Mother advocates for choice in birth options

Cesarean shouldn't preclude natural deliveries, some say

Devina Garrett, 23, said she felt relieved and empowered when she gave birth naturally to her daughter, Moriah, in January.

Her first child, 3-year-old Ammon, was delivered by a cesarean section.

“I was happy to have the chance,” she said. “Some doctors won’t allow you to have a natural birth after having a cesarean, and it’s something I felt I had a right to decide. I know that some woman prefer cesareans and sometimes they just have to be done for the health of the mother or the child. But I also think that women should be able to have a birth on her terms and have other options.”

Garrett gave birth to her daughter through a delivery method known as vaginal birth after cesarean, or VBAC. It’s a form of delivery that is becoming dramatically less available to Kansas women in large part because doctors and insurance companies are keen to minimize potential for liability.

Three-year-old Ammon plays Candy Land with his 6-month-old sister, Moriah, and his mother, Devina Garrett, of Lawrence. Garrett gave birth to Ammon through a cesarean procedure, but opted to birth Moriah naturally. She is now an advocate for vaginal births after cesareans, or VBACs.

The Kansas Department of Health and Environment reported that the number of VBACs in the state declined by about 50 percent between 1998 and 2003. In 1998, 876 VBAC deliveries occurred in Kansas. By 2003, the figure had dropped to 467.

“The scar from a cesarean increases the risk that a woman’s uterine wall will rupture during a vaginal birth,” said Dr. Stephen Myers, an associate professor of obstetrics and gynecology at the Kansas University School of Medicine. “The risk is small, but it’s not zero.”

There’s about a one in 200 chance that a woman’s uterine wall will rupture, Myers said.

But that risk has prompted some hospitals to ban VBACs. There also have been some malpractice insurance providers refusing to insure physicians if they allow vaginal births for women who previously have had a cesarean section.

Banning and fighting

The risk may be small for a woman giving birth naturally after previously having a cesarean section.

But, Myers said, if a problem occurs, the hospital could be viewed as liable.

Lawrence Memorial Hospital will allow VBACs, but none have been done. The hospital leaves the decision up to physicians.

St. Francis Health Center and Stormont-Vail HealthCare in Topeka and Newman Regional Health, a hospital in Emporia, have opted to not allow VBACs.

The Topeka hospitals banned the delivery procedure a couple of years ago.

“It’s a safety issue, and it’s a community standard in Topeka. Neither hospital allows them,” said Stormont-Vail spokeswoman Nancy Burkhardt. “But what it also comes down to is we’re not able to provide the support staff needed to ensure the safety of the mother and the baby.”

The Topeka Birth & Women’s Center is one of the few Kansas clinics or hospitals outside Kansas City known to allow VBACs. But the practice could soon cease there, too, said Dr. Josie Norris, medical director of the center.

Norris said a discipline committee for the Kansas State Board of Healing Arts has determined she should not be allowed to do VBAC deliveries outside of a hospital. And she doesn’t know of any hospital nearer than Kansas City where she could offer VBACs, which would make it impractical for her to continue the service.

No final outcome has been decided in Norris’ case. There is a possibility the board will discuss her case at its monthly meeting Saturday in Topeka.

The possible order against Norris’ clinic is a concern for some, including Garrett, because of its potential to limit delivery methods. Norris said preventing her from offering VBACs took away a woman’s choice.

“It’s not fair,” she said. “Women are losing their right to have a say in this.”

Malpractice matters

The American College Of Obstetricians and Gynecologists stated in its 2003 standards that an anesthesiologist and an obstetrician should be immediately available during the delivery in case an emergency cesarean section was needed.

“Many malpractice insurers won’t allow VBACs unless physicians have the support staff in place,” Myers said. “Some anesthesiologists may not want to do that, and many aren’t enthusiastic about the idea. You can’t say for sure when a woman will be ready to give birth.”

KaMMCO, which is one of the largest malpractice insurance providers for physicians in Kansas, likely will insure medical providers as long as they are licensed, trained and in good standing with the Kansas State Board of Healing Arts, said Larry Gill, vice president of marketing and loss prevention for the company.

“We’re not going to get into the practice of medicine at KaMMCO,” he said. “We let the doctors make those decisions. But there’s nothing to preclude a provider from saying they won’t insure someone.”