to give them both sides of the argument.

    There are risks to epidurals, c-sections, Vbacs and homebirth. YOu have to decide where your comfort level is. However, I cannot teach my patients everything I know about L&D in 12 hours. I am just not that good a teacher! And if you do know someone who is, give them my number.

  7. Pinky, isn't it all in the language of the explanation, you said you work in a hospital that Does VBACs, I thought women had vbacs not hospitals. Nothing on labour and delivery should be about cost analysis it should be about what is best for birthing mother and soon to be newborn. Neither side of the argument have anything to do with money.
    You also called birth women your patients. Sadly your mail reflects to me the medicalised attitude that prevails in most countries.

  8. It's also important to note that their estimates of the rate of NN death or CP are probably higher than in reality. For example:

    "Indeed, Sachs et al (7) noted that the risk of serious complications after uterine rupture might be as low as 1% or less. Although rates of complications might be this low at some institutions, we conservatively estimated that 10% of neonates would have major complications (death or cerebral palsy) after uterine rupture."

    In other words, they used a number that was a factor of 10 higher than some estimates of major complications. If they went with the 1% rate of major complications after uterine rupture, then we'd have 3.7 NN deaths and 3.7 cases of CP per 100,000 women, not 37 & 37.

    They also estimated that 20% of CP during vaginal births occurs during the birth, but everything I've read put that number at 1-2%, with the rest of CP occurring before labor. That's the reason for the invention of EFM, but CP rates haven't changed at all even though now almost all women have continuous monitoring. If I have time, I'll try to look and see where I've found that.

  9. The VBAC bans are a subject near and dear to my heart. I attended VBACs until the fall of this year when my hospital implemented a policy of no VBAC unless surgeon, anesthesiologist and surgical team (the nurse and scrub person) stayed in house for the entire labor and the surgery dept promptly made a decision not to provide an in house team. Prior to that, when I had a VBAC client in labor, I would notify all of the above who would remain close by and available, while I stayed with my client for the entire labor. I now cannot offer VBAC at all, despite having an excellent success rate in the previous 6 years. (Only 2 planned VBACs converted to repeat cesareans, both non-emergent.)
    My biggest issue with these policies is just what rixa states: we force women to take the risks we decide we want them to take, rather than allowing them to make their own decision. In my practice, women now have to agree to a repeat cesarean or travel an hour to get to a provider who can attend a VBAC. While previously women who'd had a previous cesarean and showed up to me for care attempted VBAC at something like 80%, now that they'd have to travel, less than 10% are choosing to leave my practice for a VBAC attempt.
    My biggest concern is that women need to be able to make this decision for themselves. It's not fair that in 2008 if you are planning a large family and have the misfortune to carry your first child breeech your choices are so limited in my area that you are fairly coerced into multiple cesareans to have the large family you want.
    All clients in my practice did not previously choose to VBAC, which is just fine - it was their decision. Now, however, their choices are so limited (and in some cases with insurance issues a VBAC provider is completely unavailable) that they are forced to plan surgery they don't want to be able to use the provider and hospital in their own community.

  10. Doctorjen, do you think presenting this research to the people who make those decisions (in addition to the AAFP's position on VBACs that is evidence-based) would make any difference?

  11. Lisa Barrett

    I am not speaking about money when I say cost benefit analysis. I mean, risk analysis. For every action you take, you have to look over the pros and cons.

    Example= Primary elective c-section at 40 weeks. Con = baby at higher risk for respiratory problems. Mother at risk for operative complications. Pro = baby cannot have a shoulder dystocia. Mother will not be diagnosed with chorio. Chorio increases the risk of CP. I could rattle off more but you get the gist of it.

    I use the word patient because people then understand who I am speaking about. I could say laboring woman but that leaves questions. Like which laboring woman? When I say my Patient that means I have entered into a nonverbal contract with this woman. I have a relationship. It is not meant to be an offensive word. It is not the word itself but the meaning we attach to it.

    My patient will probably describe me as Her nurse. I don't see that as a problem. My patient may also ask for Her Epidural. It is not meant to mean ownership as much as it is meant to mean we have been assigned to each other.

