VBAC SUMMITMiami, Florida    |   Sept 28-29, 2013

The Climate

In the private American healthcare system, doctors and hospitals are more likely to find cesarean sections more profitable than natural births. Many health professionals are feeling squeezed by tightened payments for services and increasing practice expenses. The flat “global fee” method of paying for childbirth does not incentivize providers who support an often longer vaginal birth. Many payment schedules reimburse more for cesarean than vaginal birth. A planned cesarean often meets the needs of busy professionals who must juggle hospital work, in office care and their home/family lives. On average hospital fees for cesarean birth far exceed those for vaginal birth, which ultimately means more profits for hospitals (11).

Some experts cite consumer demand as a contributing factor in the rising cesarean rate. Cesarean delivery on maternal request (CDMR) is defined as a primary cesarean delivery at the maternal request in the absence of any medical or obstetric indication (21). It remains unclear what contribution CMDR makes to the overall increase in cesarean delivery. As an ACOG Committee Opinion on the subject stated in 2007, "Cesarean delivery on maternal request is not a well-recognized clinical entity, and there are no accurate means of reporting it for research studies, coding, or reimbursement" (21). There is some evidence that a growing number of women were requesting cesareans. Much of the current knowledge is based on analyses comparing elective cesarean deliveries without labor (not CMDR) with the combination of vaginal deliveries and unplanned and emergency cesarean deliveries (instead of planned vaginal deliveries) or outcomes of actual modes of delivery (19).  Findings from a large and well-designed national study, Listening to Mothers, reported that less than 1 percent of mothers (only 1 of 1,300 women surveyed) who had a first cesarean actually requested one. The survey, conducted by Childbirth Connection, a leading nonprofit organization that works to improve maternity care, noted that, in contrast, nearly 10 percent of those surveyed reported feeling pressured by a health professional to have a cesarean delivery, and 42 percent believed that fear of being sued leads physicians to perform unnecessary cesareans (9).

In the face of increasingly interventive maternity care mothers may also be choosing cesareans due to the support they receive from their providers to schedule surgery. The loss of control of birth choices, rising induction rates and hospital policies which restrict basic necessities such as food, drinks, and movement can lend to a climate where mothers feel more in control of a birth date and provider they choose with a guarantee of provider support. In the case of VBAC vs. elective cesarean, this is especially true as finding a VBAC provider has become increasingly difficult and the restrictions for birth with those providers are often burdensome. The fear of going through vaginal birth only to wind up with a cesarean after fighting the entire pregnancy and labor for a VBAC can become so overwhelming that some mothers simply choose to cut to the chase and schedule surgery.


NIH Consensus Development Conference: 
State-of-the-science statement on Vaginal Birth After Cesarean intended to provide health care providers, patients, and the general public with a responsible assessment of currently available data on vaginal birth after cesarean (VBAC).

Click here to download