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Women around the country are finding that more and more hospitals that once allowed vaginal birth after Caesarean, or VBAC (commonly pronounced VEE-back), are now banning it and insisting on repeat Caesareans.

About 300,000 women a year have repeat Caesareans (1/3 of all Caesareans performed/yr). The rate of vaginal births in women who have had Caesareans has fallen by more than half, from 28.3 percent in 1996 to 10.6 percent in 2003. Major medical centers still perform such deliveries, but many smaller ones have banned the practice, saying that it is riskier than once thought and that they do not have the staff to handle emergencies that may arise.

Obstetricians estimate that there is a 1 percent chance that the old Caesarean scar will cause the uterus to rupture during a subsequent labor, which can cause dangerous blood loss in the mother and brain damage or death in the baby.

A decade ago, the risk of rupture was thought to be 0.5 percent or less. The percentage of babies injured after a rupture is not known but is thought to be low. Many women are willing to take the risk, and the hospitals’ stance has become a charged issue, part of a larger battle over who controls childbirth.

Some women say their freedom of choice is being steamrolled by obstetricians who find Caesareans more lucrative and convenient than waiting out the normal course of labor. Doctors say their position is based on concern for patients’ safety.

On a practical level, many women prefer vaginal birth because they recover more quickly and with less pain than they do from a Caesarean. In addition, each Caesarean increases the risk of complications in the next pregnancy, so women who want more than two or three children often hope to avoid the operation.

Some doctors and hospitals freely acknowledge that fear of being sued has driven their decisions. Hospitals say they cannot comply with guidelines issued in 1999 by the American College of Obstetricians and Gynecologists, which call for a doctor to be available “immediately” throughout active labor during such a birth, to perform an emergency Caesarean if needed.

A telephone survey by an advocacy group, the International Cesarean Awareness Network, found 300 hospitals around the country that had quit offering the deliveries.

Some doctors worry that banning the procedure may lead women who have had Caesareans to try giving birth at home or in birthing centers that are not equipped to perform an emergency Caesarean if it becomes necessary.  A solution may be that hospitals that do not allow normal birth after a Caesarean should refer women to hospitals that do. 

Some women see a Caesarean as having an operation instead of giving birth, and feel it means missing out on life’s most joyful rite of passage. A study published in an obstetrical journal in 1997 found that when women with a previous Caesarean were offered a natural delivery, 30 to 50 percent wanted it. [ NYT: Denise Grady, 29Nov04]