New York Times Examines Factors Affecting VBAC Rates As NIH Conference Begins

Main Category: Pregnancy / Obstetrics
Also Included In: Women's Health / Gynecology;  Public Health
Article Date: 10 Mar 2010 - 3:00 PDT

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The New York Times on Tuesday examined efforts to increase rates of vaginal births after caesarean sections at the Tuba City Regional Health Care Corporation, a small hospital run by the Navajo Nation and financed partially by the Indian Health Services. According to the Times, the hospital "prides itself" on having higher VBAC rates and lower overall c-section rates than wealthier, more renowned hospitals.

This week, NIH is hosting a conference to evaluate factors affecting the nation's low VBAC rate, which dropped significantly since a peak of 28.3% of births in 1996. Tuba City, with about 500 births annually, "could probably teach the rest of the country a few things about obstetrical care," the Times reports.

For years, health experts advised women who had given birth via c-section during a first pregnancy to have c-sections in subsequent labors because of concerns that a vaginal birth could cause the c-section scar on the uterus to rupture. In 1980, an expert panel announced that women who had c-sections for a first pregnancy could safely give birth vaginally for later pregnancies, prompting a rise in VBACs. However, after a series of ruptures, deaths and lawsuits related to VBACs, the American College of Obstetricians and Gynecologists issued stricter VBAC guidelines, and the rate fell below 10%.

The national c-section rate has been rising for the past 11 years and now stands at 31.8%, driven largely by cases of repeat c-sections. The World Health Organization recommends a target c-section rate of 15% for low-risk women, though there is no consensus about an ideal U.S. c-section rate. Many health experts -- including ACOG -- believe doctors overuse c-sections. They argue that unnecessary c-sections expose too many women and infants to the risks of the surgical procedure and accumulate several billion dollars annually in excess medical costs.

Differences From Other Hospitals

At Tuba City, the 2009 VBAC rate was 32%, and the overall c-section rate was 13.5%. The favorable rates are partially due to Tuba City's use of nurse midwives to staff the labor ward, the Times reports. Nurse midwives focus on coaching pregnant women through labor, and they often will wait longer than obstetricians before advising a c-section. Nurse midwives also are less likely to induce pregnancy before a woman's due date, a practice that can also increase the chance of needing a c-section. Nationally, nurse midwives attend roughly 10% of c-sections, though the American College of Nurse Midwives hopes to raise that rate to 20% by 2020.

For other hospitals to replicate Tuba City's model, it would require "fundamental changes in medical practice, like allowing midwives to handle more deliveries and removing the profit motive for performing surgery," the Times reports. ACOG recommends that obstetricians and anesthesiologists be "immediately available" in case complications arise during VBACs, and many hospitals ban the procedure because they cannot meet the recommendation. According to the Times, Tuba City's physicians live on the hospital grounds to ensure they are immediately available during a VBAC. In addition, Tuba City is insured by the federal government, meaning private insurers cannot threaten to raise premiums or withdraw coverage if the hospital allows VBACs (Grady, New York Times, 3/6).

Reprinted with kind permission from http://www.nationalpartnership.org. You can view the entire Daily Women's Health Policy Report, search the archives, or sign up for email delivery here. The Daily Women's Health Policy Report is a free service of the National Partnership for Women & Families, published by The Advisory Board Company.

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