In VBAC (Vaginal Birth after Cesarean)

A few weeks ago at the American Congress of Obstetricians & Gynecologists annual meeting, Dr. Grünebaum presented his prize winning paper concluding that home VBAC resulted in worse neonatal outcomes compared with hospital VBAC. No challenge there. Other studies of home VBAC have reached the same conclusion. It’s what comes next that’s the problem. Grünebaum opines:

As professionals, we are ethically obliged to reduce preventable, . . . risks of birth. Women who express an interest in planned home birth should be informed that it results in increased risks of perinatal and neonatal mortality and morbidity that can be prevented by planned hospital birth. Providing our patients with this information strengthens a woman’s autonomy to make an informed decision about the place and circumstances of birth.

And it does this, how?, seeing as he apparently washes his hands of the obligation for him and his fellow professionals to provide hospital VBACs.* One is reminded of Lady Catherine in Pride and Prejudice, who, when her cottagers were disposed to be discontented or too poor, sallied forth to scold them into harmony and plenty.

On another front, Maine recently legalized direct-entry midwifery but at a price. Midwives are not allowed to attend VBACs (or breeches or twins, for that matter) in homes or birth centers. Maine isn’t the only state to set these limitations on licensure, which closes the door on out-of-hospital VBAC attended by a midwife, who by virtue of meeting licensing requirements, has met criteria for knowledge and skill.

So what’s a woman who, quite reasonably, doesn’t want to go back under the knife unless there’s a good medical reason for it, to do? She mostly can’t get a VBAC in the hospital at all, and even when she can, it is hedged about with so many non-evidence-based limitations, that her likelihood of vaginal birth is substantially diminished and her chances of scar problems may be considerably increased. She can’t get a VBAC at home from a licensed midwife or in a freestanding birth center because that would get the midwives providing her care into legal hot water. Unless she is willing to have an unattended home birth, the least safe of all the possibilities for VBAC, her options narrow to an elective repeat cesarean, which brings us to the question: If it’s an ‘elective’ cesarean, how come she didn’t get to vote?

 

*For those interested in a thorough rebuttal to Grünebaum’s position, Medscape published a commentary, “Making Out-of-Hospital Birth Safer Requires Systems Change,” a few days later.

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