VBAC is rare even in a hospital




It is hard to believe that home delivery after cesarean delivery is even considered in the United States in 2008. It is equally unbelievable for the American College of Nurse Midwives and the American Public Health Association to support the practice. I doubt that many obstetricians would attempt vaginal birth after cesarean delivery (VBAC)—even in a hospital—in a patient who has undergone two C-sections.

In Illinois, a bill is pending that would allow midwives to deliver without supervision in a free-standing birthing center. I believe physicians are partially responsible for this development. Some of these midwives have the support of physicians who are mainly interested in getting referrals. The burgeoning of the feminist movement in the 1980s brought many good changes, but it also fostered the attitude that “anything goes.”

If midwives want to practice independently, they should shoulder the same burden that physicians do in terms of malpractice coverage. I hope that very few physicians defend these types of cases.

Rida W. Boulos, MD, MPH
Associate Professor of Clinical
Obstetrics and Gynecology
Chair and Program Director
UIC College of Medicine
Peoria, Ill

Nurse midwives get an unfairly bad rap

I was very disappointed with Dr. Barbieri’s editorial on home birth. Although it was ostensibly about a home delivery after two cesarean sections, it effectively denigrated all home births.

I delivered more than 2,000 patients in hospital between 1988 and 2000 and was also fearful of home deliveries. Then I entered into a collaborative agreement with a certified nurse midwife who attends home births, and I have participated in many of these births myself. More than 25 women—both primiparas and multiparas—have been safely delivered at home. One patient required hospital transfer for pain management, but still had a successful vaginal delivery. No Apgar scores lower than 8, no maternal or neonatal morbidity.

At our Buffalo (New York) hospitals, we have a cesarean section rate in excess of 30%, and these patients will pay the price in terms of current and future morbidity; hemorrhage; infection; placenta accreta and previa; and adhesions. Women undergo induction of labor for every reason imaginable, every patient has continuous electronic fetal monitoring despite solid evidence that it does not improve outcomes, and we continue to blame patients and attorneys for our inexorably climbing cesarean rate. Dr. Barbieri noted that 10% to 15% of planned home deliveries require transfer to a hospital. Even if every one of those patients ended up with a cesarean section, that rate would be far better than our hospitals’.

Women who choose home birth are a select subgroup, both in their personal outlook and in their health. It’s definitely not for everyone, but nothing is gained in trying to restrict it further, especially when ObGyns as a group have become ever more interventionist and cannot point with pride to our outcomes. I have been impressed with the skill, judgment, and patience of the midwife with whom I work. We could learn from midwives to the benefit of our patients, but the tone of the editorial makes me suspect that is unlikely.

Katharine Morrison, MD
Buffalo, NY

Dr. Barbieri responds:

Views represent both ends of a spectrum

I thank Dr. Boulos and Dr. Morrison for their thoughtful responses to my editorial concerning home birth following multiple prior cesarean deliveries. They provide bookends on the spectrum of expert opinion, with Dr. Boulos against and Dr. Morrison supportive of home birth following multiple prior cesarean deliveries. My main concern remains that home birth, especially in high-risk situations, appears to be associated with an increased risk of newborn morbidity and mortality, compared with delivery at a birthing center or hospital. Based on a review of 1,453 attempted vaginal births following cesarean delivery at birthing centers, unbiased investigators concluded that the practice is not safe for the mother or newborn.1 If delivery at birthing centers is not safe, certainly home birth is not safe in this particular high-risk situation.

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