Once a C-Section, Always a C-Section?

After having a caesarean section, why few women have a subsequent vaginal birth

A baby being delivered via caesarean section (Jorge Cabrera/Reuters)

Every third woman who goes to the hospital to have a baby will likely have a C-section.

After a few days of recuperation, she will leave with her new baby, her new scar, and her chances of safely having more than two children greatly diminished.

C-section rates have skyrocketed in the last two decades. These costly and invasive surgeries, once rarely done, are now routine with a third of all births resulting in the procedure. Of those, nearly half are repeat C-sections.

This is based in large part on the fact that for almost two decades hospitals have refused to let women attempt natural labor after a C-section, based on recommendations from the 90’s by the American College of Obstetricians and Gynecologists (ACOG) restricting the practice. Hospitals held so steadfastly to these guidelines that the C-section rate went from 20 percent in 1996 to 31 percent by 2006. In other words, once a C-section, always a C-section.

But in 2010, ACOG eased restrictions, giving the green light to trial of labor after a C-section (TOLAC) and vaginal birth after a C-section (VBAC). The result? The C-section rate went up, from 32.4 percent to 33.7 percent where it's holding steady.

There are incentives for doctors and hospitals to perform C-sections. They’re faster, bring in more money, and present a lower risk of lawsuit. But now that natural birth after a C-section is considered okay, there are roadblocks.

"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."

Ecker may not think the guidelines were restrictive, but they certainly had an effect on the majority of the hospitals in the country. Between 1996 and 2010, the C-section rate went from 21 percent to 32.8 percent and the VBAC rate dropped from 28 percent to 8 percent.

In 2010, ACOG changed the guidelines again.

"[The 2010 ACOG report] still says ACOG thinks that immediately available is safest," said Ecker, who helped write the 2010 report. "But it recognizes that 'safest' is a relative term, and that places that don't have [anesthesia and surgeons] immediately available shouldn't necessarily bear the label of unsafe."

One of the biggest reasons for this clarification was the growing push by entities like the National Institutes of Health—which had released its own change of heart about TOLACs earlier in 2010—to reduce the number of C-sections nationally. Overall, C-sections are safe. However, they have risks, and the risks increase with every C-section. Women who've had multiple C-sections are at greater risk of complications like placenta previa, where the placenta covers or blocks the cervix; placenta accrete, where the placenta implants too deeply in the uterine wall; and placenta abruption, where the placental lining pulls away from the uterine wall. All of these conditions can cause massive hemorrhaging, the need to remove the uterus, and even death in severe cases.

A 2006 Robert Wood Johnson Medical School study found that pregnancy after a caesarean delivery was associated with increased risk of placenta previa, about 6.3, per 1,000 births, compared with a post-C-section vaginal delivery, which had a rate of 3 per 1,000. The study also found that two C-sections doubled the risk of placenta previa and was associated with a 30 percent increased risk of placenta abruption in the third pregnancy. In other words, after two C-sections, more children becomes a risky proposition.

"The risk of rupture or having to do a hysterectomy are also incredibly low numbers," Levy said. "So really it's just a question of the magnitude of the risk. It's a very low risk if you're only going to have two children and they're both by C-section. If you're planning on six children that's a different issue and a higher risk."

Since the release of the 2010 guidelines, no national statistics show the number of hospitals doing VBACs. However, the findings of a 2012 study by researchers at the University of California, San Francisco show trends in California birthing hospitals.

In that study, researchers looked at 243 birth hospitals in the state and surveyed nurses to find out the access to TOLAC across the state, if there had been a change in access since ACOG's 2010 proclamation, and the characteristics of TOLAC and non-TOLAC hospitals.

The study concluded: "Despite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44 percent of California hospitals do not allow TOLAC. ... Of the 56 percent allowing TOLAC, 10.8 percent report fewer than 3 percent VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California."

A big barrier to VBAC is money. As of 2010, both commercial insurance and Medicaid payers paid approximately 50 percent more for caesarean than vaginal births. In many cases, this means thousands more dollars per procedure to hospitals and hundreds more per procedure to doctors. In their 2013 study health care economists Erin M. Johnson and M. Marit Rehavi looked at the interaction between patient information and physician financial incentives in healthcare.

Johnson said they found that in fee-for-service payment models, physicians are typically (though not always) reimbursed more highly for C-sections than for vaginal deliveries. Johnson said that though the data varies a bit, estimates put the amount doctors are making at between $380 and $500 per C-section. And Medicare pays even more, around $2,295 for a C-section and $1,926 for a vaginal delivery on average, Johnson said.

Some doctors balk at this.

"I can't speak to hospitals in general," Mass General's Ecker said. "But I can speak to the notion that doctors make more money from Caesarean sections is just an old canard; that's just not true. I am aware of very few doctors that get paid on the type of delivery that they do. And increasingly … physicians are salaried and even someplace like Massachusetts, prenatal care is a global fee. You get this much for labor and delivery, it doesn't matter to me how I do it. So I just don't think that's so. I don't think that people or hospitals are doing more caesarians to make more money."

Johnson and Rehavi's study also looked at HMO-owned hospitals where physicians are salaried, and there doctors don't have an incentive, hospitals do. Johnson said women at HMO hospitals are 17 percent less likely to have a C-section than at non-HMO owned hospitals.

