After delivering their first babies through caesarean sections, Melanie Smith and Kelly Roell were determined to have their next children the natural way.
But the Tampa moms had trouble finding doctors who would perform a vaginal birth after a C-section, or VBAC. Roell said she called 10 different practices before finding one. Smith eventually decided on a home birth with the help of a midwife.
They're in declining company. The number of American women who give birth vaginally after a previous C-section has plummeted. Fewer than 8 percent of women now have VBACs, down from a high of nearly 30 percent in the mid 1990s. The decline mirrors the overall rise in caesareans, which now account for 40 percent of Florida births.
The falling VBAC rate can be traced to several factors:
• The risk of complications from a post-caesarean vaginal birth, which are rare but can be catastrophic.
• Lawsuits, and as a result, more cautious guidelines for doctors from the American College of Obstetricians and Gynecologists.
• Greater public acceptance of caesareans as a safe and easy method of childbirth has more moms electing the procedure.
Doctors and VBAC supporters, however, counter that the main risk, uterine rupture, is less than 1 percent. They also say that repeat caesareans carry their own hazards, such as respiratory problems for the infant and an increased chance of complications with future pregnancies for the mother.
That factored into Smith's decision to deliver her next child vaginally. Though the mom of twins doesn't know whether she'll want a fourth child, "I don't want to be told that I can't have more children. I don't want the decision stolen away from me."
For about 70 years, doctors subscribed to the dictum, "once a caesarean, always a caesarean."
That began to change in the mid 1970s, when improvements such as better fetal monitoring made VBACs a safer option, according to the American College of Obstetricians and Gynecologists.
The rate of women having vaginal births after C-sections climbed from 2.2 percent in 1970 to 28.3 percent in 1996.
But with more VBACs came more incidents of uterine rupture, some fatalities, and then litigation against doctors. The American College said many physicians and hospitals began to discourage, or even discontinue, the practice.
The group also issued new guidelines in 1999, recommending that VBACs be attempted only in hospitals with physicians "immediately available" to respond to emergencies. Earlier, the group stated only that doctors be "readily available."
VBAC rates fell sharply after that, dipping to 7.9 percent in 2005, the most recent data available.
The American College maintains that VBACs "can be an option for many women." In a brochure, it lists reasons why a woman might opt for a VBAC:
• No abdominal surgery.
• Shorter hospital stay.
• Lower risk of infection.
• Less blood loss and need for transfusions.
But it also notes that VBACs are not an option for every woman. The type of incision used, the number of previous caesareans, the size of the fetus, length of pregnancy and other medical conditions all factor in.
Still, of the women who try VBAC, 60 percent to 80 percent "succeed and are able to give birth vaginally,'' the college says.
Both have risks
Giving birth may be the most natural thing in the world, but both VBACs and repeat caesareans come with significant risks. VBACs can result in a rupture of the uterus, hysterectomy, increased maternal infection and the need for transfusion.
Repeat caesareans, due to multiple incisions in the uterus, can increase chances of complications with future pregnancies.
They also pose risks for babies. A June study from the University of Colorado School of Medicine found that infants born after repeat caesarean delivery have more respiratory problems than those born vaginally after a previous C-section.
Though many hospitals and physicians won't go as far as to say they ban VBACs, the numbers tell the story.
St. Joseph's Women's Hospital in Tampa delivers more than 7,000 babies each year, by far the most in the bay area. In 2008, four babies were delivered by VBAC. And so far this year, three have been delivered through VBAC. St. Joseph's officials say the doctor determines the most appropriate method of delivery.
Cost and choice
Dr. Mahnee Dinsmore knows how difficult it is to find a doctor who will support a VBAC. As one of two obstetricians at Trinity Women's Care in west Pasco County, she says she has patients who drive from Tampa and St. Petersburg to see her.
How doctors are paid could be another reason there aren't more VBACs, she said.
The doctor's reimbursement for a VBAC for a Medicaid patient would be about $1,150 for a delivery that could take many hours. A repeat caesarean would pay about $800, but would take about an hour, Dinsmore said.
Dinsmore said she always asks patients if they want to deliver vaginally, but assesses them carefully to ensure they are good candidates. Most of her patients opt for repeat caesarean deliveries. The ones who want a VBAC are usually those who've traveled a distance to find her.
"They are usually women who are very committed to natural childbirth," Dinsmore said.
Kelly Roell and Melanie Smith are members of the Tampa chapter of the International Caesarean Awareness Network, a grass roots group whose mission is to prevent unnecessary caesareans through education, support women during caesarean recovery and promote VBACs.
After her first child, Brady, was born in 2007 by C-section at Tampa General, Roell, 31, was determined to deliver her second child vaginally. But as a high-risk patient — she has a blood clot disorder — Roell had a difficult time finding a physician to agree. She eventually found USF Physicians Group.
Roell delivered her son, Kaden Daniel, on Friday morning through a VBAC. He weighed in at a healthy 8 pounds, 5 ounces.
Like Roell, Smith, 30, didn't plan on a caesarean section the first time around. But after more than two days of labor, which she described as "miserable and terrible," she gave birth to twins Abigail and Annabelle via C-section in March 2008 at Tampa General Hospital.
"I gave it my darnedest. I tried and tried," she said.
With the help of a midwife, she is planning to give birth at her Tampa home next month.
"I really want to experience it," Smith said. "It's part of being a woman. I don't want to miss out on the experience."
But just in case there are problems, she's ready to go to nearby University Community Hospital.
Richard Martin can be reached at firstname.lastname@example.org or (727) 893-8330.