Monday, March 9, 2009

A History of VBACs and Cesareans in the USA

Several blog visitors have brought up questions about why the cesarean rate is so high now and why attitudes towards VBACs have changed over time.

So let's take a moment to discuss a simplified bit of the history of cesareans and VBACs (Vaginal Birth After Cesarean, pronounced "vee-back") in the USA.

The Days of Low Cesarean Rates

For most of the 20th century, cesareans were a rarely-used procedure, used only in truly life-threatening situations after all other options had been exhausted. The risks from the operation were so significant that doctors were very reluctant to use it without true need.

Doctors in the USA also followed Dr. Edwin Cragin's 1916 dictate of "once a cesarean, always a cesarean." They were very reluctant to do a cesarean on a woman because that usually meant that all her future children would also be born by a similarly risky operation.

They recognized that the decision for cesarean affected a woman's entire reproductive life, and also had other potential life-long consequences (scar tissue, bowel obstructions, damage to other organs, etc.).

For this reason, the cesarean rate hovered between 1 - 5% until about the 1970s.

Cesareans Become Safer

Over time, changes in technique and technology came about that made cesareans safer and easier. This was a good thing.

Antibiotics became common, cutting the risk of infection. Blood transfusions became available. Anesthesia improved greatly, and eventually, the development of regional anesthesia (via epidurals and spinals) decreased the risk of complications over general anesthesia (where the mother is unconscious).

Surgical techniques also improved. Instead of doing "classical" vertical incisions (up-down incisions, from belly button to pubic bone), doctors began using a low-transverse incision (side to side, just above the pubic bone). Low transverse incisions caused less bleeding, were less prone to wound complications, and were less likely to rupture (come apart) in a future pregnancy.

This conversion from vertical to mostly low transverse incisions also made VBAC a safer choice to consider.

The Cesarean Rate Begins To Climb Rapidly

As technology improved and cesareans became safer, doctors started doing more and more of them. As you can see below, the cesarean rate rapidly increases between 1970 and 1988, until it reaches an all-time high (for that time period) of 24.7% in 1988.
  • 1970 - about 5%
  • 1975 - about 10%
  • 1980 - about 16%
  • 1985 - 22.7%
  • 1988 - 24.7%
This was a huge increase in a relatively short period of time, and it set off many alarms in public health officials. By the late 1980s, there was a big push to reduce the cesarean rate, and after 1988 the cesarean does start to go down somewhat again, though it never again dropped below 20%.

Of course, sometimes doing more cesareans was a good thing. For example, instead of risky high forceps deliveries (which often caused injuries to both mother and baby), cesareans became the delivery of choice. Birth injuries related to forceps declined. In that situation, cesareans probably were safer.

However, this also soon meant that even judicious low forceps use (which can help turn a poorly positioned baby and make vaginal birth possible) came into disuse. Vacuum extraction is now used instead of forceps most of the time, but it has its risks too, so many doctors prefer to go straight to surgery instead.

Generally it's a good thing that instrumental delivery has gone down, but along with the loss of this has come a loss of knowledge that mild positional issues can be resolved by any method other than cutting the baby out. For example, studies show that manually repositioning a baby can cut the cesarean rate dramatically, without the risks of instrumental delivery.....but few doctors and hospitals are being taught these skills anymore.

New technology such as External Fetal Monitoring (EFM) also increased the cesarean rate, but without improving fetal outcome in most cases. Despite this, EFM has become "standard of care" and continues to crank up the cesarean rate even today.

In time, more and more doctors saw the cesarean as the "go-to" choice for births they perceived as more risky, either medically or legally. More and more breeches began to be delivered by cesarean, and many babies suspected to be "big" were sectioned out. Mothers with any sort of complication became automatic candidates for a cesarean, even when other choices existed.

Even more influential in the meteoric rise in cesarean rates was the increased use of labor inductions (which strongly increases the risk for cesarean, especially in first-time mothers). Induction of labor allowed doctors to practice "daylight obstetrics" and have more reasonable hours, but the price was more surgery for the mothers and often, more intensive care visits for the babies.

As a result, there was an unprecedented explosion in the cesarean rate. This was quite controversial; many public health officials (including many doctors) decried the strong rise in cesareans and actively looked for ways to reduce the rate.

Others, however, began to be seduced by how convenient cesareans were for scheduling their time and also saw scheduled cesareans as a way out of the increasing risk of malpractice suits.

