Birth Action Coalition Our Bodies, Our Babies, Our Births

I am a mother of a toddler who was born by cesarean. I recently moved to the Santa Barbara area and was disappointed to learn that in 2003, the Cottage Hospital system banned vaginal birth after cesareans (VBACs). According to the Santa Barbara News Press article that covered the decision,

"The American College of Obstetricians and Gynecologists recommended in 1999 that physicians, including an anesthesiologist, be ‘immediately available’ 24 hours a day at any facility that sanctions a so-called VBAC […] Cottage cannot meet the staffing standard, Dr. Alex Soffici, medical director of perinatal medicine there, said Tuesday. ‘Very few hospitals outside of universities are going to be offering this.’ The prime concern is that during labor a woman’s uterus can rupture along her existing C-section scar line. Critics are quick to note what several sources report — that such tears happen less than 1 percent of the time. […] Added obstetrician-gynecologist Dr. David Raphael: ‘The problem is when things go awry, things change immediately and that could be a dramatic outcome for the mother or the baby.’"

Recent research shows the risk of uterine rupture among women with one prior low uterine segment cesarean in spontaneous, naturally occurring labors to be about 0.5%.

I have several concerns about this situation that I hope you will address:

• Women go to hospitals to give birth because they often feel that a hospital is best equipped to handle birth emergencies. According to the Cottage Hospital website, the hospital handles 2400 births a year. I am concerned that if Cottage can’t meet the staffing standard for VBACs, that means the hospital doesn’t have the ability to perform an emergency cesarean 24 hours a day/seven days a week. If the hospital cannot accommodate a medical emergency such as uterine rupture, how can they respond and treat other real, but rare, labor emergencies such as cord prolapse (approximately 0.14-0.62% of births) or placental abruption (approximately 0.65% of births), both of which require the baby to be born ASAP usually by immediate cesarean sections?
• The cesarean rate in this country has risen well above the World Health Organization’s recommended rate of 10-15%. According to the Santa Barbara News Press article from 2003, at that time approximately 28% of births at Cottage Hospital were cesareans. Add to that the approximately 4% that were VBACs but are now required repeat cesareans and you get a 32% cesarean section rate — more than twice that recommended by the WHO. Healthy People 2010 recommends a reduction in cesarean births in the US to 15% by 2010. I am concerned that the cesarean rate in Santa Barbara is so high, because cesareans are not risk-free operations, and I would like to know what the hospital is doing to address the over use of cesareans.
• I am concerned that Cottage Hospital is understating the risks of primary or subsequent cesarean surgeries yet exaggerating the risks of VBAC. Cesareans pose serious risks to mothers, including two to four times a greater chance of maternal death, 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. Cesareans also pose risks to the infant, including an increased risk of respiratory distress syndrome, prematurity, the development of childhood asthma, and a 1-9% chance the baby will be cut during surgery. 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.

I understand that having an anesthesiologist at the hospital at all times is expensive, and cannot be billed to a patient’s insurance unless he or she ends up being needed. However, I am concerned that emergency anesthesia should be available at all times if Cottage Hospital is going to be a safe place for women to be in labor and deliver babies.

As suggested by the 2003 article, 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?

Giving birth is a life-changing event in the life of a woman. She needs to be able to work with her care provider to make decisions that are best for her so that she will feel good about the experience for the rest of her life. With the exception of the VBAC ban, I have heard good things about the birth centers in the Cottage Hospital system. I hope that you will re-examine this policy and give women who have had a previous cesarean and are candidates for VBAC the chance to choose between VBAC and repeat cesarean. Thank you for taking the time to consider my request. I would like to follow up with you with a phone conversation next week and I look forward to hearing your thoughts on this matter.

 Sincerely,

Jessica Barton

cc: Dr. Donna Kell