Though the controversy surrounding vaginal birth after cesarean was born out of medical culture, the misgivings about VBACs have taken on a life of their own via word of mouth. It has deeply ingrained itself in the American beliefs about birth. Even in the media, vaginal birth after C-Section is portrayed as a mythical and dangerous goal. Most recently, The Walking Dead invited criticism from the unlikely natural birth and VBAC advocates when they changed a key element of the Walking Dead story line, Lori’s vaginal birth after cesarean section. Characters in the series even led up to her failed trial of labor by saying she may not be able to have a vaginal birth because of her previous C-Section. Though a television show about zombies is hardly the authority on Obstetrics in America, this show and similar portrayals emphasize just how widespread our negative perceptions about vaginal birth after cesareans are.
The history of C-Sections in America is diverse and dates as far back as 1916 with Dr. Edwin Cragin’s maxim, “Once a cesarean, always a cesarean.” (Ugwumadu 2005). The most recent entry in the VBAC timeline, however, is as recent as the late 90’s. From the 80’s through the 90’s, VBACs actually became quite prevalent. However, with the increasing use of labor inductions, most notably a drug called Cytotec, many of the mothers attempting vaginal birth after cesarean were experiencing an alarming rate of Uterine Rupture. Many mothers and babies suffered and even died as a result and, subsequently, many large lawsuits were filed.
As a result of the lower cost of a vaginal birth in comparison with a c-section, a contrasting phenomenon began to occur, mandatory VBACs. Many mothers who were not good candidates for vaginal deliveries or who preferred to have a repeat cesarean were pressured into labors they should have never experienced. With the precarious consequences of poor management, VBACs became quite a liability. Rather then acknowledging the error in the way they were handling these births, obstetric providers, as a whole, lumped VBACs together as an unsafe method of delivery. Moreover, because of VBACs gone bad, malpractice insurance providers began penalizing physicians and care facilities with unscrupulous premiums. Some even refused coverage altogether. The VBAC-lash had officially begun and, consequently, the rate of cesarean birth began to rise at an alarming pace.
Now in 2012, 1 in every 3 births is surgical (Well Rounded Mama, 2009). Despite overwhelming evidence to support the contrary, many OBs refuse to offer trial of labor to mothers who have had even one previous cesarean. Many hospitals have bans against them. We live in an age of defensive medicine.
Despite ethical contradictions to such a practice, skyrocketing costs associated with malpractice insurance, increasing fears of litigation, and insurance providers even refusing to cover physicians and hospitals that offer VBAC births, many doctors have been cornered into a place where they practice defensive medicine. Richard Waldmen , 61st President of the Academy of Obstetrics and Gynecology, was quoted in May of 2010 saying,“ We do not get sued for doing C-Sections; we get sued for doing C-Sections too late.” Though many providers would deny it to your face that they work defensively, The Jaskson Healthcare report cites the overuse of cesarean sections as an effect of the practice. It is estimated that 38% of C-Sections are performed to avoid litigation (Arnold, 2011 ). Furthermore, OBs, more than ever, fear physiological birth. Even in very productive and influential talks about the safety of vaginal birth after C-Sections, professionals in the field look at trial of labor as if it is an experiment that could go terribly wrong, therefore warranting a more cautionary approach. Without a doubt, many advocates and providers argue that it is unethical to make claims with no basis and equally unethical to impose their fears as providers on patients (Vedam 2010). The consequences of these practices extend far beyond monetary cost or even the high cesarean rate itself. Defensive medicine breeds defensive patients.
In my own community, there are only two practices that are home to VBAC friendly providers and only five doctors altogether that openly attend these births in the whole county. This limited choice in birth options violates an obstetrician’s obligation to respect a patient’s autonomy (Charles 2012). Some ethics experts would argue that, despite a care provider’s duty to respect the autonomy of a patient, it is also a provider’s right to self preservation. However, with risk so negligible for most VBACs in contrast to repeat c-sections, it is hard to see exactly what providers have to lose here other than control. With no other procedure, would we be sitting here debating over a patient’s right to refuse the recommended treatment? My own grandmother denied open heart surgery after weighing the risk in conjunction with her advanced age. No doctor threatened her with her own life like OB’s often do with new mothers’ and their children’s.
Because of this refusal of care, many women are pushed to the fringe of culturally acceptable and even safe birth practices. When moms are not treated respectfully, when their bodies are infringed upon by a barrage of interventions they neither need or want, or when they have a traumatic experience in a health care setting, they search out other options. In the last few years, we have seen a marked increase in home births. While many things are undoubtedly at play in the increase, current research suggests women who choose this birth option cite bad experiences with previous deliveries as a large motive in their choice.
Though home birth is and should be considered a valid option for women with low risk pregnancies, the data is clear that many women who choose a home birth do so in response to severe dissatisfaction of the United States’ current maternity system (Faye, Niane, & BA 2011). More troubling still, women who are risked out of VBACs in hospital settings or risked out of midwifery care in birth centers and at home often turn to riskier alternatives, including home births with less qualified attendants or unassisted births at home. It has become the underground secret of birth culture. Many of these women would more than happily deliver in a hospital setting if only they were ‘allowed’ to deliver the way they felt right for them. The fear of being violated in the hospital outweighs their fear of birth complications at home by themselves.
Just as with the increase in uterine ruptures in the 90’s, obstetrics, as a whole, neglects to take any formal responsibility for these trends in birth. They deflect the blame elsewhere and label it as a fad. The first step to fixing a problem is acknowledging that you have one. With a c-section rate over 40% and with American women losing all faith in the maternity system meant to protect them, I would say we most certainly have a problem.
Ugwumadu, A (2005) Does the Maxim “Once a Caesarean, Always a Caesarean” Still Hold True? PLoS Med 2(9):e305
Well-Rounded Mama (2009, March 9). A History of VBACs and Cesareans in the USA [Web log message]. Retrieved from
Arnold, J (2011, January 10). Defending Ourselves against Defensive Medicine [Web log message]. Retrieved from
Feldman, P., Cymbalist, R., Vedam, S., & Kotaska, A. (2010). Roundtable Discussion: “No One Can Condemn You to a C-Section!”. Birth: Issues In Perinatal Care [serial online]. September 2010; 37(3): 245-251. Available from Academic Search Premier.
Charles, S. (2012). The Ethics of Vaginal Birth after Cesarean. Hastings Center Report. [serial online]. July 2012; 42(4): 24-27 Available from Academic Search Premier.
Faye, A. & Niane, M. & BA, I. (2011). Home birth in women who have given birth at least once in a health facility: contributory factors in a developing country. Acta Obstetricia Et Gynecologica Scandinavia. 90(11), 1239-1243 Availiable in Academic Search Premier.