Birth Action Coalition Our Bodies, Our Babies, Our Births

Note: I am putting this up, not because I think people need to write in depth letters like this (shorter is actually probably better) but so that you are aware of what letters Cottage has already received, and in case you would like to see references from studies. -JB

Dear Dr. Soffici,

Thank you for your in depth reply to my letter requesting that Cottage Hospital re-examine its VBAC ban policy. I have spent some time over the last month researching more information about VBAC and some of the things you said. I still have several questions.

Several times in your letter you quoted the 1/200 uterine rupture rate that I used in my letter. However, at one point, you equated the risk of uterine rupture with the ris of fetal death. Among thirty studies comprising 56,300 VBACs, the rate of stillbirths and newborn deaths attributable to uterine rupture was 1 in 3,3001. In another study2, of 4516 women attempting VBAC, there was 1 perinatal death. So the statistic depends on the population studied, but the risk of fetal death due to uterine rupture from a VBAC attempt is on the order of 1/3300, not 1/200. In addition, according to several studies I found, 1/200 is a high estimate of the risk of uterine rupture which depends upon the population studied and induction methods used, and varies between 1/200 and 1/4152. VBACs aside, according to the Center for Disease Control, in 1998 the fetal death rate in the US was 6.7 per 1006.7 live births plus fetal deaths3. In other words, a fetus is approximately 20 times more likely to die from causes other than uterine rupture.

I was surprised to read that even in the absence of VBACs you still see the occasional uterine rupture. I did some reading and found that in a study conducted in California4 "only 34% of uterine ruptures were attributable to labor." In other words, 66% of the women experiencing a uterine rupture after having had a prior cesarean were not in labor when the rupture happened. So, elective repeat cesarean delivery did not prevent the ruptures. Since elective repeat cesarean doesn’t necessarily prevent uterine rupture in the majority of cases, it seems even more important for Cottage Hospital to work to decrease the primary cesarean rate.

In your letter you mentioned the hospital’s "decision to take the safest route and discourage these procedures." I would argue that VBAC is not a procedure and cesarean section is not always the safest route. The safest mode of delivery varies from woman to woman and pregnancy to pregnancy. According to a 2006 study published by the American College of Obstetricians and Gynecologists5, "a trial of labor after cesarean seems to be as safe for the mother and infant as planned cesarean delivery, and the hospital stay is shorter." That is why women should be allowed to make this choice for themselves with their care provider.

In the last paragraph of your letter you mentioned that university hospitals still offer VBAC for patients and for the training of their residents. In the UK where I had my first baby, VBACs are routinely offered, and the National Health Service bases decisions like these on outcomes and research. According to ‘A Guide to Effective Care in Pregnancy and Childbirth’6, a text for obstetricians and midwives in the UK which is the ‘gold standard’ of evidence-based care:

"Overall, attempted vaginal birth for women with a single previous low transverse cesarean section is associated with a lower risk of complications for both mother and baby than routine repeat cesarean section."

"The morbidity (illness) associated with successful vaginal birth is about one-fifth that of elective cesarean. Failed trials of labour, with subsequent cesarean section, involve almost twice the morbidity of elective section, but the lower morbidity in the 80% of women who successfully give birth vaginally means that overall women who opt for a planned vaginal birth after cesarean suffer only half the morbidity of women who undergo an elective section."

In my previous letter, I said I was concerned that if Cottage Hospital cannot meet the staffing standard for VBACs, that means the hospital does not have the ability to perform an emergency cesarean 24 hours a day, seven days per week. I was glad to read that Cottage hospital "is ready to perform emergency cesareans 24x7" and that "Cottage has the ability to mobilize and act quickly when needed." If this is the case, then I still do not understand why VBACs are not being allowed. If we use the uterine rupture rate of 1/200, and the previous figure that 4% of births at Cottage were VBACs before the ban, Cottage would still only expect to see a uterine rupture due to VBAC every 2-3 years and a fetal death due to VBAC every 10 or so. This seems very low to me, and certainly less risky than many of the other births that take place at Cottage due to other complications.

