Risking the Future: Repeat C-Section or Vaginal Birth?


Now there is one more reason for women to consider their childbirth options and to fight for their right to thorough, unbiased and accurate information when thinking about what kind of birth for which they’d like to plan.  According to US News & World Report, a new study undertaken at the University of Colorado, Denver, School of Medicine, found that repeat cesarean sections are not only riskier to newborn health than VBACs (vaginal birth after a previous cesarean section) but also result in a more costly birth:

Babies delivered by elective, repeat cesarean section delivery are nearly twice as likely to be admitted to the neonatal intensive care unit (NICU) than those born vaginally after the mother has previously had a c-section…

"In addition," noted Dr. Beena Kamath, the study’s lead author and a clinical
instructor of pediatrics at the University of Colorado School of
Medicine:

the cost of the birth for both mother and infant was more expensive in the elective repeat c-section group compared to the vaginal birth after c-section (VBAC) group.

There has been a long-standing debate over the safety of VBAC childbirth to women as compared to repeat c-sections, one that has become more heated as maternal
health/midwifery/out-of-hospital birth advocates have pushed back on "conventional wisdom" about birthing choices. Midwives have long asserted, with much evidence to back them up, that VBACs are not only safe in low risk pregnancies but in fact safer for women than a repeat c-section. 

Though over the last few years some use the results of studies to "prove" that VBACs are not as safe for the mother (based on the fact that uterine rupture can occur during a VBAC), in fact those studies have been repeatedly dissected and disputed. There are risks associated with VBACs, but the evidence shows, according to Childbirth Connection:

If you do not have a clear and compelling need for a cesarean in the present pregnancy, having a VBAC rather than a repeat c-section is likely to be:

  •     safer for you in this pregnancy
  •     far safer for you and your babies in any future pregnancies

As Seattle-based, Certified Professional Midwife and Seattle Midwifery School instructor, Tracy Cooper tells me,

What we know about VBAC is that there is about an 85 percent success rate if a woman
is really supported – if doctor or midwife believes in giving the
woman a fair shot at that.  A vaginal birth is still safer than a
c-section. C -sections are stil major surgery, with risk of blood loss and
infection, as well as secondary trauma to other organs. The same is also true for
a VBAC. Even with the risk of uterine rupture, a VBAC is stil safer than
a repeat C-section. Not only is it safer, but it’s more cost effective to
not have internventions, NICU costs, etc.

The rates of c-sections in this country overall (planned and unplanned), have risen dramatically in the last few years.  Now, 1 out of every 3 births are via cesarean section. And having one c-section is a predictor for future birth as well. According to the study, women who have a c-section for their first birth have a 90 percent chance of delivering via c-section again. 

"It’s one of the reaons why it’s so important to reduce the primary c-section rate. Once you’ve had that primary c-section, you’re more likely to have a secondary c-section," says Cooper.

US News & World Report writing on the study’s findings of initial and future c-sections quotes Dr. Alan Fleischman, senior vice president and medical
director for the March of Dimes, based in White Plains, N.Y.:

The decision to have your first c-section is very important. There should be a clear medical indication [because] your first may dictate subsequent [delivery methods].

What we know is that, making allowances for the overuse of medical interventions during childbirth, vaginal birth in the United States carries inherently less risk to the mother than c-sections do and can lay the foundation for more choices for future childbirth options as well. Now, with this new study, the evidence also suggests that babies born via c-section have poorer health outcomes than do newborns born vaginally. 

(Dr. Beena) Kamath’s team found that 9.3 percent of the c-section babies were admitted to the NICU, but just 4.9 percent of the vaginally delivered babies were. A nd while 41.5 percent of the c-section babies required oxygen in the delivery room, 23.2 percent of the vaginally delivered babies did. After NICU admission, 5.8 percent of the c-section babies needed the oxygen compared to 2.4 percent of the vaginally delivered babies.

These are some startling statistics – almost half as many newborns birthed vaginally were admitted to NICU (Neonatal Intensive Care Unit) as those birthed through cesarean section. In addition, both the length of the hospital stay and the total costs were larger for women undergoing c-sections than for women who birthed vaginally. The group with the worst health and economic outcomes were actually the "failed VBACs" but, as Cooper points out:

The group that needed the most advanced levels of respiratory support with bag and mask and intubation was actually the failed VBAC group–but this was the smallest group, and still, if you combined all the intended VBACs, their outcomes were overall still better than the intended c-section group.  Also, although the financial costs were highest in the group of "failed VBACs", overall the intended VBAC group’s costs were still less than the intended c-section group.

There are the concrete take-aways of a study like this: newborns suffer from fewer respiratory and other health complications, hospital stays are shorter and less costly and the woman’s health outcomes are generally more positive as well. 

And there are critically important peripheral or unintended conclusions to draw from this kind of an exploration as well. Women need to know that having a vaginal birth after a prior cesearean section is possible, says Dr. Fleischman with the March of Dimes. Many hospitals and providers currently will not do VBACs because of perceived risks which is why, as Tracy Cooper tells me:

The more studies we do and the more we push back, the more we say, actually – no – VBAC is safer for moms and babies, the better it will be for women! There needs to be that voice that people can hear loud and clear so doctors and hospital staff feel supported to offer this and women have access to a full range of options.

