Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

VBAC rates are low, but are obstetricians to blame?

Kenneth Lin, MD
Conditions
March 25, 2010
Share
Tweet
Share

My daughter, who turns two years old in June, is becoming something of a medical rarity. This isn’t because she is showing signs of a late-developing handicap or extraordinary ability for her age – it’s because she came into the world as a vaginal birth after Cesarean section (VBAC), delivered by a certified nurse midwife.

Although more than three-quarters of women who choose a trial of labor over a repeat Cesarean section successfully deliver vaginally, studies showing slightly elevated risks of rupture or infection of the uterus with VBAC, pressure from insurance companies concerned about lawsuits, and restrictive medical guidelines discourage most women from even trying.

After reaching a high in 1996 of 28.3 percent of women who previously delivered by Cesarean, the national VBAC rate today is fewer than 1 in 10. As a result of all of these repeat Cesareans, 1 in 3 births in the U.S. today occur by Cesarean.

For the past two days, a conference at the National Institutes of Health has sought to understand the reasons for the decline of VBAC, and what might be done to reverse what most believe to be a negative trend. An independent panel will release a draft statement summarizing the take-home points from the conference. What the statement probably won’t say, but what I believe to be a large part of the truth, is that the U.S. has such a low VBAC and high Cesarean rate because obstetricians deliver most of our babies, and obstetricians aren’t primary care clinicians.

The old medical maxim “when you hear hoofbeats, think horses, not zebras” refers to the fact that common conditions are more likely to present than rare or estoteric conditions. A dry cough, for example, is more likely to be due to allergies than Erdheim-Chester disease. Vomiting and diarrhea are much more likely to be caused by rotavirus than Vibrio vulnificus.

Primary care clinicians internalize this maxim during their community-based training programs; specialist physicians – who spend most of their training learning to diagnose and treat “zebras” at academic medical centers where patients with uncommon conditions are referred for care – typically abandon it early on. And even though many women visit obstetricians for routine gynecologic care, when it comes to the primary care-specialist attitude divide, Ob/Gyns come down clearly on the side of the specialists.

I could offer lots of anecdotes about why the above is true from having worked with OB/GYN physicians throughout medical school and residency training (when I delivered more than 80 babies and assisted in about half as many Cesarean sections), but objective data support the notion that labor managed by family physicians and professional midwives is considerably more likely to result in a vaginal birth than labor managed by an obstetrician, even controlling for factors such as maternal age and risk status.

It isn’t difficult to understand why. If an obstetrician is feeling uncertain about how well a patient’s labor is progressing and has an inflated estimate of the probability that something might go wrong (the zebra), it’s very hard to resist the temptation to eliminate the uncertainty by delivering the baby surgically, then and there. On the other hand, if the surgeon is at least a phone call away (the American Academy of Family Physicians’ 2005 guideline on trial of labor after Cesarean noted that there’s no good evidence that having a 24-hour on-call surgeon and anesthetist in-house improves maternal or infant outcomes), the family physician or nurse midwife might be more patient with the hoofbeats, betting they’re hearing a horse.

And, in fact, in a 2004 study of nearly 18,000 women who attempted VBAC, the most feared complication of uterine rupture (which requires an emergency Cesarean), occurred in less than 1 percent of cases. As mentioned earlier, a trial of VBAC is successful more than 75 percent of the time.

It’s a real shame that women in the U.S. are discouraged from attempting them more often.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

Submit a guest post and be heard.

Prev

VBAC should not be a woman's right

March 25, 2010 Kevin 51
…
Next

Primary care is disproportionally hurt by Medicare cuts

March 26, 2010 Kevin 12
…

ADVERTISEMENT

Tagged as: Hospital-Based Medicine, Specialist

Post navigation

< Previous Post
VBAC should not be a woman's right
Next Post >
Primary care is disproportionally hurt by Medicare cuts

ADVERTISEMENT

More by Kenneth Lin, MD

  • How to recruit more students into family medicine

    Kenneth Lin, MD
  • When should you prescribe statins for older adults?

    Kenneth Lin, MD
  • Clinical practice guidelines have problems, but they’re not broken

    Kenneth Lin, MD

More in Conditions

  • Clinical ghosts and why they haunt our exam rooms

    Kara Wada, MD
  • High blood pressure’s hidden impact on kidney health in older adults

    Edmond Kubi Appiah, MPH
  • How declining MMR vaccination rates put future generations at risk

    Ambika Sharma, Onyi Oligbo, and Katrina Green, MD
  • How one unforgettable ER patient taught a nurse about resilience

    Kristen Cline, BSN, RN
  • Why regular exercise is the best prescription for lifelong health

    George F. Smith, MD
  • When the weight won’t budge: the hidden physiology of grief, stress, and set point

    Sarah White, APRN
  • Most Popular

  • Past Week

    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Harassment and overreach are driving physicians to quit

      Olumuyiwa Bamgbade, MD | Physician
    • Why peer support can save lives in high-pressure medical careers

      Maire Daugharty, MD | Conditions
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • Addressing menstrual health inequities in adolescents

      Callia Georgoulis | Conditions
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
  • Recent Posts

    • The shocking risk every smart student faces when applying to medical school

      Curtis G. Graham, MD | Physician
    • Clinical ghosts and why they haunt our exam rooms

      Kara Wada, MD | Conditions
    • High blood pressure’s hidden impact on kidney health in older adults

      Edmond Kubi Appiah, MPH | Conditions
    • Deep transcranial magnetic stimulation for depression [PODCAST]

      The Podcast by KevinMD | Podcast
    • How declining MMR vaccination rates put future generations at risk

      Ambika Sharma, Onyi Oligbo, and Katrina Green, MD | Conditions
    • The physician who turned burnout into a mission for change

      Jessie Mahoney, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 45 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Harassment and overreach are driving physicians to quit

      Olumuyiwa Bamgbade, MD | Physician
    • Why peer support can save lives in high-pressure medical careers

      Maire Daugharty, MD | Conditions
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • Addressing menstrual health inequities in adolescents

      Callia Georgoulis | Conditions
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
  • Recent Posts

    • The shocking risk every smart student faces when applying to medical school

      Curtis G. Graham, MD | Physician
    • Clinical ghosts and why they haunt our exam rooms

      Kara Wada, MD | Conditions
    • High blood pressure’s hidden impact on kidney health in older adults

      Edmond Kubi Appiah, MPH | Conditions
    • Deep transcranial magnetic stimulation for depression [PODCAST]

      The Podcast by KevinMD | Podcast
    • How declining MMR vaccination rates put future generations at risk

      Ambika Sharma, Onyi Oligbo, and Katrina Green, MD | Conditions
    • The physician who turned burnout into a mission for change

      Jessie Mahoney, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

VBAC rates are low, but are obstetricians to blame?
45 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...