Five central themes emerged from the analysis of the interview transcripts: fear of liability, minimizing risk, convenience of cesarean, defining "immediately available, " and marginalization of midwives. Obstetricians tended to be more risk-averse than the midwives, but there were not always clear differences between the groups. Thus, exemplar narratives were selected to demonstrate variations in perspective within a given theme. It is important to note that these differences represent competing ideologies of birth that cannot exclusively be ascribed to a particular provider group.
Fear of Liability
For a number of providers, fear of liability was a major impediment to offering a trial of labor for women with a previous cesarean. According to Dr. Diane (all names are pseudonyms), who practices in a suburban community hospital, "obstetricians are in a constant fear of being sued, so they're taking a path of least resistance." This fear was often generated from experience with a lawsuit. Dr. Arthur, a senior obstetrician in a rural community hospital, offered his perspective:
If you have a problem [during a trial of labor], you are going to get no sympathy from the medico-legal community. They are going to be all over you, and if you end up with a ruptured uterus, you are going to be lucky if you get a viable newborn and you don't have a lot of problems with the mother. And nobody is going to be sympathetic for any unusual pattern on the monitor...you can't tell me of a single failed VBAC that resulted in a ruptured uterus that wasn't a disaster medico-legally.
Interestingly, fear of liability around VBAC was not limited to those practicing in community and rural hospitals. Even obstetricians in academic medical centers, with 24-hour obstetrical and anesthesia coverage, reported that some of their colleagues refused to allow women a trial of labor at all. When asked why this was so, Dr. David responded: "I think the problem with VBACs is largely with lawsuits. I think it's a question of not wanting to get sued!"
Some providers, however, took a more pragmatic approach to their concerns about liability, particularly in terms of how it affected their practice. Dr. Angela put it this way:
I've had plenty of negative experiences with VBAC. Plenty of people with uterine ruptures, plenty of people with scar dehiscence. Failed VBAC, I had to section them and you're looking through the serosa at the baby! That doesn't mean I'll stop doing it, but it means I do approach it with caution, like I would anything else.
Midwives were also concerned about potential liability, for both themselves and their obstetrician colleagues. CNM Grace said she thought that obstetricians "very much had to tailor their practice to the legal malpractice climate." Similar to Dr. Angela, however, Grace was not inclined to change her practice based on fear of a lawsuit:
I just think it's a bunch of crap that you have to change your practice when you know something is safe because somebody might sue you. Anytime you get a less than optimal outcome, people want to blame, people want to sue. You may have done everything right, and it doesn't matter, so you can't live your life being afraid of that...there's so much you can control, and things have a way of happening sometimes. It's just kind of a personal philosophy, too. I just think that most long-term midwives get to that point. Otherwise you'd be too afraid to do anything. Birth is amazing, and not always predictable.
Of the 11 obstetricians in the study, 4 had sovereign immunity, and 7 reported that they did not carry malpractice insurance due to the high costs of premiums. Data were not collected on the other options for obstetricians. All 12 midwives said they carried malpractice insurance. None had sovereign immunity or the financial means to utilize the other options, such as letters of credit or surety bonds. (Table ). The providers used several strategies to manage the risks associated with caring for women with a previous cesarean. Avoidance was the most common strategy. According to Dr. Arthur:
But here at this Level I [rural, community hospital], there's no way that they can meet the requirements of ACOG's recommendation. So I think there are too many areas that you can't cover trying to do a VBAC, and as a result of that, I have chosen to just deliver all of my previous sections by cesarean section.
Other providers in community hospitals continued to offer a trial of labor, but they also attempted to minimize their risks of liability by recommending it only to the most motivated and adamant women. Dr. Patricia did not feel comfortable encouraging women toward VBAC unless they expressed a "strong" desire to try it:
They really do need to express an interest in it. I do feel really hampered by being in the State of Florida with no professional liability insurance. So the safest thing for the baby is a repeat C-section. I will never get hammered on that in the court of law. I will get hammered in a court of law allowing a VBAC to occur.
Midwives who were delivering babies without an in-house consultant physician or anesthetist felt particularly vulnerable. CNM Stacy, a community-based midwife in private practice, expressed relief about no longer attending VBACs because of her experiences with delays during emergencies:
I was somewhat saddened when we stopped doing them because I think in our practice we had a very good success rate for delivering previous C-sections. But one time it took over 15 minutes for somebody from anesthesia to get there, and when you're sitting there and the baby is going bad, it was a difficult position to be in. So I finally made peace with it.
Convenience of Cesarean
Both obstetricians and midwives said that the convenience of scheduling a repeat cesarean was appealing for several reasons. First, many women preferred to avoid labor and appreciated the convenience and control that repeat cesarean afforded. Second, having to remain immediately available throughout a trial of labor imposed significant lifestyle and practice limitations, particularly for providers in rural, solo, or small-group community practices. Dr. Charles, a community obstetrician in practice with a midwife, offered his thoughts on why the convenience of repeat cesarean was attractive for obstetricians:
It's certainly easier to do a repeat C-section, so why not just say, 'Shoot, I don't have to deal with VBACs, great! The few patients that want to go out of town [for a VBAC] can go there, and I get to have a little bit easier life.' I think when you get to the heart of it, that's what's going on.
