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Two Maryland Hospitals Reduce Birthing Options Available To Pregnant Women

MOTHER'S WORRY: Sarah Wheeler delivered her daughter Jessica (pictured) via cesarean section and wanted to avoid the procedure for her next child, but a new ban on vaginal births after cesareans got in the way.

By Christina Royster-Hemby | Posted 12/22/2004

In March 2004, a routine visit to her OB/GYN’s office left an eight-months-pregnant Sarah Wheeler in tears. Wheeler, now 37, says that up until that visit, she had been told that she would be able to deliver her baby vaginally, rather than via cesarean section. Wheeler had already had a cesarean three years earlier when she had her first child, and she did not want to have to go through it again—she was afraid, she says, that the procedure would be particularly painful the second time around.

“I had heard that it’s harder to recover from a second cesarean, and it was,” Wheeler says. “I already had a 3-year-old at home, so I wanted to be up running around with her [after my son’s birth], but I couldn’t. It’s difficult to look after two children when you’re in pain.”

Wheeler falls into a category of mothers who have been prevented from having a natural vaginal birth because they have previously given birth through cesarean section, a surgical procedure in which incisions are made in the abdomen and uterine membranes so that the baby can be removed from the womb. Doctors say that women who have vaginal births after cesarean sections (known as VBACs) are 1.1 percent more likely to experience a ruptured uterus during delivery. According to a study released Dec. 16 by the National Institutes of Health, which appeared in the New England Journal of Medicine, there is an increased chance during VBAC that a baby may suffer brain damage during delivery, or that the mother may experience hemorrhaging and need a blood transfusion.

The increased potential for injuries also means increased potential for malpractice suits against doctors, many of whom are beginning to feel that VBACs are not worth the risk. So far the procedure has been banned at two hospitals in the state: The Memorial Hospital at Easton, which banned them in 2003, and Frederick Memorial Hospital, which banned VBACs in August. Wheeler says she was denied a VBAC at Frederick Memorial in April, months before the ban at the hospital was instituted.

Maureen Corry, executive director of the Maternity Center Association, an organization that promotes safe, effective maternity care, says the area hospitals join others nationwide in doing away with the VBAC procedure.

“I think that this is part of a trend that is expected to grow, unfortunately,” she says. “In 2002 we conducted a national survey called Listening to Mothers, which was the first national survey of U.S. women’s childbirthing experiences. The survey covered women who gave birth over a two-year period, and showed an increase in the number of women with a previous [cesarean] who were denied the option of a VBAC, from 42 percent to 58 percent during the year before the survey. This trend is going to continue, due to rising malpractice insurance rates and defensive medicine. But the best way to deal with these concerns is to reduce the number of primary cesareans, so women will not be denied access to VBAC.”

Many women, like Wheeler, feel it should be a woman’s right to choose whether to give birth vaginally or via surgery.

“I am very aware of the fact that both a cesarean and a VBAC are risky procedures, but I felt that a VBAC was the least risky given my condition,” Wheeler says. “It’s my body, and I should be able to give birth the way that God intended me to give birth. And [doctors] shouldn’t be able to tell me that I can’t.”

Wheeler did her own research on the risks associated with both forms of birthing, and argues that despite what medical professionals say, a VBAC would have been the best choice for her and her son, Joseph, who was born healthy via cesarean in April. She points out that the risk of complications during delivery is as low as 0.4 percent for women who do not opt for labor induced by the drug Oxytocin, for instance. It is primarily the use of this drug that drives up the chance for problems with vaginal deliveries.

Wheeler had a cesarean during her first pregnancy because she had developed preeclampsia, a hypertensive condition in which mothers develop high blood pressure, which in turn can cause both infant and maternal illness, or even death. It took her eight weeks to recover from the surgery. During her second pregnancy, Wheeler did not develop any medical conditions, and she wanted a vaginal birth, partly because the recovery period for a second cesarean operation is generally even longer than the first.

It’s now been seven months since Wheeler had her second cesarean, and she says she still experiences pain and numbness in her abdomen and extreme discomfort during her menstrual cycle.

“What really angers me is that my doctor is the one who told me the dangers of having repeat cesarean sections—the scar tissue, the repeated incisions, and how it weakens the uterus,” she says. “I feel that the women in Frederick deserve better, and that we should be given the right to choose.”

