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VBAC at Home: Courageous or Crazy?

Lissa Rankin's picture

According to an article written by CNN Senior Medical Correspondent Elizabeth Cohen, Aneka was told that, because she had three previous C-sections, she could not attempt a VBAC (vaginal birth after Caesarean) of her fourth child. Hospital after hospital, doctor after doctor, denied her the right to try. But after watching Ricki Lake’s 2008 documentary The Business of Being Born, Aneka decided she didn’t want a fourth C-section. With no local hospital willing to support her autonomous decision, Aneka decided to take matters into her own hands. She found a midwife willing to deliver her baby at home – and after 20 hours of labor, she delivered her fourth child.

Aneka’s decision to advocate for her own health care wishes – potentially at the expense of her baby’s safety ­– have since polarized online communities, splintering people into those who advocate for natural birth and those who value the guidelines of the traditional medical community. Some natural birth advocates celebrate Aneka’s courageous decision and lift her up as an iconic home birth revolutionary. Others chastise her for defying the advice of doctors and putting herself and her baby at risk of potentially dying as the result of a ruptured uterus or other VBAC-related complication.

What Do I Think?

I’m an OB/GYN, and most of my readers know that I speak out when I have an opinion, so yes – I do have an opinion, but it’s not a polarized one. Honestly, I can see both sides of the debate. Sure, this story sounds uplifting and makes for great headlines: "EMPOWERED WOMAN DEFIES AUTHORITY AND WINDS UP WITH HEALTHY BABY AND NO SURGICAL INCISION."

Sure, I’ll bite. You go girl! More power to ya! Down with the man. And all that jazz.

But while all’s well that end’s well, this story would have been cast in a very different light had Aneka or her baby died in childbirth, or had her baby wound up with cerebral palsy as the result of childbirth complications stemming from her decision to have a high risk birth at home. The risk of such an outcome, while rare, is real. And yes, I’ve seen it happen. You don’t ever forget those kinds of things.

Let’s consider both sides.

In Support of Aneka & Her Decision

Aneka did her homework, understood the risks, and made a conscious choice to take her body into her own hands. She refused to be bullied into the medicalization of her birth and stood up for what she desired, in spite of the lack of support she found from her local doctors and hospitals. That she was willing to overcome her fears, be authentic about who she is and what she wants, and stand for what she believed in the face of intense pressure to conform makes me want to jump up and hug Aneka. If only more of us were willing to do the same, I believe the world would be a better place.

In Support of The Doctors & Hospitals

Those of us who have witnessed what happens when a woman with a prior C-section ruptures her uterus know how quickly things go south. One minute, everything’s peachy. The next minute, the baby’s heartbeat drops off and you may have a mere 7-10 minutes to get that baby out lickety-split before the baby winds up disabled or dead and the mother ends up hemorrhaging to death.

What’s the chance that a uterus will rupture? 0.5-0.9% if you’ve only had one C-section before and 1-3.7% if you’ve had two or more. Which means that you’ve got a good chance of avoiding such a disastrous outcome. But what if you’re that 1%?

My Two Cents: It’s All About Informed Consent

Ultimately, it’s all about choice. I believe that Aneka has the right to understand the risks, to make a thoughtful, well-informed decision, to weigh the pros and cons, and ultimately, to buck authority if that’s what she chooses to do. She doesn’t need anybody judging her, bullying her, or manipulating her into doing something with her body that she chooses not to do.

When I worked at a public health clinic delivering babies where 99% of my patients were Somali immigrants, I often recommended C-section or other medical interventions to women who chose not to heed my advice. While some of my colleagues would whip off their gloves and refuse to care for these women – dismissing them as “uneducated, immoral heathens with no appreciation for the value of life” ­– I respected these women as equal partners in a health care relationship.  Coming from a vastly different culture, many of them held very different beliefs about their health care, and many had a profound faith in Allah that rendered them capable of completely surrendering to what would inevitably happen, with or without whatever medical intervention I was offering.

