TAMPA — After delivering her first baby by caesarean section, Erin Yeager knew she wanted different for her second.
"I wanted to do what my body was made to do," said the Clearwater woman. She wound up driving across Tampa Bay to a hospital where she could attempt a vaginal birth after a caesarean.
While top obstetrical experts consider VBACs safe and appropriate for healthy women with uncomplicated pregnancies, it's tough to find a local doctor who'll go along, advocates say.
Yeager's quest took her to the University of South Florida's obstetrical group at Tampa General Hospital, which last year performed 224 VBACs.
"There was nowhere else to turn," said Yeager, who credits USF and TGH for supporting the "perfect birth" of her daughter.
This friendly reputation wasn't on display when the chief of obstetrics made headlines for emailing a pregnant patient to say he was so worried about her baby, if she didn't report for a c-section immediately he might have no choice but to send out law enforcement to get her.
As it turned out, the woman lived an hour from Tampa General and had sought out the practice specifically because it would consider helping her deliver vaginally after four caesareans.
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Rates of caesarean delivery have risen sharply in recent decades, now accounting for about a third of births nationally and more than 40 percent of deliveries at many Tampa Bay hospitals.
"Once a caesarean, always a caesarean" used to be medical mantra. Today experts say many women can safely attempt a vaginal birth after caesarean.
The benefits include faster recoveries and fewer infections for the mother, who avoids major surgery. Rupturing the uterine scar, the potential catastrophe many fear, occurs in less than 1 percent of cases.
In 2010, the American College of Obstetricians and Gynecologists attempted to promote VBACs by issuing less restrictive guidelines. But many women still aren't interested or can't find doctors willing to provide them.
State figures show fewer than two dozen VBACs were performed last year at St. Joseph's Women's Hospital, which delivered the most babies in the Tampa Bay area.
"There are wide swaths of the country where (access) is a problem," said Dr. William Grobman, a professor of obstetrics and gynecology at the Northwestern University medical school, who helped write the 2010 guidelines.
"There are large issues that this has to do with, including medical legal liability," he added, "but also changing perceptions in society about the benefits and risks of caesarean versus vaginal birth."
Shying away is "not bad medicine,'' said Dr. Lorraine Bevilacqua, who chairs the division of ob-gyn at St. Joseph's. "It's just a personal preference."
Her practice, Lifetime Obstetrics and Gynecology, will do VBACs for women at low risk of complications, but most patients prefer another c-section over labor, she said.
At Bayfront Medical Center in St. Petersburg, the delivering doctor is expected to stay with the mother during the entire labor for a VBAC.
"Depending on how long — and we cannot predict how long the whole labor process will be — the fact that you have to physically sit at the hospital makes it very difficult," said Dr. Raphael Guichard of New Beginnings Obestetrics and Gynecology, which doesn't offer VBACs.
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It was a "VBAC-friendly" reputation that led Lisa Epsteen to USF's obstetrical group, which practices at Tampa General.
The Spring Hill mother was interested in attempting a vaginal birth after four prior caesareans.
She met several times with Dr. Jerry Yankowitz during her high-risk pregnancy, ultimately accepting his recommendation to deliver her by caesarean, she said. But they disagreed about the urgency of the situation, and Yankowitz sent the soon-to-be-famous email.
After a flurry of legal and media attention, Epsteen delivered a healthy, 11-pound boy at Tampa General on the day she requested. She spoke to the Tampa Bay Times after receiving the email, but hasn't responded to subsequent interview requests.
Patients, midwives and others rallied in support of USF and Tampa General. Though Yankowitz wouldn't discuss Epsteen's case because of confidentiality laws, he did agree to talk generally about VBAC practices.
Offering VBACs makes sense at an institution that trains future doctors, he said. "We should be practicing the highest standard. It's the academic difference."
Supporters in the community say that since becoming USF department chair about two years ago, Yankowitz has reached out to midwives performing home births, who often are more accustomed to hostility from the medical establishment.
"It was like pigs flying," said Charlie Rae Young, owner of Barefoot Birth, recalling how Yankowitz personally visited one of her patients who had wanted a home birth but had to transfer to the hospital. "It's really, really rare to be received so well."
Yankowitz said he has always practiced alongside midwives, who are part of the USF service. In most healthy pregnancies, he said, they can provide excellent care and can spend more time with patients than many doctors can manage. If there's a problem, a midwife can call in a perinatologist with expertise in high-risk pregnancies, like Yankowitz.
Certified in both maternal fetal medicine and genetics, he spends much of his time advising on the odds that a fetus with a major heart defect will survive or that a mother with a serious health condition can carry to term.
Still, he says, most births don't require a high-tech approach.
"I don't disagree with people who say the process may be overmedicalized," he said.
"Is there a way to balance all those technical advances that we've done so they are put where they are supposed to be?"
That's the approach he takes when talking to a woman who wants to attempt a vaginal birth after a caesarean.
"A lot of it is just trying to put it in perspective," Yankowitz said. "You can lay out the risk, but ultimately the women has to decide."
Letitia Stein can be reached at firstname.lastname@example.org or (727) 893-8330.