The NJ Star Ledger addressed the difficulty in finding providers for vbac in NJ:
After C-section, some mothers dare defy trend
Sunday, July 01, 2007
BY CAROL ANN CAMPBELL
Star-Ledger Staff
Weeks after her Caesarean section, Dana Roberts could not bend over because she hurt too much. She could not laugh, and even with narcotic painkillers it felt as if her stomach was being scratched with sandpaper. They said, 'We'll do a 'C' to get the baby out.' They made it sound so easy," the Manville resident said. "But they didn't tell me I would watch everyone else take care of my baby. That I couldn't count her toes. That for weeks it would feel like my stomach was exploding."
Roberts, 32, is pregnant again and desperately wants to avoid a surgical delivery for her second child. But her desire to give birth vaginally this time pushes against a trend in New Jersey. Over the past decade, the number of women having a vaginal birth after a Caesarean -- a VBAC -- has plummeted, a Star-Ledger analysis of state health data found.
Some doctors refuse to perform VBACs. A handful of hospitals refuse, too.
A decade ago, 34 percent of New Jersey women who had Caesarean sections delivered another child vaginally, the analysis shows. Last year the figure had shrunk by three-quarters to 8.5 percent. At many hospitals, just 2 percent to 4 percent of women with previous Caesarean sections deliver babies without surgery.
To supporters of VBACs, the dramatic shift signifies a sharp increase in the medical management of birth, and a lack of choices for women. To many doctors, though, avoiding VBACs is simply safer because otherwise, on rare occasions, the mother's uterus can rupture at the site of the previous incision -- a potentially catastrophic complication for mother and child.
These doctors say the rise of VBACs in the 1990s was fueled by health insurers seeking to save money on surgeries, not by medical evidence, and that anything less than a perfect birth outcome today could result in multimillion-dollar lawsuit against the physician.
Louis A. Schwarz, an obstetrician in Hackensack said he will not do VBACs. When the uterus breaks, the doctor likely gets sued," he said, "but that's not why I don't do them. I've seen bad results from VBACs, and if you've seen those bad results you don't want to go back. Why would I double the risk of complication for my patient?"
Schwarz cited an influential 1996 New England Journal of Medicine study that found the risk of major complications doubled for prior-Caesarean mothers who went through labor, compared with those who underwent a scheduled repeat C-section. In the study of 6,138 women with prior Caesareans, 3,249 women tried to give birth vaginally. Ten women in the group experienced uterine rupture and two of the babies died because of the rupture. No mother in either group died.
UNWELCOME
Some hospitals turn away women who want VBACs.
Hackettstown Community Hospital tells women upfront that it no longer delivers VBAC babies.
"We feel this is a high-risk delivery better performed in a tertiary (high-level) facility," a statement from the hospital said.
Proponents of VBACs argue that the risk is slight and the rupture often can be managed. They note that Caesarean section is major abdominal surgery that carries its own risks to the mother, such as infection, blood clots and hemorrhage. In addition, they say a vaginal birth allows women to immediately bond with and care for their new baby.
"Birth has become more medically managed today than even a decade ago, and maternal and neonatal outcomes have not improved," said Billee Wolff, a nurse and childbirth educator in Bergen County.
Wolff said some women are seeking out VBAC-friendly doctors and midwives. "Some doctors say they do VBACs -- but if the baby hiccups during labor, the mother is off to the O.R.," she said.
For Dana Roberts, finding a practitioner who supports VBACs meant driving an hour from home. She sought out Midwifery Care Associates in Pennington, which says it has assisted in 44 VBAC attempts, 42 of them successful, in the past 17 years. The practice's overall Caesarean rate is just 5 percent.
"We've seen an increase in the past year of women who can't get VBACs near their home, so they are coming to us," said Louise Aucott, a certified nurse midwife with the practice. The midwifery practice does many home births but will assist with VBACs only at the Capital Health System Mercer Campus, in Trenton
.
"This should be a choice that women make after considering all their options," said Aucott. She said Roberts has an "excellent" chance of delivering her baby without surgery.
Roberts, a food scientist, said she is looking forward to a more natural approach. She wants to hold her baby right after birth -- something she could not do after her Caesarean. "I've learned what I can do to make a difference this time," she said.
SCAR PRESSURE
Meanwhile, the statewide Caesarean rate -- the highest in the nation -- continues to rise. More than 37 percent of women who gave birth in New Jersey last year did so surgically, according to state health statistics. At some hospitals, nearly half of all births are surgical.
