Birth Action Coalition Our Bodies, Our Babies, Our Births

Douglas H. Kirkpatrick, MD, President
The American College of Obstetricians and Gynecologists
PO Box 96920
Washington, DC  20090-2188

June 23, 2008

Dear Dr. Douglas H. Kirkpatrick:

In the summer of 2007, I chose to have a VBAC homebirth after two prior cesareans.  It was a fabulous, completely uncomplicated, and easy homebirth VBA2C.    If I had followed standard protocol and ACOG guidelines, I would have had a major surgical birth, and all the significant risks that come along with major surgery instead of the quick and easy recovery I experienced.  My wonderful VBA2C has heightened by concern regarding current ACOG policies that I believe are harming women and stripping women of a basic reproductive right – the right to attempt a vaginal delivery.

I ultimately chose a homebirth because I was scared of laboring and attempting delivery in a hospital given the current completely unsupportive climate among OBs for vaginal birth after cesarean, especially multiple cesareans. The truth of the matter is that the written policy at my local hospital, at least at my time of delivery (July 2007), clearly stated that I "was not a candidate for a trial of labor" simply because I had two cesareans.  Plus, that is the official policy of ACOG.  I didn’t know who I would face in labor, or what pressure I would receive to be forced into an unnecessary cesarean if I actually came into a hospital.  So I chose to stay home to have my baby.  I am not alone. I am on a number of VBAC e-mail lists and discussion groups, and there are thousands of women in America choosing a VBAC homebirth because ACOG policies make VBAC hospital births extremely difficult or impossible.

I am writing to ask for your assistance in getting ACOG to reverse their draconian VBAC policies that have NOT improved the outcomes of mothers or babies[i], but:

1. Led to an alarming increase in unnecessary cesareans by virtually eliminating VBACs (latest VBAC figure is an astonishingly low 9.2%)[ii]
2. Led to over 300+ hospitals in America "banning" VBACs[iii]
3. Led to malpractice insurance carriers not covering doctors who perform VBACs – this has caused a particularly dire situation in Oklahoma where the vast majority of doctors in the entire state have stopped taking VBACs
4. Maternal death is on the rise in America for the first time since 1977 – the increase in cesareans are one possible cause[iv] [v]
5. More women being forced, against their will, into major surgery, and consequently, being forced to accept the risks of major surgery whether they want to or not
6. VBAC homebirths have dramatically increased – thousands of women are being forced to birth at home, unattended, because no obstetrician is willing to attend their VBAC births

Based on the comments I read on the numerous VBAC discussion lists, there is a general feeling among many women desiring VBACs that the current ACOG policies have nothing to do with protecting the best interest of women, but rather, are based on protecting the best interests (time and money) of ACOG’s doctors.  A growing number of women believe the ACOG policies are intended to make birth more convenient for OBs, as scheduled cesareans are usually less time and occur during weekday business hours, and also generate far more money than a vaginal birth.  I certainly don’t believe this is the case for most OBs, but again, the current policies of ACOG do not seem to reflect the medical literature available showing that VBACs are safe, even after multiple c-sections, and that increasing number of c-sections carrying alarmingly higher risks for women.  The Landon study (2006) showed a uterine rupture rate of .7% for single prior cesarean women and .9% for multiple prior cesarean women, statistically insignificant.[vi]  The Nisenblat study (2006) showed that women undergoing a third or higher cesarean faced an 8.7% risk of a "major complication."[vii]  A number of studies also show that many ruptures are linked to induction[viii], and that uterine rupture rates in women who go into spontaneous labor are only about .4% - an extremely small risk.[ix]

When I was pregnant with my third child, I was sure that given the new research, ACOG would be issuing a new VBAC policy statement easing their restrictive guidelines, and even encouraging VBACs in otherwise low-risk women, even those with multiply prior cesareans.  My VBA2C baby is almost a year old, and this still hasn’t happened.

There are two very ironic things about the current ACOG policies that restrict VBACs for women – 1. ACOG seems to support a woman’s right to "choose" when it comes to elective cesareans, yet it does not support a woman’s right to "choose" vaginal birth, and 2. Uterine ruptures, albeit very rare when induction agents are not used, can usually be medically managed in a hospital setting, yet the restrictive policies are forcing thousands of women to birth at home, without access to immediate care in the very rare event of an emergency.

Ultimately, ACOGs policies are not helping women.  I believe they are reducing patient access to care, stripping women of a basic reproductive right, and they are making women less safe.

It is my sincerest hope that you will work to reverse the restrictive VBAC policies, bringing true birth choices back to prior cesarean section women, and ultimately improving the health and well being of women seeking VBACs.

Please consider sharing my letter and story with any ACOG officers and fellows you feel might be willing to help improve the situation for VBAC and VBAmC women in America.

 Sincerely,

Amber L. Craig

[i] J. Zweifler, et al., "Vaginal Birth after Cesarean in California: Before and After a Change in Guidelines," Annals of Family Medicine 4, no. 3 (2006): 228-234.

[ii] Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2005. National Vital Statistics Reports 55, no. 11. December 28, 2006.Available at: www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_11.pdf.  Retrieved April 21, 2008.

[iii] International Cesarean Awareness Network. Hospital VBAC Bans Push Record-High Cesarean Rates Bans Force Women into Unnecessary Surgery. November 23, 2004. Available at: http://www.vbac.com/pdfs/ICANrecordhughcesareanrates.pdf. Retrieved April 21, 2008.

[iv] Miniño AM, Heron MP, Murphy SL, Kochankek, KD. Deaths: Final Data for 2004. National vital statistics reports; vol 55 no 19. Hyattsville, MD:  National Center for Health Statistics. 2007. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_19.pdf. Retrieved April 21, 2007.

[v] Ogburn Jr. P. Deadly Deliveries. New York Times. October 14, 2007. Available at: http://www.nytimes.com/2007/10/14/opinion/nyregionopinions/14CIogburn.html. Retrieved April, 21, 2007.

[vi] Landon MB, Spong CY, Thom E, Haut JC, Bloom SL, Varne MW, Moawad AH, Steve N. Caritis SN, et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol 2006; 108:12-20.

[vii] Nisenblat V, Barak S, Griness OB, Degani S, Ohel G, Gonen, R. Maternal complications associated with multiple cesarean deliveries. Obstet Gynecol 2006; 108: 21-26.

[viii] D. J. Ravasia, S.L. Wood, and J.K. Pollard, "Uterine Rupture during Induced Trial of Labor among Women with Previous Cesarean Delivery," American Journal of Obstetrics and Gynecology 183,  no. 5 (2000): 1176-1179.

[ix] G. C. S. Smith, et al., "Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery,"
New England Journal of Medicine 352, (21 April 2005):1718-1720.