A couple weeks ago, I read a comment from an OB who said if his practice supported VBAC, he and his partners could each expect to have 1 "preventable" neonatal death following a uterine rupture. He asked if that was acceptable. On Dr. Amy's blog, she says that no one in the advocacy community addresses the issue of the "excess" deaths caused by VBAC. And then the NIH released information showing the neonatal death rate for VBAC was over twice as high as the rate for repeat c-section. There is ample evidence that more babies will die during VBACs than during repeat cesareans- so why should VBAC be a valid option?
First and foremost, I want to make it clear that I'm not in favor of anyone losing her baby. I simply can not imagine the grief, the pain, the countless ways someone's life would be forever changed by that kind of loss. I don't expect any woman to "take one for the team" by losing her baby during a VBAC attempt; I absolutely do not believe in vaginal birth at all costs. What I want to address here is whether or not the greater risk of neonatal death during VBACs should affect policy-level decision-making and support for VBACing moms.
After thinking about it for a couple weeks, my simple answer is no. I see a huge logical problem in arguing that VBACs should be banned (or that OBs have a legtimate right to refuse to support VBAC moms) due to the increased risk of neonatal death. While the NIH statement does show that more babies die during VBACs, they go on to say that the risk is virtually the same as it is for any first-time mom. This made me wonder, why isn't the "dead baby card" pulled out for first-time moms? Why are they not counseled to schedule their c-sections at 38 or 39 weeks so their babies won't die? If everyone can have a c-section and the noeonatal mortality rate could be cut by 60% or so, why NOT tell everyone she should deliver that way? There must be inherent benefits to vaginal delivery, and those benefits must be great enough that they outweigh the increased risk of neonatal mortality.
So why do the inherent benefits of vaginal delivery not seem to affect VBAC policy? Two words: malpractice liability. It is expected and accepted that a certain number of primiparas will lose their babies to late-term stillbirth or complications of childbirth, and those cases will (generally) not result in enormous lawsuits. One baby lost to uterine rupture, though, could destroy the livelihood of even the best OB. I've seen it said over and over: Would you risk everything to support a woman's VBAC? Would you risk your career, your savings, your family's financial security? Would you really?
The biggest problem I see is the lack of transparency and honesty in the discussion. When OBs focus on "preventable" deaths and yet don't require ALL of their mothers to schedule cesareans, it's clear that the issue isn't just preventable deaths. When others rail at advocates for not addressing "excess" deaths but don't talk about why it is only VBAC deaths that matter, they are completely missing the point the advocates are making. When we as advocates direct our ire toward providers who really are between a rock and a hard place-- you know, we're all spending so much time being pissed off and defensive that we're just not getting anywhere.
I think the NIH conference was a great start in clearing the air between activists, providers, and VBAC moms. I hope to see the issue of "excess" deaths in VBAC continue to be put in perspective on a policy level (as it was in the NIH statement), so that women can have access to complete and accurately portrayed information as they decide how to deliver their babies.