The debate over the "best" and "most optimal" cesarean rate began to rage and still continues today.

VBAC Becomes More Common

When the cesarean rate was only around 5%, the "once a cesarean, always a cesarean" dictum wasn't a pressing public health issue. But as the cesarean rate went up, that dictum became more of an issue.

If more and more women had primary (first-time) cesareans and all of them had to have repeats for every child, then the cesarean rate had the potential to expand at an unheard-of rate.

VBAC was seen by public health officials as one way to keep the cesarean rate from rising even higher. In addition, more women started questioning whether they had to have a cesarean for every single child. Although still controversial, VBAC became more and more acceptable as an alternative.

In the late 70s and the 80s, concurrent with the rise in the cesarean rate, US doctors finally began really researching VBAC, showing that it was a safe and reasonable choice. Still, there was quite a bit of resistance to VBAC at first, and women had to struggle to find caregivers who would "let" them VBAC.

Many women were told that they would "kill their babies" if they tried to VBAC, yet they heard through the grapevine that VBACs were more common in Europe, and that some U.S. practices were beginning to attend VBACs also. Women began pushing back, trying to make sure VBAC was available universally.

Out of this struggle, a grass-roots women's health movement began, pushing for more choices in childbirth. Women like Nancy Wainer Cohen, Esther Zorn, and Lois Estner pushed to make VBAC a choice for all women, while other pioneers like Suzanne Arms, Penny Simkin, Robbie Davis-Floyd, Sheila Kitzinger and many others pushed for reform of outdated childbirth practices like universal episiotomy, pubic hair shaving, mandatory drugging of the mother, prolonged separation of mother and baby, promotion of formula feeding over breastfeeding, etc.

The International Cesarean Awareness Network (ICAN) was born in 1982 (under a different name at first) and consumers finally had an organized voice demanding the right to choose VBAC. In 1983, Nancy Wainer Cohen and Lois Estner published Silent Knife, a book about VBACs that still remains a classic even now, more than 25 years later.

The power of the consumer to demand change began having an impact, and by the early 90s, VBAC was available in the vast majority of U.S. hospitals.

VBAC Management Began To Change

By the early-to-mid 90s, VBAC became the norm in many places, reaching its peak in 1996.

Research in the 80s had shown that VBAC was an eminently reasonable choice, so more and more hospitals and doctors began offering it. However, they knew from research that in rare cases, the uterine scar could separate in a subsequent pregnancy (uterine rupture), so they were very cautious in how they managed VBAC labors.

VBACs in the 80s were rarely induced, and pitocin augmentation of labor was done very conservatively and with great care.

This began to change in the 90s. As induction of labor became the norm in other labors, so it began to be applied liberally to VBAC moms.

Inducing VBACs became commonplace; many doctors believed that inducing early increased VBAC success (despite studies showing the opposite effect).

In addition, a new induction drug came along called Cytotec (generic name: misoprostol), which was cheaper and more convenient to use than other induction drugs. It was only after a number of years of use and some pretty horrible outcomes that it was "discovered" that Cytotec actually strongly increased the risk for uterine rupture in VBAC moms.

Although researchers still argue about it today, it's become apparent that inducing labor by any means also increases the risk of uterine rupture. Some induction methods increase the risk much more strongly than others, but all methods show some increase of risk over spontaneous labor. This is particularly true if the mother has never had a vaginal birth before, or if multiple induction agents are used. Cytotec in particular raises the risk of rupture strongly.

This routine induction of VBAC was the beginning of a crisis for VBACs.

VBAC-lash Begins

Because VBAC in the early 90s was so mismanaged, by the late 90s a movement against VBAC was starting to take hold. There were several factors in this VBAC-lash.

Because vaginal birth is cheaper than major surgery, promoting VBAC was seen as a way to cut costs for insurance companies. Unfortunately, this meant that VBAC became required in some places, and some women were not given a choice about whether or not to VBAC.

This was the first step on the road to VBAC-lash, because not all women want to VBAC, nor are all women suitable candidates for it.

Some women were required to labor who had contra-indications for labor. Others were forced to labor in crowded hospitals with very inadequate supervision. Conditions in some places were so poor that even when signs of a rupture were obvious, the woman did not receive timely intervention. Other women were induced with dangerous drugs like Cytotec that had a very high rate of rupture.

