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."
Comments
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egavin (anonymous) says…
The International Cesarean Awareness Network, Inc. (ICAN) is a nonprofit organization founded by Esther Booth Zorn in 1982. ICAN's mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean (VBAC).
Please contact ICAN if you need support or information:
www.ican-online.org
Eva Gavin, mhsa
ican Regional Coordinator
913-381-9450
www.icanofkc.org
lori (anonymous) says…
Interesting that hospitals feel they aren't able to provide for the care of a woman and her infant in the event of an emergency. Uterine rupture isn't the most common obstetric emergency. According to the July 3rd issue of the BMJ, it takes 2941 repeat c-sections to prevent one rupture related hysterectomy. So they will perform almost 3,000 repeat c-sections (additional income, and easier to schedule staffing around, certainly) to prevent one emergency hysterectomy in a VBAC client. But there are other situations totally unrelated to VBAC that require immediate surgery and possible hysterectomy. What happens when a mother has placenta accretia, for example, and needs an immediate hysterectomy to survive? And they are seem to be implying that uterine rupture only occurs with mothers who have had a previous c-section, which is not true.
Since they are saying since they aren't able to deal with the emergency of rupture, they are also saying they aren't able to deal with other emergencies that require immediate surgery. That doesn't make sense. It sounds like they shouldn't be able to attend *any* births since they obviously aren't able, by their own admission, to care for the mother or child in an emergent event. We should probably just be requiring EVERY mother to have a c-section, since apparently, according to Stormont Vail, hospitals like theirs aren't capable of handling obstetric emergencies.
According to Contemporary OB/GYN of Feb 2005, 588 repeat c-sections must be done to prevent one severe adverse outcome. Meaning that 587 of the mandatory repeat c-sections would have been healthy vacs. Meaning that 587 women were forced to undergo a medical procedure that was NOT safer for them or their baby, and in fact puts them at greater risk for major complications during a subsequent pregnancy.
In the same set of recommendations that the American College of Obstetricians and Gynecologists say that VBAC should be attempted only in institutions equipped to respond to emergencies with physicians immediately available, they also state that most women with one previous c-section are candidates for a VBAC, and that the ultimate decision on attempting a VBAC or undergoing a repeat section should be made by the patient and her physician (ACOG Practice Bulletin; no. 54). Hospitals like Stormont Vail are very conviently only responding to half of the recommendation, and choosing to ignore the others. What sort of standard of care is this?
lori (anonymous) says…
I'd like to add that there is no other precident like this in medicine, where a patient is not given all available safe options for treatment, where NOT providing informed consent is the "standard of care." Because that is what is happening when the hospitals are saying that they aren't going to let a woman choose a VBAC; apparently they get to decide what is best for her, and she has not choice in the matter. As for the hospital deciding for a repeat c-section for the safety of her child, that is rediculous. No where in medicine is anyone forced to undergo a medical procedure for the safety of another person. No one is forced to donate blood or provide a kidney without their consent, even if the person needing it will die without it.
KristaJoy (anonymous) says…
Any hospital that is not prepared to deal with a sudden emergency such as the extremely rare event of uterine rupture is not going to be prepared to deal with any of the other extremely rare complications of pregnancy. Uterine rupture is no more likely to happen than other "emergencies" such as cord prolapse, something that *all* pregnant women, not just VBAC's, could have happen.
Perhaps other pregnant women choosing to be consumers at these hospitals should ask themselves if they want to have care given at a place that cannot guarantee a quick trip to surgery if warranted in that rare circumstance.
lori (anonymous) says…
Hospitals, doctors, and insurance companies need to stop putting forth the image that they can 100% guarantee a 100% safe birth for mama and baby. They can't. No one can.
C-sections are not without risk. It's major abdominal surgery, and carries the very small but very real risks of hemorrhage, perforation of bowel and/or bladder, hysterectomy, infection, and death of mother and/or baby. Not to mention an increased risk of rupture, placental insufficiencies, and stillbirth during subsequent pregnancies, with the risks increasing with every additional c-section.
Why not offer women education and counselling, and let them choose a birth option that works best for them? Why not present the facts, and let a woman and her care provider weigh these options based on the woman's personal health history, future birthing plans, and personal preference? If she makes an informed choice to schedule a repeat c-section, support her in that decision. If she makes an informed choice to attempt a VBAC, support her in that decision.
All hospitals are required by their accrediting body to provide informed consent for procedures. Having the ability to make an informed consent also means having the ability to make an informed refusal to consent to a procedure. Hospitals that are not providing the option to refuse a repeat c-section are violating thier own patient bill of rights and should be in danger of losing their JCAHO accreditation. I wonder if the hospital lawyers remember this?
LawrenceMommy (anonymous) says…
I am astounded by the practice of forcing women into major surgery, without informed consent, because of liability fears. I had a c-section with my first, because of medical necessity. Mine was a result of a mistake during medication administration by a nurse that caused trauma that wouldn't allow me to fully dilate. I am 100% in favor of medically necessary c-sections, but I will not be forced into that "option" by a doctor that doesn't want to face any risk.
I will be going to KC to have my next baby. If that wasn't an option I would be thinking very hard about having a home-birth with no medical professionals in attendance. How much safer is that than a VBAC in a hospital? They couldn't care less about health and safety...just their bottom lines. And in any other field people would be up in arms. It's just disgusting.
lori (anonymous) says…
Good for you, LawrenceMommy. Since apparently money is the bottom line, maybe when hospitals realize that mothers are demanding to be active participants in their care, and that they will take their business elsewhere, where they can make the informed choice of a VBAC *or* a repeat section, maybe THEN those hospital lawyers and CEOs will rethink their positions. Maybe then they'll remember that little thing called informed consent. Maybe they'll remember that women are actually intelligent beings who are willing to be advocates for their care, and seek out care that they want.
mandymommy (anonymous) says…
I just want to second what's been said here in the comments. It is outrageous that only in obstetrics are "they" allowed to take away rights to personal medical decisions like this. It is the mother's choice to take on that tiny, tiny risk (no, it's NOT zero, but neither is anything, duh) in order to reap MORE benefits. Let's talk about the risk of multiple c-sections on the mother and baby. You don't usually get those from these litigation-scared OBs. We have to take a stand on this issue now!