If these women chose not to have a C-section – even one that might save their baby’s life – I bowed to their wishes and helped shepherd their child into the world in a way that melded with their individual belief systems.  To inflict surgery upon another individual against their will is assault, plain and simple.

Most of these cases wound up with happy endings. Some did not. But ultimately, my job was merely to educate, to offer guidance, to make recommendations, and then to respect the wishes of my patients. Period.

Be An Empowered Patient

The moral of this story is that you do have a choice.  You may think that the medical complex rules your health care, but they don’t. YOU rule your health care. You get to choose. It’s your life. It’s your body. Do your homework. Ask lots of questions. Read Elizabeth Cohen’s fabulous book The Empowered Patient. Demand respect. Understand the risks. Think things through to their worst possible outcome. Find a new doctor or hospital if you need to. Then insist upon having your autonomy upheld. It’s all about informed consent. Be an informed consumer, make empowered choices, and never let anybody walk all over you and your body.

You are in charge. Don’t let anyone ever convince you you’re not.

What do you think? Was Aneka’s behavior heroic? Reckless? What are your thoughts on natural birth? Vaginal birth after Cesarean? Do you make informed choices about your own health care? Would you ever stand up to authority to demand that your wishes and your body be respected? Do tell…

Respecting your autonomy,

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This blog, and the book on which it is based, is a complement to - not a substitute for - professional advice and intervention, and is not intended to replace the advice of a gynecologist or medical professional, who should be consulted about any health care issues that may affect the individual reader. The information contained in this book is the product of observations made by the author in her practice, as well as her review of relevant literature in her field of expertise. The literature at times reflects conflicting opinions and conclusions. The views expressed herein are the personal views of the author and are not intended to reflect the views of any group or organization with whom the author is affiliated.

Comments

Alexis Neely's picture

VBAC in a Birth Center

My daughter was born via c-section in November 99 due to my naivety and a combination of over-protective doctors, unempowered midwives and an uninformed pregnant mama who was ready to not be pregnant anymore.

I swore to myself that when my second child was born, I would do it differently.

When I went on the hospital tour at 36 weeks preggo w/ my son in 2003, I knew that if I labored there I would have a c-section again, despite that my doctor was one of the few docs in LA in favor of VBAC and that I had hired a former labor/delivery nurse turned doula with lots of experience with VBACs.

I immediately called the Hollywood Birth Center to see if they would take me at that late date. They said yes.

I completed my prenatal appts w/ them and 4 weeks later, I gave birth to my son without any type of medical intervention at the birth center.

A dream come true.

Thanks for sharing this Lisa.

Alexis

Maria's picture

It in Gods hands.

Hi Lissa,

I had an emergency C-Section with my first child. My son was 9lbs 141/2oz and 22 1/4 inches... a big boy to say the least. He was all wrapped up in the cord. We almost lost him.

My daughter was a VBAC. I was induced for 2 days and no progress...1 centimeter dilated after 48 hours. They broke my water and told me it would be another day of waiting. 90 minutes later she was born. I had great luck getting my kids inside of me, but not much getting them out.

I believe in God's will, whether you are at home or in the hospital, you will get what you are meant to get. I have had friends who have had horrific outcomes in hospitals and some who have had wonderful outcomes at home.

I personally would never take any chances with my children's health. My health is a different story. I have called and scheduled test when my doctor wouldn't listen. I knew I needed my Gallbladder out so I ordered my own ultra sound. They were not too pleased with me, but I was right. It saved them a law suit...at least that is what I told them. :o)

I am so glad to hear that Aneka has a healthy baby and is healthy too. That is all that matters in the end.

SHARON HOCKENBURY's picture

vbac

I had 3 sections, then a VBAC in the hospital, then a VBAC at home. The next birth started at home and ended with a ER section because of complete uterine rupture. Obviously I survived, as did the baby with no longer complications. I went on to have 2 more scheduled sections, then a VBAC in the hospital. Yes, I had a VBAC after a complete uterine rupture. My choices were totally informed and entered in with full understanding, and yes it took courage. The empowerment came from the CHOICE. I am thankful I had the opportunity and the support system. It was not easy to advocate for what I believed to be the right choice for me, but I am glad I did.

