"You can't pin it on one thing. It's so multifactorial," said Whitney Pinger, director of midwifery services at George Washington University and a member of the American College of Nurse-Midwives. "There's no one thing to blame, there's no one person to blame, there's no one provider to blame. We are all in this together, we got ourselves into it as a society. "
Back in the late 1960s, C-sections accounted for about 2 percent of births. When they were performed, it was because the health of the mother or baby or both was in danger. By 1970, fetal monitors were all the rage, and with them every blip the baby experienced was broadcast for all to analyze. It was also around this time that doctors stopped doing vaginal breech deliveries—that is, allowing a woman to deliver a backwards baby vaginally—and forceps deliveries also fell out of fashion. With these changes, the C-section rate rose to 5 percent in 1970. By 1996, that number had jumped to 28 percent. But the number of VBACs also rose and reached an all-time high of 28 percent by that same year.
There are risks inherent to both VBACs and C-sections. The one that most people worry about with VBACs is uterine rupture. This happens when there is a tear in the uterine wall, usually at the site of a previous C-section scar. This can lead to extensive bleeding for the mother and oxygen deprivation for the baby. When this happens, the woman has to have a C-section before the oxygen loss causes brain damage to the baby, said Barbara Levy, vice president for health policy at ACOG.
Statistically, when women attempt labor with one previous C-section, rupture happens in about 7 to 9 women per thousand. That number goes up to between 9 and 11 per thousand for women attempting natural birth with two or more C-sections. So uterine rupture does happen, but with those numbers, it's considered a rare occurrence. It also happens during repeat C-sections, to 4 or 5 women per thousand.
That said, by 1996, VBACs were happening a lot, which in turn meant uterine ruptures were happening more often. In response, ACOG issued a series of increasingly restrictive recommendations regarding VBACs.
"It's all about safety," Levy said of why the more restrictive guidelines were issued. "When you think about it, if the result is life-long brain damage to a child, who is willing to take that risk? Even if that risk is one in a thousand, not one in a hundred, can we—knowing that that is a risk--put policies and procedures in place that don't obviate that risk? And I think that's the fundamental issue. Who is going to take that liability?"
The guidelines, in essence, said hospitals offering VBACs needed to have a physician available who was capable of performing a caesarean "immediately," as well as 24/7 in-house anesthesia.
"I'm not someone that would have said there were restrictions on VBAC," said Jeffrey Ecker, speaking of the guidelines. Ecker is a high-risk obstetrician at Massachusetts General in Boston and a member of ACOG. "But as you've probably gathered, a lot of the focus was around the language of what resources needed to be available and specifically, 'immediately' available for women undergoing a trial of labor. And it was that I think that drew the label of restricting VBACs."