"In this setting, [HMO hospitals], physicians and hospitals have the incentive to perform vaginal deliveries in lieu of C-sections," Johnson said. "Outside of HMO-owned hospitals, where most physicians are reimbursed on a fee-for-service basis, the financial incentive is to perform C-sections in lieu of vaginal deliveries."

"From a hospital standpoint, it’s easier to staff a routine, scheduled caesarean delivery," Levy said. "So you can say it's scheduled for 7:30 in the morning and I can have my staff there at 6:30 and I know how long it's going to take and I have all that in place. That’s much easier than saying I have to staff up for whenever this lady is going to come in and we don't have any idea when that is and be just available and ready."

C-sections, in that sense, are more convenient. They can be planned, stacked up, and generally several can be done in a day. More C-sections per day means more money for the hospitals.

Women who went to for-profit hospitals in California were 17 percent more likely to have a caesarean than if they went to a non-profit hospital, according to a 2010 study done by California Watch, a group founded by the Center for Investigative Reporting. This held true regardless of location or socio-economic makeup of the area.

Another stumbling block for VBACs is the size of the hospital. Since ACOG first said hospitals offering the procedure needed to have a surgeon and anesthesiologist "immediately" available, smaller and more rural hospitals have complained that is untenable. And that largely remains true even after the easing of restrictions.

"Unfortunately the logistics of health care and cost just don’t allow that to happen," said Levy. "If you're a small hospital—and we know that two-thirds of the hospitals in this country that deliver babies deliver fewer than 1,000 per year—if you’re talking about trying to staff a hospital like that to do some of these higher risk things, it's problematic. Who's going to pay for that?"

In a practical sense, the hospital has to either keep an anesthesiologist on staff or have one within a few minutes of the hospital. It also means that neither the doctor who can perform a C-section nor the anesthesiologist can be involved in another procedure at the same time and an emergency room has to be unoccupied.

"So in a high-volume place, that's relatively easy to set up," Levy said. "And in a low volume place, it's really hard."

That said, ACOG in its 2010 guidelines pointed out that the lack of a surgeon and anesthesia team standing by is no reason to deny a woman a VBAC. Some hospitals employ laborists, who know how to deliver babies both operatively and surgically. Some others have pool resources with nearby hospitals. Others have just been referring women to other hospitals that offer VBAC.

Which is great, unless you live in a place like Wyoming or Alaska, where getting to one of those hospitals can mean hours of commuting. At that distance, if she wants a VBAC, if she's planning on having more than two children, she's got to find housing arrangements near the hospital for the week to 10 days surrounding her due date. And she may also have to find childcare for her other children, if she doesn't have a partner.

These scenarios are not just playing out in the wildernesses of wide-open states. In the University of California study, researchers found that the mean distance from a non-TOLAC to a TOLAC hospital was 37 miles.

Then there's litigation.

"Honestly, I think most obstetricians would like to be able to offer (VBACs) to our patients," Levy said. "But if (the mother) is unlucky and the family is unlucky and a bad thing happens, the cost of that bad thing is born by that family and it will generate a lawsuit. Because, in order to pay for all of that, the family needs compensation… The only way they can get paid to do that kind of care is to sue and they sue the hospital because they are the ones with the deep pockets. And that is I think what's preventing institutions from offering VBACs."

There are doctors practicing today who have come up through the field in an age where TOLACs and VBACs are rare. Some of them have never done one, and that alone could cause a doctor to pause. And the University of California study hinted that this trend may continue.

"In our survey, six hospitals with obstetrical residents did not offer TOLAC," the study reads. "We do not know if these are the only hospitals in which these residents train but the lack of exposure to TOLAC management may be an important factor in the trainees’ willingness to allow women a TOLAC post-residency."

But putting aside institutional hurdles, some women who just don't want to try natural birth after a C-section—they deem it too risky, or are discouraged by their doctors.

Using an actual patient as an example, Michele R. Lauria, an obstetrician and professor of obstetrics, gynecology, and radiology at Dartmouth University’s Geisel School of Medicine, said with the woman's last pregnancy, she went to term, pushed for five hours, and her baby didn't come out. It was a normal size baby.

"Her chance of having a successful VBAC is about 30 percent," Lauria said. "If you have a C-section after you've been in labor, C-section after labor is associated with higher bleeding and higher rates of infection. And so if your chance for a successful VBAC is only 30 percent and you're up for a day and a half in labor, and you end up with a C-section anyway, it's just not enticing to people. It's hard for even us to find the value proposition."

If the patient is overweight or has had a prior abdominal surgery, and the physician has to do an emergency C-section because of a uterine rupture, "it would take you quite a while to get in (the abdomen), which would pose extra risk to the baby. In that scenario, people are going to say 'hey, I want to do a repeat C-section.'"

In the end, it comes down to how much risk doctors, hospitals, and patients are willing to tolerate. But, Pinger argues, getting on a path to fewer C-sections will require the efforts of all three.

"All of us: the doctors, the midwives, the women, the policymakers, the lawyers, the risk managers, all of us need to tackle this together,” Pinger said. “It's our social responsibility to tease out the many factors and make adjustments that are safe for mother and baby."