Does vaginal birth have a future?

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By Jill

The editorial, Does vaginal birth after cesarean have a future?, which appeared in the July 2010 issue (Vol. 22, No. 07)  of OBG Management is currently being discussed on the internet. Just for fun, read the editorial and substitute “vaginal birth” or “VB” for “vaginal birth after cesarean” and “VBAC.” Irrelevant sentences were deleted. Nothing was added.


Does vaginal birth have a future?

VB is destined to fade out of practice and memory unless we accurately, and individually, assess the risks it poses to patients and babies

Once again, vaginal birth, or VB—has arisen as a topic of interest in obstetrics, as demonstrated in this issue of OBG Management. I say “once again” because, frankly, I thought that the matter had become irrelevant—reminiscent of a debate over vaginal breech delivery in the 1970s and 1980s now largely resolved in the United States, thanks to evidence-based randomized clinical trials.

And I considered VB finished when I compared the target VB rate established in the US Department of Health and Human Services’s Healthy People 2010 report against the astounding data that we see reported today:

  • In 1998, the US primary cesarean delivery rate was 18%; the Healthy People 2010 target was 15%. Today, that rate exceeds 25%.
  • In 1998, the repeat cesarean delivery rate was 72%; again, the Healthy People 2010 target was 63%. In 2003, however, the repeat cesarean rate had climbed to 88.7%—and today, that rate exceeds 90%.

So the question remains: How can medical science help patients and physicians make the best decisions about VB?

What are the risks?

The true risks of VB are unknown. However, we do know—all the data are in agreement—that elective repeat cesarean delivery, performed at the appropriate gestational age, is safer for fetus and newborn than a trial of labor.

We also know that most mothers accept a greater burden of risk for themselves if there is potential benefit for their newborn. (An example is expectant management of severe preeclampsia remote from term, when a delay in delivery offers no maternal benefit but does offer potential benefit to the newborn.) With VB, mothers must be willing to accept the risks of the procedure; better ways to assess that risk have been proposed to help them make a decision.5

Be certain that your patients know the hospital-specific cesarean delivery rate and VB success rate—and if you don’t have those data, then tell the patient that you don’t.

What does VB cost?

The data with which to answer this question are hard to obtain cleanly; ultimately, however, the choices we make should be based on proper medical decision-making, not cost. That said, I remain unconvinced that VB overall offers significant savings over cesarean delivery when total cost (not just the cost of postpartum care or the cost of post-delivery length of stay) is examined.

Furthermore, the expense of settling malpractice claims of “VBs gone awry” is never included in estimates of the cost of care.

How are VBs reimbursed?

The current structure of reimbursement for health care doesn’t favor VB. In most regions of the country, 1) physicians’ reimbursement for performing a VB is either the same as, or lower than, it is for cesarean delivery and 2) most hospitals enjoy a greater margin on the hospital stay postcesarean than after a vaginal delivery.

Given the increased time involved in managing a VB, a change in reimbursement to recognize the greater effort and exposure to liability would be a reasonable step for payers—if there is true interest in reversing the trend away from VB that we’re seeing.

How well do patients accept VB?

It’s tough to sell a product that people don’t want. My anecdotal experience (meaning that my conclusions are unencumbered by data) is that informed health care personnel who themselves have had a cesarean delivery almost uniformly select cesarean delivery subsequently. They know the data and they’re aware of the risks. Often, they aren’t planning on having more than two children, so the problem of placenta accreta in the future doesn’t apply.

These observations suggest, to me, that maybe 1) we need to do a better job counseling patients or 2) our society’s value system overwhelmingly favors predictability of delivery and safety of the newborn at the expense of even a slight increase in risk to the mother.

Alas, common sense is the most difficult thing to legislate

VB was, and is, a good idea. It’s based on sound principles and good intentions. Now, we’ve moved to the other end of the spectrum: It seems we offer VB to anyone who wants it, regardless of comorbidities.

Applying common sense to the matter, we might be able to agree on a solution that makes VB attractive and, more important, safe for our patients and for us. Furthermore, we must diligently keep track of our own data on maternal and neonatal outcomes so that we can most appropriately counsel our patients.

It’s up to us to determine whether VB should stay or go

I estimate that we have a window of opportunity of 5 to 10 years to resolve whether VB remains part of practice. If we don’t take that opportunity, we’ll be left with a generation of physicians who have little or no experience performing the procedure. VB will disappear, in a self-fulfilling prophecy—which, when you think about what happened with vaginal breech delivery, may not be a bad thing.


Related reading

George Macones, M.D.’s abstract in NIH Consensus Development Conference: Vaginal Birth After Cesarean: New Insights, which states in part:

How Safe Is Safe Enough?

Beauty, and risk, are in the eyes of the beholder. Short-term maternal complication rates (uterine rupture) are similar to other procedures in obstetrics and medicine overall. Short-term neonatal risks are possibly increased with VBAC, although close in magnitude to complications observed with any vaginal delivery. The effect of multiple repeat cesareans on maternal health can be profound, mainly due to complications of multiple surgeries and issues related to abnormal placentation. [Emphasis mine]

Lauren Plante’s article, Mommy, what did you do during the industrial revolution? Meditations on the rising cesaran rate, which contains the epic statements:

Industrial obstetrics strips the locus of power definitively away from women. The history of childbirth in America reflects a persistent trend of increased control by physicians and increased medicalization. Childbirth moves, first, out of the home, and now out of the vagina.

(Dr. Plante’s article was cut and pasted onto some personal blogs last year if you want to Google it.)