Childbearing women have a fundamental right to choose how, where and with whom they want to give birth, but in the United States women who choose to labor for a VBAC (known as TOLAC, trial of labor after cesarean) in a hospital are often being denied that right. Effectively giving thousands of women no choice but to concede to major abdominal surgery that put women and babies at risk for complications and mothers with multiple cesareans at risk for placental problems.
According to the National Institutes of Health (NIH), since 1996 about one third of hospitals and one-half of physicians have stopped providing care for VBAC. In 1996 the VBAC rate in the U.S. was 28%. Today it’s less than 10%. A report on the trends of home vaginal birth after a cesarean indicates that denial of access to care for VBAC has prompted an increasing number of women to labor for a VBAC at home.
Three out of four women who labor for a cesarean do give birth vaginally and the risks of major complications from laboring for a VBAC are less than 1%. The reason given by physicians and institutions to deny medical care for these expectant mothers have no foundation in science. Denying care for VBAC also presents a clear conflict of interest for providers and institutions who want to protect themselves from a potential medical malpractice suit, a frequent explanation given to deny care.
Physicians who do want to support these mothers are forced to pay additional malpractice insurance premiums and are often discouraged to support women who want to labor for a VBAC by their hospital’s administration.
Here is what the National Institutes of Health say about laboring for a VBAC:
Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.
Women who have a trial of labor, regardless of ultimate mode of delivery, are at decreased risk of maternal mortality compared to elective repeat cesarean delivery.
Comparing mothers (pregnancy with all gestational ages) with a uterine scar who labored for a VBAC with mothers who had a scheduled repeat cesarean the NIH found:
|Maternal Mortality at Delivery||Per 100,000 live births|
|Women who labored for a VBAC||
|Women who had a planned repeat cesarean||
For low-risk women, the risks of laboring for a VBAC are the same as for any other woman giving birth for the first time.
According to the NIH, these are the odds of a uterine rupture in low-risk women laboring for a VBAC compared to other unpredictable complications that also require an emergency cesarean.
|Per 1,000 women who labor||Risk for Complications|
|Uterine rupture (separation of uterine scar)||
|Shoulder Dystocia ( baby’s shoulders are too wide to fit through the pelvis)||
|Placental Abruption ( placenta separates from the uterus before the baby is born)||
|Umbilical Cord Prolapse (umbilical cord precedes the baby’s head through the cervix)||
The risk of laboring for a VBAC is the possibility of a uterine rupture, the separation of the uterine scar from the previous cesarean. It is a serious medical emergency that occurs in less than 1% of VBAC labors and requires an immediate cesarean. Hospitals who deny women the option to labor after a cesarean say they cannot provide an “immediate” emergency cesarean as recommended in the American College of Obstetricians and Gynecologists (ACOG) guidelines for VBAC (Practice Bulletin #115) .
But, the National Institutes of Health concluded that there is no evidence to support ACOG’s selective safety recommendations for VBAC. The “immediately available” recommendation was based on consensus and expert opinion rather than strong support from high-quality evidence. Dozens of maternity care organizations and individuals also objected to the restrictive guidelines.
Women giving birth for the first time are also at risk for unpredictable complications that require an emergency cesarean. However, they are not denied medical care nor are they told that the hospital cannot provide an emergency cesarean, should they need one.
The NIH encouraged leaders in maternity care and insurance companies to work together to change the status quo and give more women access to medical care for those who want to labor for a VBAC.
ACOG and the Society of Maternal-Fetal Medicine recently admitted in their Safe Prevention of the Primary Cesarean guidelines that too many cesareans are being performed exposing mothers and babies to avoidable harms without improved outcomes. Providing low-risk women medical care to labor for a VBAC can reduce their exposure to the harms of a cesarean section.
Denial of Informed Consent and Informed Refusal
Physicians have an obligation to provide women with a prior cesarean with information about the benefits and risks for both repeat cesarean and for a VBAC. Women have the right to an informed consent or informed refusal of either options based on the accurate information provided.
ACOG’s Committee Opinion on Ethics (#439) states:
Seeking informed consent expresses respect for the patient as a person; it particularly respects a patient’s moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities, and to support of the patient’s freedom to make decisions within caring relationships.
Refusing to provide medical care for women who want to labor for a VBAC and forcing them to “consent” to a repeat surgery denies their right to bodily integrity, self-determination and the freedom to make their own healthcare decisions. It also questions the integrity of that “caring relationship.”
Physicians have an ethical obligation to provide the best care possible for their patients including the primary ethical obligation, First Do No Harm.
Many hospitals and providers have found a way to safely support women who want to labor after a cesarean. All it takes is the will to make that happen.