As a result, some babies were lost, some babies were damaged, and some mothers lost their uteri. This was a tremendous tragedy, and those families were justifiably upset and well within their rights to sue.

Because more and more VBACs were induced, more and more cases of uterine rupture began appearing, more babies died or were harmed, and doctors and hospitals faced some spectacularly big lawsuits. This played a huge role in the VBAC-lash.

But instead of blaming the overuse of induction, mandatory VBACs regardless of suitability, and mismanagement of labor, doctors began saying that it was actually VBAC that was unsafe.

Now mind, research does NOT support this; if you examine the research carefully, the rate of rupture in spontaneous labor VBAC does not change over time. It remains around one-half of one percent on average; some studies show rates as low as 0.2% or even less.

The risk of serious, permanent harm to the baby or mother is even lower. Babies are at far more risk of dying from amniocentesis, a procedure that doctors do not hesitate to recommend.

Yet suddenly, VBAC was considered "too dangerous" because doctors were lumping all VBACs (induced and not, carefully chosen and not) together.

Right or wrong, doctors' perception of VBAC began to change, and they began to see it as tremendously risky.....both in absolute risk to the mother and baby, and in medico-legal risk to themselves. Many doctors decreased the number of VBACs they attended, and some doctors stopped offering VBACs at all.

By the very end of the 90s, there was a distinct downfall in the rate of VBACs, and after 2000 the rate really began dropping off.

The reason for this dropoff is that in 1999, ACOG issued new guidelines for attending VBACs, requiring doctors and anesthesiologists to be "immediately available" during a VBAC labor. This means the OB and the anesthesiologist had to be IN the hospital during a VBAC mother's whole labor. This was financially and logistically impractical, so more doctors quit attending VBACs.

A lot of smaller hospitals instituted official VBAC bans because they could not meet the "immediately available" guidelines. This has had a particularly significant impact on states with lots of rural or small-city hospitals.

Because there had been a few spectacularly high lawsuit awards, many malpractice companies raised rates for or refused to cover doctors who attended VBACs. Therefore, even some doctors who still believed in VBACs and wanted to attend them often felt like they could not afford to continue, or that their hands were tied by hospital and malpractice insurance policy.

Because of malpractice insurance issues, even some large hospitals with 24/7 surgical and anesthesia coverage also began to not "do" VBACs, or began to strongly discourage them.

Now the rate of VBACs in this country has dropped significantly, with many women essentially being forced into repeat cesareans, as documented in the recent TIME magazine article.

Currently, about 92% of women who have a prior cesarean undergo cesareans with all their subsequent children. This is about the same low level of VBACs as in 1986, just as the VBAC movement really started to take off.

We are not quite back to the days of "once a cesarean, always a cesarean" because about 8% of women with prior cesareans still do somehow manage to have VBACs in this country despite all the bans......but basically, we are almost there.

Yet a few voices of sanity still prevail. The authors of an 2006 Irish study on VBAC state:

The North American studies have highlighted correctly the risks of [rupture] in women who labour with a previous caesarean section. We are concerned, however, that obstetricians individually and collectively may have overreacted to their publication and that some have been too quick to revert back to a policy of ‘once a caesarean, always a caesarean’. This simplistic mantra may have been appropriate at the start of the 20th century, but our experience suggests that such a ‘one policy fits all’ approach may not be in the interests of both mother and baby at the start of the 21st century.
Cesarean Rates Soar Again

Combine the anti-VBAC climate in the country with the fact that cesareans make more money for hospitals, more money (hour for hour) for doctors, and make the lives of doctors and hospitals incredibly more convenient, and cesareans in this country have truly become epidemic.

Doctors like to claim that the steep rise in cesarean rates in the USA is because maternal demographics are changing.....mothers are older, fatter, have more multiples, etc. However, careful examination of the research shows that cesarean rates are increasing for ALL women, regardless of risk profiles.

Another argument is that women are requesting all these cesareans and the poor doctors' hands are tied. But there is no convincing research that cesarean on maternal request plays a large part in cesarean rates.

Blaming the explosion of cesarean rates on the mothers just doesn't wash....the truth is it is physician practice patterns that are driving the rates.

Because practice patterns differ between doctors and hospitals, you have a much higher risk for cesarean in some hospitals than in others. For example, in New Jersey, some hospitals still have cesarean rates in the 20-36% range, but many hospitals now have about a 40% cesarean rate. This is becoming more and more common.

