Part 3:
Ethical, Economic, and Personal Costs of a high-Cesarean/low-VBAC rate
As fully described in Part 2, the multiple serious complications caused by placenta previa and/or and placenta accreta-precreta are not routine childbirth problems that are prevented by new obstetrical technologies or easily solved by modern obstetrical techniques.
Instead they are extremely serious, often life-threatening complications that require specialized surgery. In many instances, this means transferring the mother to a large regional hospital that is far away from her home and family. Post-operative care after such surgery often requires the new mother to spend several days in the ICU. Bonding and breastfeeding are terribly disrupted (if not impossible) when mothers are in the ICU while their babies are in the neonatal intensive care unit (NICU). Compared to women who had non-surgical births, the length of the initial hospitalization and the mother’s risk of re-hospitalization are drastically increased for women who had a Cesarean.
When high cost of care at the time of delivery is added to the delayed and downstream complications, post-Cesarean sequela are extraordinarily expensive — a negative version of ‘the gift that keeps on giving‘. In addition to the huge financial expense, there is the human cost in morbidity (serious complications that are not fatal, but may result in permanent disabilities) and preventable loss of life months or years later.
Treatment of a placenta percreta always requires an emergency hysterectomy, so there will be no more pregnancies for that particular mother. For many families this is a personal tragedy in addition to the physical pain, suffering and big hospital bills. There is at least one documented case of a delayed maternal death eight months after her Cesareans delivery from a bowel obstruction caused by post-op adhesions. {ref: Saras Vedam, CNM article}
The public generally assumes that repeat Cesareans are simple, safe and will eliminate all potential problems associated with laboring after a previous Cesarean, but unfortunately the risk of placenta accrete-percreta after two cesareans (0.6%) is greater than the risk of uterine scar giving away after one prior low transverse cesarean during a non-induced/augmented planned VBAC (0.4%) {Landon, Hauth, & Leveno, 2004}.
With a half million repeat cesareans every year, lack of access to vaginal birth after cesarean means the rate of abnormal placental implantation is continuing to increase exponentially.
Policies that prevent a subsequent vaginal birth merely exchanges the risk of uterine scar separation in a current pregnancy for the far more serious risk of placenta previa, abruption, accrete or percreta in a future pregnancy. Clearly this is an important public health issue.
The Central Role of Prevention ~ reducing CS rate, increase the rate of VBACs
There is no doubt that the VERY best, most humane and most cost-effective response to Cesarean-related complications is prevention. The best way, in fact, the only way to prevent the cascade of complications from a previous Cesarean is to dramatically reduce the number of primary Cesarean sections to the optimal rate (under 15%) and be certain that 100% of women who needed a Cesarean have unfettered access to non-surgical childbirth services in subsequent pregnancies if that is their choice.
When judged by the health outcomes for new mothers and babies, the optimal Cesarean section rate — a number that has the most benefit and least detriment to both mother and baby — is from 5% to 15%, depending on the health status of the childbearing population, with C-section rate between 10 and 15% as the national average. {ref} Our current 33% rate is 3 to 6 times higher.
If we reduced that 1.3 million by two-thirds (i.e. an 11% CS rate), 866,666 more American mothers would have normal vaginal births instead of Cesarean surgery. The annual number of CS would drop from over 1.3 million to a mere 433,000. This would dramatically reducing the pool of women (and nervous obstetricians!) who would have to face the issue of VBAC in future pregnancies.
A peer-reviewed paper on placenta abruption published in the American Journal of Obstetrics and Gynecology in 2006 was extraordinary for its repeated admonitions to obstetricians to avoid Cesarean delivery if at all possible. In the grave circumstance of a placenta abruption, most of us would assume that Cesarean surgery was immediately necessary.
But even in these difficult circumstances, the obstetrician-authors of this paper spent consider time discussing the virtues of ‘conservative management’ for the majority of patients who did not required immediate emergency intervention. For them, careful watching and waiting, prolonging the pregnancy as long as possible and facilitating a normal vaginal birth was advised. Under these extremely serious conditions, obstetricians are working very hard to avoid surgical delivery and to preserve the mother’s ability to give birth normally. Such efforts are to be applauded.
How minor or “ordinary” problems can work against a laboring woman
But unfortunately for healthy women with boringly normal pregnancies who don’t have any kind of high-stakes obstetrical complication to be managed (and confer subsequent bragging rights), there is not the same intense commitment by the obstetrical profession to avoid Cesarean surgery. As happens quite often, even healthy women can develop a relatively minor variation during labor, such as slow progress or minor EFM tracing that causes the physician or institution to fear the possibility of litigation.
In far too many of these ordinary cases, the ‘problem’ with vaginal birth is not any immediate maternal or fetal distress, but obstetrician or institutional ‘distress’ over a litigious risk as perceived by the obstetrical cultural. An immediate Cesarean is almost always the easy answer from the obstetrician’s personal perspective.
Unfortunately, these pro-Cesarean decisions are not an ‘easy’ for laboring women. They will be left to bear the considerable intra-operative risks and all the delayed and downstream complications amply noted.
It is too late to prevent a primary Cesarean for 1.3 million women who already had CS in each of the previous years. But the negative effects on childbearing women and the babies of future pregnancies can be eliminated or dramatically reduced by not automatically performing a repeat Cesarean, as either a matter of the obstetrical group’s policies or as a consequence of VBAC bans by the locals hospitals.
Unfortunately, that is still not the way the world is working in 2015.
Practical issues facing VBAC families in California
In a perfect world, neither hospitals, obstetricians, affected childbearing family, nor midwives would have to make the impossible choices currently associated with planning to have a normal vaginal birth after a previous Cesarean.