    I find you post very interesting. I will ask my laboring woman tonight how she feels about being refered to as my patient.

    And Starparticle I am sorry to hear about you loss.

  12. Saw this on MDC, scary and sad. I feel lucky that my hospital decided NOT to ban VBACs even though they don't meet the ACOG's requirements (no 24 hour anesthesia).

  13. Okay, I'm really not very well versed in VBAC politics. Could someone explain to me why can't women just sign some paper that says they won't sue in the event of a uterine rupture in exchange for a trial of labor?

  14. Judit... I may be able to answer that question. Truth be told, waivers don't hold a lot of water when something goes wrong. There are too many intricate details involved with a "VBAC gone bad"... a woman can find the littlest, tiny detail in their labor and claim, "But THAT wasn't in the waiver. If I had known that, I wouldn't have signed the waiver."

    Along with that, if a child with severe CP who needs total care is paraded in front of a jury in a court room, most people know that an emotional jury is not going to deny parents monetary help for caring for that child for the rest of its life, even if the parents signed a waiver stating that they would not sue. They would see that as cruel.

    Another example (though it has nothing to do with a VBAC)... we worked with a woman recently who was advised to have an induction near her due date. She declined. (And for the record, I stand by that decision. I think a woman MUST be able to make her own decisions about her body.) However, time went on... doc continued to advise an induction (sorry, can't give more details for privacy reasons)... she continued to decline. A few weeks went by and she finally went into labor. She had a long labor and her baby didn't look good. She was advised to have a c-section. She declined over and over.

    Eventually, the baby went south... an emergent birth followed... and the baby died, despite all efforts.

    Again, I totally stand behind her. I don't agree with her decision (based on information I know but cannot share) but I must stand behind her decision to choose her own path.

    However, lawyers have already contacted the hospital. And the staff and physicians are worried because we all know that in the vast majority of birth-related lawsuits, sympathetic juries will side with the mother who has lost her child. It does not matter that she declined many, many, many requests to intervene.

    So on some level, I see why doctors are being cornered in the birth world. It's a "damned if you do, damned if you don't" world. In many cases, it doesn't seem to matter what a doc says or does, he or she will get sued anyway. No, the physician doesn't always lose. But it's VERY expensive, time-consuming, and stressful.

    Take a look at my blog... you will see that I am not the type of person who blindly supports "the system". I actually am quite an advocate of normal and of a woman having a right to choose. But we need to be careful as a society... if we want the right to choose, we need to learn to accept the responsibilities of our choices, whether we choose to have babies at home or in a hospital or elsewhere.

    I think that's a major downfall in our culture. We want to choose, but the minute something goes wrong, we want to blame someone else.

    On the flipside... a waiver signed for a VBAC can work against the mother too. She may be unable to take recourse against a physician or staff member for very negligent behavior. Something unrelated to the previous c-section may go wrong but when she tries to sue, she may be told, "But you signed a waiver stating that if anything went wrong, you wouldn't sue." This has the potential to leave her very vulnerable, depending on a judge and jury.

    Sorry this is so long.

  15. Team Harris--I completely agree that we have to accept responsibililty for our choices, rather than seek to place blame elsewhere when something doesn't go as planned. Now, of course there will be situations where it would be appropriate to seek some kind of recourse when it was someone else's choices that negatively affected us.

    I think we need a no-fault compensation system for all babies injured, brain damaged, dead, etc around the time of birth; regardless of circumstances all parents would receive compensation. Now, it might sound crass to attach a price to a baby's life or suffering, but that's what lawsuits do anyway. Does any country have this kind of system in place?

  16. Team Harris: Fabulous post.

  17. Well, I assume most parents of injured babies sue because they need compensation to cover the astronomical costs of care, not because they want a million bucks to cheer them up. So in the rest of the developed world, with universal health care, there is probably not a problem of this magnitude?
    Team Harris, thanks for explaining in so much detail, and all the examples. Makes sense. Except I totally don't get why that mother sued. Did the lawyers just descend like vultures I wonder? It sure puts the 'dead baby card' in a whole new perspective though!


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