NIH, VBAC and the politics of resentment

The NIH Consensus Conference on Vaginal Birth After Cesarean has just released its findings. Despite the fact that the conference statement offers strong support for a far more liberal VBAC policy, VBAC activists are currently parading before the panel during the public comment portion and attempting to outdo each other in their vilification of doctors. It’s almost as if the panel findings are irrelevant. Their anger, self pity, and conspiracy theories are so important to activists, that they cannot let them go. In fact, they appear to be far more important to activists than the actual issue under discussion.

The NIH conference on VBAC was convened because doctors and policy makers (as well as patients) believe that the current VBAC policy is misguided and potentially harmful. As the statement explains:

Vaginal birth after cesarean (VBAC) describes vaginal delivery by a woman who has had a previous cesarean delivery… In 1980, a National Institutes of Health (NIH) Consensus Development Conference Panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered. The option for a woman with a previous cesarean delivery to attempt a trial of labor (TOL) was offered and exercised more often in the 1980s through 1996. Beginning in 1996, however, the number of VBACs has declined, contributing to the overall increase in cesarean delivery …

Although the number of women … faced with the question of whether to attempt TOL has markedly increased, there has been a concurrent, dramatic drop in VBAC. Yet cesarean and VBAC rates are identified as quality indicators for maternal health by policymakers, insurance providers, and health care quality monitoring groups. Success of TOL is consistently high (60 to 80 percent), whereas the risk of uterine rupture is low (less than 1 percent)…

In other words, in 1980, after reviewing the scientific literature, an NIH panel recommended offering a trial of labor to women who had had a previous C-section. As a result, VBAC became popular. Many women had successful vaginal deliveries. Only a very small proportion of women had serious complications, almost exactly what was predicted. Yet the VBAC rate peaked in 1997 and has declined precipitously since the, as the following graph shows.

Why did VBACs decline despite the fact that the benefits and risks were exactly as predicted? The answer can be summed up in one word: lawsuits. Although women offered VBAC were counseled about the small risk of uterine rupture (opening of the uterine scar during labor) and the attendant risk that the baby might die in the event of a rupture. Nonetheless, when a baby died after a uterine rupture, many mothers sued, and claimed that they had not “understood” the risks even though those risks were clearly explained. Juries were moved by these emotional appeals, and large judgments were paid out.

What did everyone learn from these lawsuits? Doctors learned that patients maintained that they could not “understand” risks no matter how carefully explained, patients learned that they did not have to take responsibility for their decisions, and lawyers learned that VBAC complications represented a bonanza.

The American College of Obstetricians (ACOG) stepped into the breach and, attempting to make things better, made them far worse. ACOG likes to remind its members that doctors have never lost a lawsuit in which they followed ACOG guidelines. Therefore, ACOG decided to promulgate guidelines that doctors could use in their legal defense. Unfortunately, the ACOG guidelines were so strict (unreasonably strict in the eyes of most obstetricians) that most obstetricians could not meet them. ACOG mandated that VBAC should only be attempted when both an anesthesiologist and obstetrician were present so that anyone who experienced a uterine rupture could be treated immediately. Most medium sized and small hospitals cannot afford to have an anesthesiologist in the hospital around the clock. Most obstetricians cannot afford to sit for hours while a patient labors. Therefore, many hospitals and anesthesiologists stopped offering VBAC.

The problem was compounded when malpractice insurers recognized that VBAC complications, though uncommon, represented an indefensible claim. If patients could claim that any consent for VBAC was essentially invalid, large payouts were inevitable. Many malpractice insurers told obstetricians that they should not preside over VBACs and, if they did, their entire malpractice policy would be voided. Obstetricians cannot practice without insurance; defying the insurer meant that an obstetrician would have to quit obstetrics altogether.

Simply put, liability concerns have sharply restricted the availability of VBAC. But that’s not how VBAC activists tell the story. Like many advocates of alternative health, childbirth activists thrive on resentment. Any situation that they don’t like is automatically ascribed to a conspiracy of evil doctors. VBAC activists insist, despite the copious evidence to the contrary, that doctors deliberately and maliciously chose to restrict VBAC. They have all sorts of purported “reasons” for this conspiracy. They claim that obstetricians make more for C-sections (for most doctors, and all doctors on salary, that is not the case), that doctors want to ruin women’s birth “experiences,” and that doctors are more concerned about protecting themselves (avoiding the loss of insurance) than about offering good medical care. They refuse to see that on the issue of VBAC, obstetricians are their allies.

The latest NIH panel reviewed the scientific literature and confirmed their earlier stance. VBAC should be offered to eligible women because the chance of success is high and the risk of complications is low. Furthermore, the conference report urged ACOG to re-evaluate their VBAC guidelines, presumably to eliminate the need for continuous presence of both anesthesiologist and obstetricians. In addition, the panel recommended that policy makers review the medico-legal strictures on VBAC, since liability concerns are driving the restriction of VBACs.

Despite all this, VBAC activists are still complaining about evil obstetricians. The public comment session immediately following presentation of the report was dominated by VBAC activists with inane demands for revision of the report. Chief among those demands was the insistence that doctors be blamed for the current situation. It makes me wonder whether these women even bothered to read the report. Or perhaps they read it but didn’t care that it represents the most promising avenue for increasing access to VBAC. Resentment is such an integral part of VBAC activism that it appears to be more important than VBAC itself.


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