Dr. Gerrit Schipper, chief of obstetrics and gynecology at Frederick Memorial Hospital, delivered Wheeler’s son. (A doctor at Schipper’s practice delivered Wheeler’s daughter, Jessica, in 2001). While Schipper can’t speak about the specifics of Wheeler’s case, he says that the risks for both mother and child are too great to allow women to opt for VBACs—not to mention for doctors, who would be the ones facing the financial repercussions should complications occur.

“I have not seen the New England Journal article, but in the synopsis I read there is still a 0.7 to 1 percent increased risk of fetal or maternal damage with a VBAC,” Schipper says. “And if you look at the article, there were, I think, 12 children who were diagnosed with a condition called hypoxic ischemic encephalopathy, during which the brain is deprived of oxygen. That means that one out of every 100 or 200 babies that you deliver could have major neurological problems. Which in today’s legal world translates into multimillion-dollar awards and settlements, running between $3 million and $15 million. . . .

“It’s not just the cost of malpractice,” Schipper concludes. “It’s the concept that physicians and health-care institutions are responsible for the outcomes when [patients] experience adverse conditions.”

Barbara Stratton is the mother of a 5-year-old boy, and the Baltimore chapter leader of the International Cesarean Awareness Network (ICAN), which Wheeler joined a few months ago. Stratton says she was in pain for a year and a half after she gave birth by cesarean (which she says was unnecessary and preventable) in 1999. Stratton and ICAN’s mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting vaginal birth after cesarean because of the emotional and physical damages that cesareans can cause to mothers and their babies. Stratton says ICAN believes the NIH study “shows VBAC is safe” and has issued a statement challenging doctors to “let mothers choose method of birth.”

“The study shows that as long as you don’t induce or speed up a VBAC labor, the risk of complications is 0.4 percent,” she says. “And I feel that cesareans certainly carry that much risk themselves.”

Stratton references a study from the American College of Obstetricians and Gynecologists (ACOG) which claims that the risk to mother and child from having a cesarean alone is four times that of having a vaginal birth. “I’ve known two cases in Baltimore in the last three years where women nearly died from their unnecessary cesareans,” she says. “So what’s the point of having another unnecessary cesarean if I don’t live through it to [be the child’s] mother?”

After enduring the cesarean, which she says “completely affected my everyday life,” Stratton became both a doula (a woman who provides emotional and physical support to women in labor) and an anti-cesarean advocate. She notes that according to the Centers for Disease Control (CDC) the number of cesareans performed in the United States is increasing every year. In 2002, 26.1 percent of women gave birth via cesarean, and in 2003, that number jumped to 27.6 percent.

Stratton attributes the rising number to the fact that obstetricians know that cesareans are fast and convenient (most babies can be delivered in about 10 minutes after the incision is made). In addition, they can be scheduled at convenient times during working hours, unlike labored births which can happen suddenly, at any time of the day or night. Stratton also notes that cesarians are more expensive than conventional births, and therefore bring in more money to doctors and hospitals.

Stratton says the move toward cesarean births is especially troubling for local women because their birthing choices are becoming increasingly limited. Frederick Hospital, for example, has done away with its midwifery program completely.

Schipper says his practice no longer uses midwives because “the cost of malpractice insurance for the midwives had become astronomical.” But he disputes Stratton’s claim that doctors are performing more cesarean births due to convenience and money.

“I believe we [doctors] get reimbursed slightly more for cesareans, but it’s not an extravagant amount,” he says. “Maybe $100. It’s neither about money nor convenience. It boils down to patient safety, and also a background of medical liability and risk assumptions.”

Women like Wheeler, meanwhile, are caught in the middle of the cesarean versus VBAC argument. She says she now wishes she had never allowed doctors to perform a cesarean on her during her first child’s birth, as she would not then have been forced to have a second one. She says she knows her condition was serious, and that her blood pressure during her first pregnancy was at “stroke level.”

“The question was, do I sit here and wait until my blood pressure goes down to a level where I can give birth, or do I have a cesarean section?” she recalls. But she says doctors did not offer her other options—and she had no idea that the procedure would prevent her from ever again having another natural, vaginal birth. “Back then, I didn’t know the ramifications of that choice.”

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