Lissa Rankin's picture

Advocating for your own rights

Yes, I do think our system is painfully broken. In fact, my next book is called Broken: One Doctor's Search For the Lost Heart of Medicine. Patients should always be able to make informed choices- even in a hospital, I believe.

Ultimately, we all must advocate for our own health. The old model of putting your care into the hands of a doctor and just trusting everything they say just doesn't work when the system is as fractured as it is.

Heartbreaking. Really.
And in large part, this is why I let go of practicing medicine. I just can't bear to be part of such a sad, desperately broken system.

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Kelli's picture

Aneka is a hero

I respect the choice of women to decide what is right for them and their baby after becoming fully informed of the risks and benefits of a procedure or the situation of their birth. After being the victim myself of an unnecessary c-section given to me despite my birth plan for natural vaginal birth, against the recommendations of ACOG for my situation, and through coersion by scaring us into believing our baby was actually at a greater risk of birth related injury or death when that was not the case, I have advocated for women demanding the type of care you describe here... "I respected these women as equal partners in a health care relationship." However, when the doctors we pay to provide us with these services refuse to care for us and the insurance companies force these care providers to pay tremendous amounts for malpractice coverage, we are working in a broken system. There is no respect for the doctors from the insurance companies and the amount of schooling they have had and their right to practice under the ethical system they uphold and their patients would seek them particularly out for, if they were free to practice in such a way. There is no respect for a patient and her rights. What about cancer patients that refuse chemo? What about our grandparents who refuse to go to the doctor even when we feel they need too? Sure there is an infant involved in this situation, but also mothers who feel they are doing what is best for that baby and their life. If you are working with an informed mother, she is capable of deciding what is best for her and her child. 1-3.7% risks are not significant enough to blanket a surgical procedure to all these mothers who would fall into this category. We do risky procedures all the time where patients have 50-50 chance of survival. Why subject an infant and its mother to surgery if there is a larger chance that that procedure would be unnecessary than necessary?
Then, we come to the point that if a doctor would have attended to Aneka, her birth would have taken place in the hospital that is equipped to handle things if her birth fell into that 1-3.7% range. But, no... In order for her to refuse an intervention until it was proven necessary, she had to birth at home. I am an advocate for homebirth, and also chose to VBAC at home. But, I believe a system where doctors refuse to treat patients for poor reasoning, is broken and dangerous. So, in my eyes, Aneka is a hero. She was an advocate for her own healthcare. Her decision might not be right for other mothers, but that isn't the point. The point was it was hers to make, and the care provider she hired respected that and trusted her skills enough to be able to help if Aneka needed her to. That is heroic in my eyes.

Dana Theus's picture

I was one of the statistics

Lissa

Thanks for this article. Great point of view. My first pregnancy ended up being a Csection where I birthed a healthy boy, promptly followed by a 1.5 pound benign tumor that blocked his exit - and had not been diagnosed. Now I didn't have a midwife, who might have sought signals beyond what the sonagram showed for why he was so late and so breach. My point is that if it hadn't been found and they'd tried to turn the baby, he could have been in trouble and as it was I almost died on the table as they removed that thing. If it weren't for a skilled surgeon I would have bled to death. The Dr recommended a second Csection because of all the unusual scarring from the first surgery and having experienced the first "this never happens" I wasn't about to take chances. Boy #2 had a flawless Csection and my recovery was easier than the first.

I think you're totally right that it's a choice, but I've never regretted my decision to go with the route that gave me the most comfort the second time around where my baby and I would be where skilled resources were available "just in case".

I would LOVE to have felt I had the option for a midwife birth. I would LOVE for the hospital to have employed midwives who could have handled the majority of my birthing issues and had Drs on call for where their skills were particularly needed... but it wasn't the choice I was given. As my oldest prepares for college, I am thankful DAILY for the skilled care I received.

Thanks again for your perspective on this.

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