I mentioned in my letter that I was concerned that Cottage Hospital may be understating the risks of cesarean and exaggerating the risks of VBAC. Your response exemplifies my point. In the paragraph responding to my statement, you mentioned only the risks of VBAC. The risks associated with cesareans are also very real and you did not respond to them.

Since writing my first letter, I learned that in 2005 The American Academy of Family Physicians Commission on Clinical Policies and Research convened a panel to systematically review the available evidence on trial of labor after cesarean delivery (TOLAC) using the Agency for Healthcare Research and Quality Evidence Report on Vaginal Birth After Cesarean (VBAC)7. Their recommendations include the following:

• Women with one previous cesarean delivery with a low transverse incision are candidates for and should be offered a trial of labor (TOL)

• TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes.

• At the same time, it is clinically appropriate that a management plan for uterine rupture and other potential emergencies requiring rapid cesarean section should be documented for each woman undergoing TOLAC.

They also state that,

"Some have questioned the assumptions that seem to underpin the immediately available policy. For example, the policy assumes that having a surgical team immediately available will reduce morbidity or mortality from uterine rupture.  The AAFP TOLAC Panel felt this was a debatable assumption. Similarly, the ACOG policy suggests that one rare obstetrical catastrophe (e.g., uterine rupture) merits a level of resource that has not been recommended for other rare obstetrical catastrophes (e.g., shoulder dystocia, abruptio placenta, cord prolapse) that may actually be more common.  However, it may be argued that, while these other catastrophes are largely not predictable, permitting a TOL in a mother with a previous cesarean is a planned event that may demand a different degree of preparedness.
While adverse consequences of a TOLAC are distinctly uncommon and must be balanced against attendant risks associated with ERCD, current risk management policies across the United States restricting a TOL after previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence. The TOLAC Panel found no systematic evidence suggesting that improved outcomes for TOLAC patients resulted from restricting a woman’s ability to undergo a TOLAC based on the availability of resources not usually present for other women in labor, the institutional setting, or the timeliness of operative delivery."

In your letter, you said that the World Health Organization’s recommended cesarean rate of 10-15% is not based on data and you mentioned "a very clear and elegant mathematical argument that the cesarean rate should be almost 100%, and that is not a statement that appeals to many, therefore the issue is left mute." Most people would agree that the ideal cesarean rate depends on the goal desired and the population you are working with. However, the WHO recommended rate is widely accepted including by UNICEF and the Healthy People 2010 Initiative, and I have not been able to find any research recommending a 100% cesarean rate. My understanding is that the 10-15% cesarean rate recommendation was based on a series of conferences to examine the use of technology in childbirth. They involved over 30 member countries and specialists from all aspects of care including statisticians and epidemiologists. The result of these conferences was a paper published in the Lancet in 19858 and followed up by a piece by Chalmers9 which list recommendations by the WHO. The recommendations from the paper include:

• Women must participate in decisions about their birth experiences.

• There is no justification to have a cesarean section rate of higher than 10-15%. Vaginal deliveries after a cesarean section should be encouraged.

Even if the mathematical argument based on optimized neonatal outcome is true, it is not very relevant in this situation because the health and safety of two people is inseparably linked. For this reason, what is best for both mother and baby may not be what would be optimal for one or the other.

According to your letter, the numbers I quoted for fetal injury during cesarean section are not accurate. I have done some more research and have found that I was, indeed, wrong about that. The rate of fetal injury due to cesarean section is approximately 1.1% according to one study.10

You also said I quoted other statistics in the third bullet point of my letter that were not accurate but you did not mention what these statistics were or how they were inaccurate. The only other statistic in that paragraph is that cesarean section carries a 2-4 times higher risk of maternal death than vaginal birth. This is documented by an article published on the American College of Obstetricians and Gynecologists website11. According to the article, "This study shows that cesarean delivery is associated with a three-fold increase in the risk of postpartum maternal death as compared with vaginal delivery." This contradicts the quote towards the end of your letter where you mentioned that "the complication rates for Cesarean sections in the last 20 years have dropped to levels that now are arguably safer than vaginal delivery."

