Do You Suffer from Physician VBAC Hysteria?
Dr. Chukwuma Onyeije, who bills himself on Twitter as an information-age Maternal-Fetal Medicine Specialist, wrote a blog post about avoiding an unnecessary cesarean following a Twitter discussion that began with this commentary of CNN’s coverage of Joy Szabo’s recent birth:
In his post, 10 Ways to Avoid an Unnecessary Cesarean, Dr. Onyeije coins the term Physician VBAC Hysteria:
Patient’s trust physicians to make tough calls by virtue of our expertise, training and because they believe that we want what is best for them. My fear is that physicians risk losing the trust and goodwill we have with patients if we steer them away from safe vaginal deliveries toward unnecessary cesarean deliveries for questionable reasons. The current trend towards not offering VBAC may have begun due to concerns regarding safety or even medico-legal exposure; however at present, it has metastasized to inordinate levels that I have referred to as PVH (physician-VBAC-hysteria).
In the comments, he outlined his opinion of the VBAC-hostile policies in the United States:
The underlying problem in the VBAC dilemma in the United States is related to the fact that more than ever before, OB/GYNs are incentivized to provide intensified care to low-risk women to justify their services. Along with the numerous reasons for increasing CS rate in the US is the problem that far too many low risk pregnancies fall into the net of overtreatment and unnecessary intervention that is modern obstetrics. It is a difficult idea for most OBGYNs (and maternal-fetal medicine specialists like my self) to accept for a few reasons. At the risk of sounding like a granola crunching Birkenstocks wearing MFM I’ll suggest two problems.
First, we all wish to believe that we are making decisions based on what we feel is the best evidence. If confronted with evidence that we may be upgrading risk in low risk women to cushion the bottom line, many would object strenuously to the charge. As I’ve indicated above, I don’t think this is the result of avarice or dishonesty. Rather, I think it is related to incentives which encourage such behavior to sustain financial relevance.
Second, the process whereby the definition of “high-risk” has shifted downward has occurred slowly and no doubt imperceptibly to many physicians. I would venture to say that most doctors trained within the last 10 years (and in particular areas of the country) feel reluctant to provide VBACs as much due to medico-legal fear as a constitutional distrust for the procedure based on limited experience. The same could be said for vaginal breech deliveries and forceps deliveries.
So the problems that we face in moving back from the brink of what threatens to be CS rates in the 40% range nationwide is daunting.
I am hopeful that the seeds of a trend toward physicians acting as trusted consultants for patient’s best interests are being planted by patients themselves. New technology and the democratization of information makes it much more reasonable for patients to participate in their care.