You would think that after having delivered two babies vaginally--one after a cesarean section--Joy Szabo's ability to give birth is sufficiently proven.
Not so, according to Page Hospital of Page, Arizona, where Mrs. Szabo delivered all three of her babies (including the one VBAC), but now faces an unnecessary and unwanted "elective" cesarean for her fourth. Page recently enacted a 'VBAC ban,' a policy that is more appropriately referred to as a "denial of service for women with prior cesarean unless they preauthorize surgery" since a vaginal birth is not so much a "procedure" that a hospital can elect to perform or not, but rather is a biological process which they can attend or not attend, but will happen either way.
According to the hospital Chief Executive Officer Sandy Haryasz, the hospital's choice not to attend vaginal births for women with a prior cesarean seems to be that birth is just too unpredicatable, VBAC just too risky. From the Lake Powell Chronicle:
"Page simply does not have the physician resources to respond to an emergency. Currently, we have two physicians who are delivering babies and a third physician will be joining us next week.
"Three physicians cannot provide the coverage recommended by ACOG (American College of Obstetrics and Gynecology). The physicians must be immediately available because of the risks of a VBAC and we cannot provide that in Page. In addition, we cannot provide an anesthesiologist to be readily available because we only have one anesthesiologist."
Never mind that the recommendation that "because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care" (p. 6) is a "Level C" recommendation (based "primarily on consensus and expert opinion" -- as opposed to "good and consistent scientific evidence" (Level A), or even "limited or inconsistent scientific evidence" (Level B)), whereas the statement that most women are good candidates for VBAC and should be offered a trial of labor is "Level A."
As Mrs. Szabo points out, however, "that's why women go to the hospital to have their babies - in case there is an emergency." A hospital that admits that they don't have the resources to perform an emergency cesarean should probably not be holding themselves out to be any safer than a birth center or midwife-attended home birth (both of which are very safe for women with low risk pregnancies, incidentally), seriously calling into question why Arizona midwives are prohibited from attending VBACs.
This also raises another question: if vaginal birth is a biological process that will happen with or without the hospital's help, what if Ms. Szabo shows up in labor? In fact, isn't she protected by EMTALA (Emergency Medical Treatment and Labor Act), which requires all hospitals that receive Medicaid funding to stabilize everyone who walks in to the Emergency Room in active labor?
Yes and no. While the Act specifies that "stabilization" for the purposes of active labor means delivery of the baby and the placenta, it makes no provision for how a hospital must treat a woman who refuses unnecessary cesarean surgery. Page Hospital is prepared, though.
"I asked Sandy [Haryasz, hospital CEO] what would happen if I just showed up refusing a c-section and she said they would obtain a court order ."
So, despite the fact that as a matter of law and medical ethics hospitals should only seek recourse to the courts to override patients' wishes in "extremely rare and truly exceptional case[s]," In Re AC. , 573 A.2d 1235, 1252 (D.C. App. 1990), the hospital is basically saying that it plans to ignore ACOG's ethical guidelines and trample on a woman's rights to bodily integrity, informed consent, and due process to comply with its lowest-level reccomendations, completely irrespective of the mitigating factors Ms. Szabo presents (i.e. two prior vaginal deliveries, including a VBAC; only one prior cesarean, etc.). Nice.
Adding insult to injury, Bill Byron, Senior Director of Public Relations for the hospital system tweets :
Re: VBAC issue & w/ all due respect, our VBAC practice based on ACOG practice guidelines common in all if not most hospitals across nation.
which, sadly, is true , and
Banner pro-VBAC w/ appropriate patients . Many large, urban Banner hospitals provide, but not in hospitals lacking high-risk capability.
I guess he forgot to add "pro-coercive medicine in hospitals lacking high-risk capability."
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I say she needs to have a home birth
and if she can't have a midwife there then she needs to find someone who will be there to help here deliver the baby at home, and if there are complication she should sue the hospital because it would be there fault for refusing her treatment along the lines of her beliefs
Unfortunately, it appears that an unassisted home birth (or a home birth with a midwife who has to go "stealth" in the event of a transfer, risking her license and even criminal prosecution) may be one of her only options.
While I support women's right to choose home birth and even unassisted birth without judgment or interference from the state, I find it troubling that more women are finding themselves forced into choosing between a home birth they didn't really want or a cesarean they really don't want. This is especially worrying considering the growing numbers of women who are finding that their prior cesareans are uninsurable "pre-existing conditions," so they feel they have to deliver at home for economic reasons.
One of the greatest advantages of home birth is the ability to labor in a place where the woman feels most comfortable and safe. For Mrs. Szabo, that seems to be in a hospital.
The last part of your comment brings up an interesting thought. I would be very interested to see what sort of legal claims could arise from cases like hers. I think that the "medicolegal climate" has (rightly or wrongly, and I tend to think wrongly) been blamed for the current state of obstetrics, and I am hopeful that it will have a hand in helping women assert their rights during pregnancy and birth.
An OB-student friend of mine told me once "You have to think about it from [the doctors'] perspective: some of them have attended VBACs that went wrong in the 80's due to use of Cytotec, and are probably pretty traumatized by that. But I think we're going to start getting to the point where we have to deal with catastrophic consequences of cumulative cesareans, and the conversation will start to change." Although I hope we DON'T have to get to that point before we can have an honest, non-hysterical conversation about the relative merits and demerits of cesarean surgery, particularly where it's not medically indicated...