The American College of Obstetrics and Gynecology continues to support a woman's right to choose a VBAC under the right circumstances, said Paul Stumpf, the group's New Jersey representative and the vice chairman of Ob-Gyn at Newark Beth Israel Medical Center. In the 1960s and 1970s almost no physicians did VBACs, he said.
"During a Caesarean, you cut the mother's abdominal wall and uterus. You cut through muscle. You can sew the muscle back together, but the scar is never as strong as intact muscle," he said. During a subsequent pregnancy and labor, the scar is under tension.
"But we found in the 1980s that you could monitor patients and there was a very low risk of bad things happening," he said.
Stumpf said the national VBAC rate reached 27.5 percent in 1995. But some women had ruptures, and publicity over these disastrous outcomes chilled enthusiasm for VBACs. The national rate is now 9.2 percent, he said.
Merely being pregnant puts pressure on the Caesarean scar. Stumpf said data from the college of obstetrics say the risk of rupture is 1.6 for every 1,000 women who have elective repeat Caesareans; 5.2 for every 1,000 women who go into spontaneous labor; and 7.7 for every 1,000 women whose labor is induced with medication.
"The chance of rupture is very small, but it can be very bad for the baby," Stumpf said. "Most people think the risk of losing a baby, even a tiny risk, is not acceptable. ... But there are risks to C-section, too. There is no perfect choice."
Joseph Ramieri, chairman of obstetrics and gynecology for Atlantic Health System, which operates Morristown Memorial Hospital, said he has seen a rise in women who need hysterectomies because of repeat Caesareans.
"It's okay to do one or two C-sections, but when you get into three or four, it's another issue," he said.
He said the overall increase in Caesareans partly stems from a lack of training among today's physicians in rotational maneuvers and forceps.
"When I was a resident we had a 5 percent C-section rate," he said.
Many physicians who perform VBACs ask women to sign a consent form that outlines the possibility of death or brain damage to the baby. Despite the fear of liability, few of the physicians interviewed for this story knew of specific VBAC lawsuits.
John Blume, an attorney with Blume Goldfaden Berkowitz Donnelly Fried & Forte, the state's largest medical malpractice law firm, did not know of any VBAC-related lawsuits filed by his firm. He said lawsuits are not driving the decline in VBACs.
"There is increased risk with VBACs," he said.
BACK TO THE NATURAL
Some women who are trying to reverse the trend are lobbying in Trenton for legislation to require practitioners to release their VBAC and C-section rates to potential patients.
"We advise women to seek out practitioners with a 10 to 15 percent C-section rate," said Stacey Gregg, a childbirth educator and spokeswoman for the International Cesarean Awareness Network-New Jersey. On its Web site, the group calls VBAC safer than repeat Caesarean for both mother and baby -- and says modern obstetrical practice is forcing women to have unnecessary surgery.
One practice in Lakewood is bucking the trend. Women's Health Associates has a Caesarean rate of 4 percent, according to Christian Hoffman, one of four obstetricians in the group, which includes a perinatologist (a specialist in maternal and fetal health) and five midwives.
The practice has delivered 317 VBAC babies, with a success rate of 86 percent, he said.
Hoffman said the practice had one rupture, which was handled well, and mother and baby "did great."
He said inappropriate use of Pitocin, a drug to induce labor, and epidurals, or spinal anesthesia, can inhibit the natural process of labor and lead to Caesarean sections.
"We try to be as natural as possible," he said.
The practice primarily sees Orthodox Jewish women, Hoffman said, and they often are motivated to give birth vaginally so they can have large families.
TheLakewood practice reflects how culture and physician practices can affect birthing methods.
"Their bodies are no different than anyone else's," Hoffman said. "Many of our patients very much want VBACs, and we don't have a problem with that."
For 10 years of hospital-by-hospital data, go online to www.nj.com/news/bythenumbers/
When her doctor said it was time for a C-section, Jaime Rowlyk of Woolwich, mom of now-2-year-old Alden, tried to negotiate. “Can you give me five minutes to think about it?” she asked. The doctor gave her just one. After 12 hours of labor with virtually no dilation and soaring blood pressure, Jaime’s body was beginning to break down; there wasn’t time for back and forth. In retrospect, Jaime believes the C-section saved her life.