According to an August 31, 200612 news release about the same article, "Researchers emphasized that cesarean delivery is major abdominal surgery and that expectant women and physicians should carefully consider cesarean-related surgical complications and the increased risk of death when choosing the method of delivery." Cesarean section is not safer for mother or baby and carries the risks I mentioned before including the two to four times a greater chance of maternal death, as well as increased risk of emergency hysterectomy, injury to blood vessels and other organs, chronic pain due to internal scar tissue, increased chance of re-hospitalization and complications involving the placenta in subsequent pregnancies, and risks to the infant including an increased risk of respiratory distress syndrome, prematurity, and the development of childhood asthma and allergies13. The recovery from a cesarean is much longer than for a vaginal birth, involving more pain, more difficulty establishing breastfeeding, and a longer hospital stay. You did not address these and they are important facts for women to be aware of when agreeing to a cesarean.

In your letter, you quoted the national death rate from cesareans as less than 1 in 100,000 and unavoidable death due to pregnancy complications as 1 in 10,000. According to the news release I mentioned above, US women have a 1 in 3,500 chance of pregnancy-related death. According to the Center for Disease Control, maternal deaths related to pregnancy are under-reported in the US14 and in 200315 were found to be between 8.7 and 30.5 or more maternal deaths per 100,000 live births. In either case, the numbers for maternal death seem to be higher than you quote, and they have risen since 1982 when the maternal death rate in the US was 7.5 per 100,000 live births.

According to the American College of Obstetricians and Gynecologists16:

"it has become clear that patients are entitled to participate with their physicians in a process of shared decision making with regard to medical procedures, tests, or treatments; once the patient has been informed of the material risks, and benefits involved; that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test, or procedure or whether to make a choice among a variety of treatments, tests, or procedures. In the exercise of that autonomy, the informed patient also has the right to refuse to undergo any of these treatments, tests, or procedures. This election by the patient to forgo a treatment, test, or procedure that has been offered or recommended by the physician constitutes informed refusal."

In one of your last paragraphs you said, "the physicians at Cottage hospital are very much aware of the dichotomy between what is safest for the unborn fetus and maternal preferences and autonomy. These controversies are often complicated by lack of data, poorly understood data, and strong emotional components." You seem to be saying that autonomy and a patient’s right to informed consent or refusal of surgery doesn’t apply in the case of VBAC. You also seem to be saying that mothers desiring VBAC are prioritizing their own health above that of their unborn child. In light of the risks to the mother and fetus due to cesarean section, and the difficulty of bonding with an infant after major abdominal surgery, I would argue the opposite. Women desiring VBAC want the best possible outcome for their unborn child.

You also mentioned that "The acceptance of women’s autonomy and right to choose their mode of delivery has led to a significant number of women simply choosing Cesarean as the preferred mode of delivery" and that this is what has caused the greatest increase in cesarean deliveries at Cottage Hospital in recent years. I found this surprising because you seem to be saying that women have the right to choose a procedure that carries more risks, as long as they are choosing cesarean over vaginal delivery. In fact, repeat cesarean and VBAC carry very different risks, low in both cases, but women at Cottage Hospital do not really have the autonomy or the right to choose their mode of delivery if the option of VBAC is not open to them.

A concern I mentioned that you did not address with your letter was the following, "I understand that fear of litigation drives a decision to ban VBAC in many hospitals. However, many hospitals have women who want to attempt a VBAC sign a form stating that they understand the risks of VBAC. Could Cottage Hospital do this?"

The American Academy of Family Physicians has produced a document17 (attached) called a Trial of Labor after Cesarean Shared Patient-Physician Decision tool. It seems like it would be a very good tool for Cottage to implement to make sure that women desiring a VBAC or an elective repeat cesarean section understand the implications and the risks of each. Alternatively, the American College of Obstetricians and Gynecologists publishes a patient information pamphlet18 that outlines the risks and benefits of VBAC. The fact that they publish such a document shows that VBAC is a reasonable option for women.

In your letter you mentioned that you have been pleasantly surprised to receive fewer than 2 complaints per year about the VBAC ban. As I am sure you appreciate, the majority of hospital patients accept the advice given by a doctor without question. A pregnant woman who has already had a cesarean is inevitably going to be particularly anxious, and if her doctor tells her that a VBAC is so risky that it is banned, she is extremely unlikely to complain. A low level of complaints seems therefore to be an inevitable consequence of the current policy rather than representing any form of evidence that that policy is correct, or what local women prefer if given a choice. I suspect you will find the hospital’s complaint volume increasing once the public becomes aware of the policy, the reasons for it, and the attitude of the hospital towards vaginal birth and cesarean section.

