Too Late for Natural Birth?

In my google alerts today, one headline stuck out: “Too late to reverse rise in c-sections?” from the Boston Globe.  It is a letter to the editor from Lois Shaevel, co-author of “Silent Knife.

Shaevel states:

For eons we females had been capable of giving birth with very little medical intervention. Then childbirth went into the hospital, and the process became a medical and increasingly surgical event.

It’s sad really.  I’m not saying that all women don’t need a hospital and that all births can be achieved non-medically, but what makes me sad is the shift in how pregnancy and childbirth are viewed by our society.  Pregnancy and birth used to be normal and expected events in a woman’s life.  Now when you tell someone that you are pregnant they ask you if you have a first trimester ultrasound scheduled yet.  When you respond by saying that you don’t plan to utilize ultrasound technology unless it becomes medically necessary, they cock their heads, look at you funny, and respond with a suspicious “huh!”

Shaevel continues: 

When Nancy Wainer and I wrote “Silent Knife” in 1983, we hoped our work would reverse the trend and give women confidence in their bodies’ innate ability to birth their babies. If this trend of surgical intervention in the natural process of childbirth continues, the only women who will birth their babies naturally 50 years from now will be those who don’t make it to the hospital in time for their caesareans.

Some women are finding ways to become more confident in their bodies.  I joined the International Cesarean Awareness Network (ICAN) which greatly increased my confidence and understanding that a repeat cesarean would likely be unnecessary.  However, the doctors will always find a way to rob us of our confidence.  One ICAN list member was told early on in her pregnancy that s/he was supportive of her choice to VBAC.  Now at 36 weeks she’s been told to schedule a repeat cesarean.  This is not an uncommon story.

Here are my thoughts on how/why this keeps happening to women who desire vaginal birth after a cesarean (VBAC).  Perhaps the doctor just wants the business and thinks s/he will be able to change the patient’s mind along the way?  Perhaps the doctor believes in a woman’s choice but loses confidence along the way?  Perhaps in losing confidence in the mother along the way, the doctor is thinking about the legal consequences of not performing an elective repeat cesarean?  Perhaps the doctor, losing confidence along the way or thinking s/he can coerce the patient into surgery, also has the $$ in his/her eyes since surgical birth costs so much more than vaginal birth?  Perhaps the doctor knows that VBAC labor can take longer, and since s/he will have to be more readily accessible thanks to ACOG directives, s/he pushes for the quicker solution – major abdominal surgery?  Perhaps the doctor is more afraid of the uncertainty of normal (as in natural) birth because s/he is not familiar with it versus that which s/he is trained to do – perform surgery?

Shaevel’s letter was formed in response to this recent Boston Globe article.  Here are a couple of important points to consider from the article:

“It’s important for us to step back and say, ‘Why is this happening, and is it in the best interest of the public?’ ” said [the state's secretary of health and human services, Dr. JudyAnn] Bigby, whose research before entering state government had focused on women’s health issues at Brigham and Women’s Hospital. “This is not a minor surgical procedure; it’s a big deal. We need to understand why this trend continues.” [emphasis mine]

She is “sufficiently alarmed” that her state’s cesarean rate now eclipses the national average of 31.1%.

Obstetricians’ fears of lawsuits may also fuel some of the increase.

“There’s no doubt about the medical-legal burden; the litigious nature of society has an impact on this,” said Dr. Fred Frigoletto, chief of obstetrics at Massachusetts General Hospital. “Very few obstetricians have been litigated because they did a C-section. But they’re always litigated because they didn’t do one.”

Fear of litigation is NEVER an appropriate motivator for medicalized childbirth.  Interventive practices are only appropriate when there is sound evidence of need.  Basing medical opinion, advice, and practices on a fear of litigation is unethical and violates the oath and creed to “first do no harm” that all doctors agree to when they become registered practitioners.

It once was popular to deliver subsequent babies [following a cesarean] by vaginal birth, but by the late 1990s the practice began to fall out of favor because of potential risks.

Potential risks – yes, it is possible that a woman’s uterus may rupture during labor.  The risk of rupture may be as low as .5%, and any doctor who puts forward a rate of greater than 1% should be asked for the research to support such a statistic.  Avoiding induction and augmentation of labor and having continuous labor support (an experienced doula and/or midwife) will help VBAC moms achieve their goals.

Anyone who doubts the importance of natural childbirth for both mother and child should register for the “What Would Mammals Do” webinar through Conscious Woman

One response to “Too Late for Natural Birth?

  1. NEW YORK – When the Golden Rule Insurance Co. rejected her application for health coverage last year, Peggy Robertson was mystified. “It made no sense,” said Robertson, 39, who lives in Centennial, Colo. “I’m in perfect health.”

    She was turned down because she had given birth by Caesarean section. Having the operation once increases the odds that it will be performed again, and if she became pregnant and needed another Caesarean, Golden Rule did not want to pay for it. A letter from the company explained that if she had been sterilized after the Caesarean, or if she were over 40 and had given birth two or more years before applying, she might have qualified for coverage.

    Robertson had been shopping for individual health insurance, the kind that people buy themselves. She already had insurance but was looking for a better rate. After being rejected by Golden Rule, she kept her existing coverage.

    With individual insurance, unlike the group coverage usually sponsored by employers, insurance companies in many states are free to choose the people and conditions they cover, and base the price on a person’s medical history. Sometimes, a past Caesarean means higher premiums.

    Although it is not known how many women are in Robertson’s situation, the number seems likely to increase, because the pool of people seeking individual health insurance, now about 18 million, has been growing steadily – and so has the Caesarean rate, which is at an all-time high of 31.1 percent. In 2006, more than 1.2 million Caesareans were performed in the United States, and researchers estimate that each year, half a million women giving birth have had previous Caesareans.

    “Obstetricians are rendering large numbers of women uninsurable by overusing this surgery,” said Pamela Udy, president of the International Caesarean Awareness Network, a nonprofit group whose mission is to prevent unnecessary Caesareans.

    Although many women who have had a Caesarean can safely have a normal birth later, something that Udy’s group advocates, in recent years many doctors and hospitals have refused to allow such births because they carry a small risk of a potentially fatal complication, uterine rupture. Now, Udy says, insurers are adding insult to injury.

    Not only are women feeling pressure to have Caesareans they do not want and may not need, but they can also be denied coverage for the surgery.

    “You have women just caught in the middle of this huge triangle of hospitals, insurance companies, and doctors pointing the finger at each other,” Udy said.

    Insurers’ rules on prior Caesareans vary by company and also by state, because states regulate insurers, said Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade group.

    Some companies ignore the surgery, she said, but others treat it like a pre-existing condition.

    “Sometimes the coverage will come with a rider saying that coverage for a Caesarean delivery is excluded for a period of time,” Pisano said. Sometimes, she said, applicants with prior Caesareans are charged higher premiums.

    “In many respects it works a lot like other situations where someone has a condition that will foreshadow the potential for higher costs going forward,” Pisano said.

    Her group has reported that although most Americans with health insurance, 160 million, have group plans through employers, the number needing individual policies will probably keep rising, because more people are becoming self-employed or taking jobs without health benefits.

    Blue Cross Blue Shield of Florida, which has about 300,000 members with individual coverage, used to exclude repeat Caesareans, but recently began to cover them – for a 25 percent increase in premiums for five years.

    © Copyright 2008 Globe Newspaper Company.

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