Instead, every community would have at least one hospital that could and would provide VBAC services. Obstetricians would be happy to care for previous Cesarean families seeking a vaginal birth, just as they currently agree to provide care other categories of pregnant women with special needs or higher risk situations.
In that perfect world, women who strongly preferred a physiologically-managed labor and birth would receive care from a midwife with hospital privileges for a planned hospital VBAC, with immediate access to a hospitalist-obstetrician in case of need.
However almost 50% of California hospitals and many obstetrical groups have VBAC bans, which functionally is a denial-of-service to affected women. Currently over 90% of women who had a previous Cesarean are being held captives by a technically lawful (but in this author’s opinion, unethical) system that nonetheless puts the economic well-being of hospitals and obstetrical groups above the lives and health of previous Cesarean mothers and their unborn/newborn babies.
These families are being asked to accept the many dangers of sequential repeat Cesareans recounted above, including death of mother, baby or both from the increased risk of complications associated with Cesarean surgery. A second or subsequent Cesarean also increases the likelihood and severity of delayed and downstream risks such a fetal demise, placenta abruption or previa and/or accrete-percreta in their next pregnancy.
Is it any wonder that the surgical focus of hospital care does not actually seem very ‘caring’ to many families, but instead is something to be avoided at all costs. These families often take the only other ‘option’ open to them, which is planning to stay out of the hospital if at all possible.
From an ethical standpoint, childbearing women should never be put in this drastic VBAC predicament best described as “between the Devil and the Deep Blue Sea”.
VBAC bans not safer; increase risks for affected childbearing women
The defensive practice of medicine that bans VBAC may make it economically more satisfactory for the institution or individual physician, but these policies clearly are not safer for mothers and babies affected by them.
The next obvious question is: What other options are available to women seeking a VBAC?
There are not a lot of options for previous Cesarean mothers-to-be living in areas of the state with VBAC blackout policies. This is even more of an extreme problem for women suffering some degree of PTSD after an exceptionally difficult hospitalization and Cesarean experience.
Regrettably, a small number of women who had a previous traumatic Cesarean delivery will choose to terminate all subsequent pregnancies rather then risk repeating what was, for them, a truly awful experience. When women with post-Cesarean PTSD do choose to maintain their pregnancy, this subset of traumatized women will do almost anything to avoid another surgical delivery. When the idea of another hospital delivery was broached, one second-time mother-to-be said:
“I just can’t go back to the scene of the crime unless me or my baby is in real trouble.”}
For extraordinarily committed women who want to avoid a repeat Cesarean, and can’t find any local hospital in California that will allow them to have a planned vaginal birth, the most frequent ‘alternatives’ they choose are:
- Waiting for labor to start and then driving 50 to 100 miles through the desert, or over a mountain range to an urban hospital that ‘allows’ a trial of labor for previous Cesarean mothers, while hoping that the on-call obstetrician is available and is also VBAC-friendly.
- Labor at home, and when the baby is about to be born, have someone call 911, so paramedics will be present at or immediately after the birth
- Have an unattended home birth with a friend or family member
As noted above, there are currently few OOH options for VBAC families if midwifery care is prohibited. Essentially they are choosing between an unattended labor, having a friend help out (both are associated with than a 20- to 40-fold increase in the risk of perinatal death) or calling 911 at the last minute.
Under the difficult circumstance of hospital and obstetrical bans on VBAC and subsequent decisions to have unattended home births, there is one orders-of-magnitude safer option — planning an out-of-hospital birth attended by a professional midwife. As an educated observer with emergency response capacity, midwives provide an on-going process for risk assessment during pregnancy and childbirth, and will facilitate emergency transfer if indicated.
This brings us back circle to the role of Ca LMs in relation to childbearing women who had a previous Cesarean. Ca LMs provided prenatal care and, if everything remained normal, a professionally-attended OOH birth to over 100 families (150 in 2014 150) seeking a VBAC each year.
Compared to the alternatives, including not receiving any prenatal care or attempting an unattended birth, the professional care of a Ca LM is dramatically safer. To be sure there is no indication of a placenta previa or abnormal implantation (especially percreta), the Ca LM would arrange for an ultrasound examine during the last trimester of the pregnancy. During active labor, the presence of a professionally-trained midwife greatly increase the likelihood of detecting abnormalities and initiating an immediate transferred to the hospital before her VBAC status or other medical issues resulted in serious complications for either the mother or her unborn baby.
The crucial question remains:
- Are California midwives an appropriate (if temporary) solution to a problem that leaves so many families with no other acceptably solutions?
- Or should midwives simply bow-out and leave such women to an admittedly dysfunctional system that “risk-shifts” and “cost-shifts”, and when things go badly, “blame-shifts”?
- Is it an ethical practice of medicine for hospitals and physicians to reduce their own economic and professional risks by passing them on to affected mothers and babies, while the dramatically-increased risks and costs associated with repeat Cesareans and their complications are passed on to our healthcare system and taxpayers who foot the bill for 50% of births in the US that are reimbursed by Medicaid ?
As if these dilemmas were not themselves vexing enough, the lawful choice of previous-cesarean mothers to receive care from a Ca LM is in danger of falling under a different kind of VBAC ban — the concerted effort by organized medicine in state legislatures across the country to get laws passed that would legally prohibit midwives from providing childbirth services to healthy women who had a previous Cesarean and now have a normal pregnancy.
As has been the case with previous issues medical issues that disadvantageous to CB women, while providing a clear economic advantage to doctors, the response by organized medicine is to make things worse these mothers-to-be by blocking off every other avenue, and trapping affected families between the devil and the Deep Blue Sea — a scheduled Cesarean or laboring at home unattended.