 

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To schedule an interview with Amie Newman please contact Communications Director Rachel Perrone at rachel@rhrealitycheck.org.

  • invalid-0

    You certainly see more and more medical research that reaches the same conclusion. However, there are other external forces at work. A few years ago our local hospital quit offering VBACs because their insurance company insisted they quit offering this service. The decision was made by the MBAs, not the MDs or the women involved. Shouldn’t we be after the lawyers and insurance companies as well?

    • invalid-0

      how many can i have. c setion

  • http://momstinfoilhat.wordpress.com invalid-0

    Not only was this study reviewed in US News & World Report, but it was published in this month’s issue of Obstetrics and Gynecology, which is the journal of the American College of Obstetrics and Gynecology (ACOG).

    This is not the first article with significant evidence supporting VBAC that they have printed recently.

    What is a shame is that hospitals, doctors, and as noted above, insurance companies are refusing this option, even though all the evidence points that it is a safer and better health decision and the intervention of cesarean is more dangerous. This happened to a friend recently, and she showed up in labor the day before her scheduled repeat section. And they still forced her to have a cesarean, even though that flies in the face of the evidence even more.

    What is ironic is that it is ACOG’s own position statement on VBAC, recommending that a team be available for immediate cesarean, is part of the justification for refusing VBACs.

    PS The formatting on these comments is awful. I clicked on formatting options the first time I attempted to reply, and I lost my comment. I even added line breaks as directed, and I still have no formatting.

  • invalid-0

    Thank you for writing this, Amie. This is a case that sorely needs to be made. When biomedical practitioners claim the weight of science is on their side, but it is clearly not, how can women access true informed choice? They can start here, at RHRealityCheck.

    Thank you again.

  • invalid-0

    1. just because a newborn ends up in the NICU doesn’t mean it is worse for the patient. Most likely they are admitted for TTN (transient tachypnea of the newborn) which is wet lungs which is a result of not having its lungs squeezed out of the liquid while it passed through the birth canal.

    same for needing oxygen after c-section. It’s just an expected consequence of C-section. I don’t think this results in any long term consequences for the baby.

    2. the statistics do show double the risk of going to the NICU, but again, this is small percentage increase. from 4.9 to 9.4 or 4.5% difference.

    3. There is definitely an increased cost, but for those of us who have had c-sections, I think it is obvious why we have repeat c-sections, because it is so much better than going through labor, worrying about episiotomy and risking 3rd degree vaginal/anal ripping/laceration. and you get to stay in the hospital for 4 days instead of 48 hrs.

    also you can avoid possible perinatal transmission of herpes, HPV and HIV

    what is the risk of uterine rupture with VBAC? if you are the one with the rupture, that risk is then 100%. What is the risk of rupture with c-section…?

    As a pediatrician, I cannot recommend c-section. but as a woman to another woman, I would strongly recommend a c-section. I see the c-section as a liberation of women from having to risk damage during childbirth and look forward to the future of artificial uteruses.

  • invalid-0

    Sophia,

    re: your point #2. From 4.9% to 9.4% is not a small percentage increase. It’s almost double. The absolute numbers are still not large, but almost double is not trivial.

    re: your point #3. Speak for yourself. I’ve had repeat c-sections, because my doctors bullied me into them, including using threats to withdraw care if I didn’t do what I was told.

    “Getting” to stay in the hospital longer was not a plus. Being in the hospital with a new baby sucks.

    There was no possibility of transmitting herpes, HPV or HIV to my baby, because I don’t have any of those things to transmit. (I also wonder if swallowing blood, as my third child did during his section, could pass those on.)

    It’s true that I don’t have to worry about an abusive doctor cutting an unnecessary episiotomy, which is good. However, major surgery to avoid possible tears/lacerations doesn’t make a lot of sense to me. Four years out from my third section, I still can’t feel my bladder, due to nerve damage – from my completely uncomplicated surgery.

    I’ve had trouble with infertility and miscarriage since my first section. I face increased risks of stillbirth and miscarriage in all future pregnancies. My future birth options are GONE. I also do have some increased risk of rupture, despite planning a repeat section. The risk comes from the scar, not from the VBAC.

    As a woman to other women, I strongly recommend avoiding a primary section, if at all possible. Mine has been screwing up my physical and reproductive health for over 16 years.

  • invalid-0

    Unless absolute needed, I would never deliver a baby via c-section.

    The vajayjay comes back to normal after six weeks anyway.

  • invalid-0

    Did you say you look forward to artificial uteruses?

    Seriously, major surgery is being sold to women as a convenience. Get the facts- make informed choices!

  • http://www.firstbathrooms.co.uk invalid-0

    thanks for writing this blog. there is a lot of information contained which i wasnt aware off.

    i think natural birth all the time.

    jen x

  • http://strongandfit.net invalid-0

    I heard somewhere that many doctors do c-sections because of lawsuits–they are afraid of complications that may occur during vaginal deliveries. Seems this article would at least help to challenge the notion that c-section is safer.