When Karri Rickard moved from Pennsylvania to Maryland, it never occurred to her that she would have a problem finding a hospital to deliver her baby. But she did. So much trouble, in fact, that Rickard and her husband are giving up their home in Frederick and moving back to Pittsburgh.
"It's sad, because we're happy here," said Rickard, 32, who headed back to Pennsylvania this month with her husband and four children. "But we want to be somewhere where they'll let me trust my body."
Rickard's problem is that she delivered her first baby by Caesarean section, and Frederick Memorial Hospital refuses to allow women who have had a surgical delivery to risk going through labor. So Rickard is moving back to be near the hospital where she delivered her other children without surgery and plans to try again with the baby she is expecting at the end of January.
"My last labor only lasted two hours. There's no reason I shouldn't be able to try going through labor again," Rickard said. "It's my body."
Around the country, pregnant women are facing similar problems as an increasing number of hospitals refuse to let women try labor after an earlier C-section, citing concerns about safety and being sued if something goes wrong.
The trend is helping push the Caesarean rate to record highs, according to data released last week by the Centers for Disease Control and Prevention. Nearly one-third of births are now C-sections, up 40 percent from 1996. The rise is driven by a number of factors, including more women opting for surgical deliveries of their first babies. But another reason is the 67 percent drop since then in the number of women attempting labor for subsequent pregnancies.
"It has been dropping quite dramatically," said Joyce A. Martin of the CDC's National Center for Health Statistics. "It's one of the factors."
The trend has sparked an emotional debate among women's health advocates, hospitals and doctors over the risks of repeat C-sections vs. vaginal birth after Caesarean -- known as VBAC -- and who gets to decide.
Some say the reduction in VBACs marks a necessary correction that protects the health of women and their babies. They point to data showing that VBAC deliveries carry a significant danger of serious complications, notably about a 1 percent risk of a ruptured uterus. That can be fatal to mother or baby unless an emergency Caesarean is performed immediately.
Others say, however, that women are being robbed of their freedom to choose how they want to deliver their baby and forced to undergo a surgical procedure that can unnecessarily complicate childbirth and has its own risks, primarily of bleeding, surgical infections and blood clots.
"We're grown-ups. We're not infants. We should be able make our own choices," said Tonya Jamois of the International Cesarean Awareness Network, which advocates against unnecessary C-sections. At least 300 hospitals have banned VBACs, according to a survey the group conducted last year.
Officials of hospital associations in the D.C. area said they knew of no other maternity hospitals -- besides Frederick Memorial -- that refuse to allow VBACs. Most hospitals say the decision should be left to the woman and her doctor. In some areas, however, including parts of the Eastern Shore, individual obstetricians or group practices have decided not to do VBAC deliveries, "which effectively eliminates that option for some people," said Nancy Fiedler, spokeswoman for the Maryland Hospital Association.
While agreeing that women should be able to make individual decisions in consultation with their doctors, many experts say the safety risks and chance of a malpractice suit make it understandable that many hospitals and doctors are unwilling to attempt VBACs.
"From the point of view of public welfare, I understand and support the view of these doctors and hospitals who would be unwilling to attempt VBAC," said W. Benson Harer Jr., a former president of the American College of Obstetricians and Gynecologists. "The risk may be low, but when something does go wrong, it is often a disaster. In a way it's playing Russian roulette."
Long-running debate
The restrictions on VBACs are the latest twist in a long-running debate over C-sections and childbirth in the United States. In the 1980s and 1990s, medical authorities launched a campaign to reduce the number of C-sections, particularly the practice of routinely performing the procedure on all women who had had one before. Repeat Caesareans were criticized as often unnecessary, subjecting women to costly and potentially dangerous surgery that complicates their recovery. Many women's health advocates viewed Caesareans as epitomizing the male-dominated, overly medicalized birth process.
But doctors became alarmed by reports of women experiencing dangerous complications. In 1999, the American College of Obstetricians and Gynecologists recommended that vaginal birth after a C-section be attempted only in hospitals where a doctor and other staff members were standing by to perform an emergency C-section if necessary.
"There were horrific cases occurring among women going through a trial of labor," said Charles Lockwood, chair of obstetrics at Yale University, who helped write the guidelines. "There's a lot of hard, irrefutable data on the increased risk. It would have been immoral to not have come out with the new recommendation."
The guidelines prompted many hospitals, especially smaller and more rural ones, to discontinue VBACs. Rising malpractice insurance rates and fear of lawsuits have accelerated that trend.
"There isn't a single state in the nation where at least some hospitals haven't abandoned VBAC altogether or cut way back," said Bruce Flamm, who studies the issue at the University of California at Irvine. "I don't see anything that's going to reverse this trend."
Some women find that their obstetricians, fearing lawsuits, also decide it is too risky to try labor.
"A lot of doctors do a bait-and-switch kind of thing where they tell a woman in the early stages of pregnancy, 'Yeah, we'll do a VBAC.' And then all of a sudden their tune changes. At that time, a woman has a hard time finding other options," said Jamois, who argues that C-sections also have risks.
Frederick Memorial stopped performing VBACs last year because of concern that the procedure was too dangerous and fear of a devastating lawsuit if something went wrong.
"Patient safety is the most important factor," said Edwin Chen, who heads the obstetrics department. "But we also had to be concerned about the danger of being sued and going bankrupt. Then we couldn't provide any care to anyone."
Although many women say they understand and are willing to accept the risks of VBAC, Harer said that often changes if a woman suffers permanent physical damage, loses a baby or is left with a child with permanent disabilities.
"This is an incredible burden on the family and one for which our society does not provide real support and care. So the only way the parents can really hope to have any normal life and get support for the child is to sue the doctor and the hospital," Harer said.
When Rickard discovered that the closest hospital that would be willing to allow her to try labor was 45 minutes away from her Frederick home, she decided she had no choice but to move to be near the hospital she used before.
"I have four children. Why have six weeks of recovery when after two hours I should be up taking a shower?" Rickard said. "My husband left his dream job down here to move us back to Pennsylvania to make sure I didn't have to have a C-section."
Women facing similar situations in other parts of the country have simply given up.
"It's so unfair," said Daphne Mertens, 27, of Emporia, Kan., who reluctantly acquiesced to a Caesarean last month after she was unable to find a nearby hospital willing to let her try labor. "I should have been able to make an informed decision about what's best for myself and my baby."
In other cases, women are opting for the more dangerous choice of having their babies at home without a doctor. That's what Barbara Roebuck, 38, of North Platte, Neb., did after her local hospital refused to allow her to try labor. The nearest hospital that would was four hours away.
"I felt I had no choice," said Roebuck, who gave birth at home in June with just her husband and two friends present. "I did lose a lot of blood. If my uterus did rupture, I knew I would not make it. I would have felt a lot safer if I was in the hospital. But I knew if I walked in the door there they'd just cut me open."
That scenario is what most alarms both doctors and advocates.
"I can't think of anything more scary than a woman with a scarred uterus attempting a vaginal birth at home," Flamm said. "I'm sure it's happening, and I'm sure some women have already died because of this, and some babies have died."
Flamm hopes hospitals will find a middle ground, perhaps bringing in extra staff when a woman attempts labor, or perhaps referring patients to nearby academic medical centers that have more staff.
"There's got to be some compromise," Flamm said. "The stakes are just too high."