1) She shouldn't go to that hospital.
2) VBACs have the risk of rupturing your uterus- killing both you and your baby or only killing the baby and you losing your uterus.
C-sections suck but as *natural* as vaginal births are, part of the danger of the very natural course of pregnancy is how unpredictable labor is. Let's not belittle that.
If she is indeed that intent on having vaginal birth she shouldn't go to that hospital and instead go to a birthing center. MUCH cheaper and they will cater to her needs.
You make some interesting assumptions (which may or may not be true, since I am not from Page, AZ). You assume:
1. That there is another hospital (or birthing center) for her to go to. the article -- which I assume you read -- says that her only other option is a "women’s care clinic in Phoenix", which google maps tells me is 4 hours, 41 minutes away by car.
2. If there WERE a birthing center near her, that it accepts VBAC clients. Not all do, and in fact it appears that the agreements with obstetricians that are required by some states specifically preclude them from attending VBACs. This varies by state, and by form of accreditation of the midwives who run the center, so again, I can't speak to AZ.
As for the *natural* aspect (I can only assume that the asterisks are meant to represent sarcasm), indeed, death is a natural risk of vaginal birth -- as is it a risk of surgical delivery.
It's not merely about whether or not c-sections suck, it's about whether a woman has the right to assess the relative risks (and, for the record, the risk of uterine rupture is very low, particularly where the woman has already delivered one VBAC), decide on a course of action, and still be able to get a birth supervised by an obstetrician. Frankly, both the AMA and ACOG agree that coercive tactics like those the hospital is threatening to employ ultimately harm maternal and fetal health by driving women away from hospitals altogether (whether I think that births generally should usually be supervised by obstetricians is totally ancillary, so I won't go into it). What she is asking for is really not that radical: an OB-attended birth in a hospital, just like the other two vaginal deliveries... just like the other VBAC. But they changed the policy out from under her to one that requires a preemptive abrogation of her right to informed refusal.
Either way, it is categorically wrong for a woman to be denied care because she won't submit to a surgery before it is medically indicated.
I assume nothing. It doesn't matter how far it is, if she wants to and is confident in her ability to deliver vaginally she can do so without a doctor there. The only reason a doctor is around for a vaginal birth is in case of serious emergency.
I didn't assume about the midwives- the article questions why midwives in AZ are prohibited from attending VBACs. Page,AZ isn't the only place with birthing centers and as your link shows- there is a hospital she can get to without a ban on VBACs.
It does matter how far the facility is. My labor with my first child didn't last long enough for me to travel the distance from Page to Phoenix. I would have given birth in the car. Thankfully, I didn't have to worry about it because home birth midwives are licensed in FL, which isn't the case for home birth midwives in AZ, they can't attend VBAC birth because the legislature hasn't caught up with a woman's right to chose how she delivers her baby.
The risk of rupture in a VBAC is very small.. less than 1%. And only a fraction of those that rupture have catastrophic results.
C-sections carry twice the risk of maternal death over a vaginal birth. They also increase the risk of the baby having breathing trouble after birth.
Neither option is without medical risk. It should be up to the mother to decide which risks she prefers to take, rather than being dictated to her by the hospital because their LEGAL is greater with a VBAC than it is with a cesarean.
There's also a heightened risk of having to have an emergency hysterectomy with each subsequent c-section, but the hospital only seems to focus on the risks of vaginal birth for some reason, and generally doesn't even inform women about the risks of multiple c-sections.
The hypocrisy involved in obstetrics is incredible.
You can't have a VBAC at this hospital because we aren't prepared for an emergency c-section if something goes wrong.
But don't birth at home! What if you need an emergency c-section for something like placental abruption, or fetal distress! Come to our hospital where we...uh...can't perform an emergency c-section if those things go wrong?
How do they make sense even to themselves?
What if you need an emergency c-section for something like placental abruption, or fetal distress! Come to our hospital where we...uh...can't perform an emergency c-section if those things go wrong?
That is what I noticed first. Are they pretty much screaming C-section whether needed or not at that hospital? If they can't handle emergencies then they are not fit to be a birthing facility, let alone a medical facility.
Exactly. Upon reading this article, I was confused as to what the benefit for ANY laboring woman would be to deliver there over delivering at home ... it sure sounds like they are completely unprepared for any emergency for anyone in labor.
UPDATE:
Mrs. Szabo tells her story here.
this is a clear example of how, in our current health "care" system, the burden falls onto the patient for everything.
the one hospital that she could safely get to in the event that her birth presented a complication, isn't equipped to support her (or many other women like her) adequately. so, rather than using this information to determine that they need more medical staff in order to meet the growing need for VBAC births (something that might have been much rarer if cesarean births weren't overused by doctors) they limit the kinds of services they are willing to provide.
what's wrong with this picture to me, is that the funds exist but are going to profit big companies instead of to provide adequate health care. i think hospitals get stuck in the middle.
They can't hire more staff. This is a 25 bed hospital in a tiny town in rural Arizona.
I oppose VBAC bans and threatening a court order was so over the top that it's ridiculous--but this is a hospital that really isn't equipped, and will never be. It operates maternity because the alternative is to force all women to travel for hours (and the 2 closest larger hospitals are in neighboring states, which poses an insurance problem--so they have to travel even farther).