Some of the midwives were critical of obstetricians, however, for what they viewed as a promotion of repeat cesarean for their own convenience. LM Rosa offered a typical perspective:
I have been appalled at how many OBs [obstetricians] will let them pick the date on their first OB visit for their repeat cesarean. Repeat cesareans are not only OK here, they're promoted! They can pick the date, which is very convenient...and they're selling, they're selling cesareans.
There were some obstetricians, however, who felt that women's choices took precedence over the doctor's convenience. According to Dr. Hanna, a community obstetrician in a small group practice, "it's much easier for us to schedule a C-section, but if it's [VBAC] something that the patient wants, then we certainly give them that opportunity."
Defining "Immediately Available"
Regardless of size or location, all of the hospitals in the sample utilized the ACOG guidelines as the defining standard of care for VBAC. Definitions of "immediately available, " however, varied considerably from hospital to hospital. According to Dr. Fay, who worked in a mid-size, urban community hospital:
Immediately available in the hospital's definition is within 10 minutes from the unit [labor and delivery]. Our office is 3 blocks away, my house is within the 10-minute window. Unless there's a problem, I am basically doing what I would normally do on call, which is not to be more than 10 minutes away from the hospital, anyway. It really doesn't change the time factor.
Dr. Patricia, who practiced in a mid-size, suburban community hospital, stated:
We require ourselves to be in-house. We have a very strange rule here that does not exist in any other hospital...if we have Pitocin, an epidural, or a VBAC in labor, the provider has to be in the hospital with the patient. We cannot leave the facility. There's no perineal obstetrics. We are here.
In other community hospitals, the immediate availability of an anesthetist was the central issue. However, as Dr. Megan described, the decision about whether or not to allow VBACs depended heavily on the political power of both the anesthesia and obstetrical groups at the Medical Staff meetings:
Our issue has been that our anesthesia group does not have a dedicated anesthesia provider for L&D [labor and delivery]. There were also some obstetrics groups that also supported that--they weren't offering VBAC and didn't have any desire to consider offering that service. So current hospital policy is that we're not able to offer a VBAC.
Marginalization of Midwives
Interestingly, there is no mention of the role of midwives in the 2010 ACOG VBAC guidelines. Because the recommendation is for the immediate availability of an obstetrician and anesthesiologist, the midwives in this study felt they were marginalized in terms of care provision and excluded from the policy-making process. There were various reasons, they thought, for why this had occurred. According to CNM Katherine:
We were doing VBACs with no problem in the hospital, and then, the doctors dropped their malpractice insurance, and we weren't able to do VBACs, even with the doctors there. Even if the woman wanted the midwives to be giving the care.
Since the physicians were required by the hospital to be immediately available during the labor and birth, some of the midwives in private practice discovered that they were being excluded for financial reasons as well. According to Florida billing practices, only 1 provider can be paid for the delivery. In most cases, the midwives found that their consultant physicians were opting to conduct the births themselves and collect payment. CNM Barbara stated:
Then the ACOG shift happened where they [hospital policy-makers] decided the OB had to be in-house, and he [the obstetrician] decided he's not going to be there in the house and not get the money for the birth. So we had to stop doing them [VBACs].
Some obstetricians thought that restricting midwives from the care of women with a previous cesarean was an unwise strategy, however. Dr. Charles, who practiced in a community hospital with a midwife, described his perspective on collaborative practice arrangements:
Now I allow my midwife to take care of VBACs. Once the patient was in active labor, I was always within 10 minutes away, and I was always in the hospital for the delivery, no matter what! Now the other group won't allow their midwives to take care of a VBAC patient, which I think is stupid, because, if anything, the VBAC patient needs more one-on-one kind of coaching and encouragement, and the midwife's in a position to do that. I think our VBAC success was as good if not better with the midwife doing it. And we had a team...our system was such that they had no financial disincentives to call me. But they never called me unless it was appropriate, so it worked out fine.
Most LMs in Florida are self-employed and have small home-birth or birth center practices. Although they are not required to have a collaborating physician of record to practice, they are restricted by the rules associated with their practice act when caring for a woman with a previous cesarean. LM Sylvia stated:
We have to have them signed up by an obstetrician with hospital privileges as likely to have a normal labor and birth. We may not even do prenatal care on somebody in that situation without having a signed collaborative management agreement. Our back-up physician, as well as an anesthesiologist, is required by the hospital to be present the whole time a VBAC is in labor, and so he's not able to make that time commitment. So he's not doing VBACs; thus, he's not signing us off for doing VBACs.
Not all LMs in Florida are in this predicament, however. Some are still able to find collaborating physicians to sign them off for a home birth, although attempting a trial of labor in a birth center is no longer allowed [34
]. Thus, birth centers in Florida are unable to offer VBAC legally, and midwives are concerned that women's choices are declining as a result. According to LM Jennifer:
I would say we've been getting between 6 and 12 inquiries a month [about VBAC]. And that's not women who are choosing out-of-hospital birth as a priority. They have gone ahead and called a bunch of OBs and hospitals and realized the fact that their choice is diminished...it's heartbreaking.