I strongly urge the hospital to reconsider its policy on this issue. There is clearly a substantial body of evidence, from highly eminent sources, which supports the view that VBAC is at least as safe, if not safer than elective repeat cesarean delivery. If given the option of VBAC, women delivering at Cottage Hospital would feel supported and respected in their decisions (whether they choose VBAC or repeat cesarean) and women from nearby counties where VBAC is not permitted would bring their business to Cottage Hospital. By giving women the option of VBAC, Cottage Hospital has the opportunity to show leadership in both clinical practice and patient rights in Southern California.

I hope that this letter, and the work I have undertaken to draw the hospital’s attention to recent evidence on the issue, will enable new discussions to begin. I look forward to hearing from you how the hospital intends to proceed with this matter.

 Sincerely,

Jessica Barton

cc: Ronald C. Werft, Robert A. Reid, MD

 Notes:

1. Henci Goer, BA, LCCE (2002) VBAC and the New England Journal of Medicine Birth 29 (2) , 150–151 doi:10.1046/j.1523-536X.2002.01782.x

2. Katharina E. Kieser, MD and Thomas F. Baskett, MB (2002) A 10-Year Population-Based Study of Uterine Rupture, Obstetrics and Gynecology 2002;100:749-753

3.  www.cdc.gov/nchs/about/major/fetaldth/abfetal.htm

4. Lisa M. Korst, Kimberly D. Gregory et al., Vaginal Birth After Cesarean and Uterine Rupture Rates in California, Obstetrics and Gynecology 1999;94:985-989

5. Ron Gonen, Victoria Nisenblat (2006) Results of a Well-Defined Protocol for a Trial of Labor After Prior Cesarean Delivery, Obstetrics and Gynecology 2006;107:240-245

6. M. Enkin, M.J.N.C. Keirse, J. Nielson, C. Crowther, L. Duley, E. Hodnett, and J. Hofmeyr, A Guide to Effective Care in Pregnancy and Childbirth. Oxford University Press, 2000.: http://www.vbac.com/chapter38.html

7.  www.aafp.org/PreBuilt/clinicalrec_tolac.pdf

8. WHO (1985) Appropriate technology for birth. Lancet ii, August 24, 436 - 437.

9. Chalmers I., Enkin M. & Kierse M.J.N.L.(eds) (1989) Effective Care during Pregnancy and Birth, Vol I & II, Oxford University Press, Oxford.

10. James M. Alexander, Kenneth J. Leveno, John Hauth (2006) Fetal Injury Associated With Cesarean Delivery, Obstetrics & Gynecology;108:885-890

11. Catherine Deneux-Tharaux, Elodie Carmona, Marie-Hélene Bouvier-Colle, Gérard Bréart (2006) Postpartum Maternal Mortality and Cesarean Delivery, Obstetrics & Gynecology 2006;108:541-548

12.  www.acog.org/from_home/publications/press_releases/nr08-31-06-2.cfm

13. M. Salam, H. Margolis, R. McConnell, J. McGregor, E. Avol , F. Gilliland (2006) Mode of Delivery Is Associated With Asthma and Allergy Occurrences in Children, Annals of Epidemiology, Volume 16, Issue 5, Pages 341 - 346

14. Arialdi M. Miniño et al., "Deaths: Final Data for 2004," National Center for Health Statistics: www.cdc.gov/nchs/products/pubs/pubd/hestats/finaldeaths04/finaldeaths04….

15. Hoyert DL. Maternal mortality and related concepts. National Center for Health Statistics. Vital Health Stat 3(33). 2007.

16. American College of Obstetricians and Gynecologists. Informed refusal. ACOG Committee Opinion 237. Washington, DC: ACOG, 2000.

17.  www.aafp.org/online/en/home/clinical/patiented/counselingtools/tolac.html

18.  www.acog.org/publications/patient_education/bp070.cfm