Some hospitals in New Jersey, California, and Florida have about a 50% cesarean rate, and there are more and more of these starting to appear. A few even have c-section rates as high as almost 60%......and the high cesarean trend shows no signs of abating.


Remember when public health officials got all up in arms in the late 80s because the cesarean rate had spiked to around 25%? Well, they did reduce it for a while (it dropped down to 20.8% by 1995), but now it has spiked again, even higher than it was then.

Only this time, almost no one cares.

Now the cesarean rate has soared up to over 30% nationally (the rate was 31.1% in 2006) and is still going up.

(The 2007 figures are due out from the CDC very for them. Also watch to see whether the cesarean rate receives much attention in the media afterwards.)

Many consumer groups like ICAN are fighting this spike in cesareans, yet hardly a medical voice is raised against this out-of-control trend.

In some states (like New Jersey and Florida) the c-section rate is almost 40% already.

Now, at the end of the first decade of 2000, about one out of every three women in the USA has her baby surgically extracted, and in some hospitals that becomes ONE OUT OF EVERY TWO....or more.

And if you have that first cesarean, it has become extremely hard to find a hospital that will give you a realistic chance at a VBAC. We are not quite back to the days of "once a cesarean, always a cesarean" but we are getting darn close.

This is the sad and sorry state of birth in America. It can change, but consumers must take the first step and vote with their feet, away from the doctors and hospitals that practice so unsafely and unjustly.

*Graph is of cesarean rates from 1989-2003 only. Source found at:


Rebecca said...

Wow, I love this. You do such a great job of summarizing the issues and history! I'm looking forward to pointing people to this who ask "What's up with the c-section rate?"

Becky said...

This is a wonderful post! I knew some of the information already, but much of it was new to me.

I am currently 24 weeks pregnant with my third child. This will be my second VBAC and I've had to fight to get it. My children and I actually moved to a different state (FL) because I couldn't find a care provider.

Anonymous said...

I want to thank you again for how well-researched and information-packed your posts are. That graph is quite arresting. As I said last time, I'm worried about how much "choice" I will actually have when it comes time for me to get pregnant and give birth, but it seems like the best option is to carefully research local hospitals and try to find one (along with a health care provider) that is less "friendly" to unnecessary c-section.

Anonymous said...

Wonderful article, thank you for all the links. The Time piece about the dangers of repeat c/s is a good article in mainstream media. I have an idea...the numbers here are astounding. Common sense and the truth IS on our side here...what do you think of getting women together to propose legislation to provide all women with third -party evidence-based informed consent on every intervention and complication that can arise in pregnancy and labor. Get WHO, CDC,NIH, and pro-birth and women's organizations behind the effort. I know we have the internet, and I-CAN, but so many women are being bullied, lied, to and otherwise manipulated into major surgery, I really feel the only way to change the "trend" is to legislate informed consent for everyone. I mean really, can we trust the hospitals an doctors to provide us with it? Isn't there a conflict of interest when they make more money on surgery? When they are scared of getting sued? Also, can we get people and organizations together to demand that medical schools continue to teach breech vaginal delivery, VBAC, manuevers and management to avoid c-sections?

We are loosing our rights and our health, the health of our precious children, it is our generation witnessing these atrocities now that needs to stand up and be heard to make the necessary changes that will prevent this disturbing "trend" from happening again.

Thank you thank you for being one of those loud voices.

Willow said...

This is a *beautiful* summary of the whole situation. Thank you!!

~Anne~ said...

Excellent article!

happymama said...

Thank you so very much for your article! It maakes a very alarming, yet accurate, point.

Mamas please remember that you always have a choice and you can always say no to what is presented to you. Unfortunately, many health care providers won't tell you this AND, they are likely to fight your right to opposition unless you stand your ground!!!

Happy VBACing! I had a fabulous VBAC, peacefully at home, in the water :) Thanks to my amazing midwife who believed in me and knew better.

Anonymous said...

Very well written great article. I posted a link to it on my blog.

SeekerofGrace said...

Awesome summary! I learned a lot. I will be a VBAC mama with my next child, and I will probably have to move to find a care-provider.

Anonymous said...

I am just trying to figure out where your sources for this article came from. It would really help me with a paper I'm writing.