An Ongoing Fight For More Control Over Birth In Atlanta

With a baby strapped to her chest, Ashley Brown juggles two hand-drawn signs outside DeKalb Medical Center. She’s down by a patch of grass near the road, but five months ago, she was inside, in labor.

“His birth was by far the worst day of my life,” she said.

It was her fourth pregnancy. Her other three babies were cesarean sections. This time, she decided with her doctor to try for a vaginal birth. But in the middle of Brown’s pregnancy, the hospital had changed its policy on that kind of delivery, known as a VBAC, vaginal birth after cesarean.

“And every time I requested an epidural, they were quick to bring me a piece of paper and tell me that once I would consent to having a C-section, THEN, I would be provided with pain relief,” Brown said.

‘An Interrogation’

She did not want a C-section, and described what happened as a kind of torture.

“I remember it feeling very much like you would imagine an interrogation gone wrong in a movie scene, where they’re trying to get information out of somebody and they’re using pain as a means to get that information,” said Brown, who eventually gave in and agreed to the C-section.

“It certainly seems widespread that many pregnant women are pressured into cesarean surgery when it’s not medically necessary,” said Shawn Steiner, an attorney with National Advocates for Pregnant Women.

She says people have an absolute right to refuse surgery, pregnant or not, but pressure to have a C-section can be subtle.

“That can take the form of a suggestion from a doctor who has more power in the relationship than a patient does. It can take the form of ‘this’ll just be easier for all of us,’” Steiner said.

Other cases range all the way up to threats of calling child protective services on women in labor.

“And this often happens to low-income people, the Medicaid population who are getting services where there’s an interest in rushing people through,” Steiner said.

She said there’s often little incentive for care providers to patiently support someone through a time-consuming labor.

Statistics on how many unwanted or unnecessary C-sections are performed are difficult to gather, Steiner said.

“It’s very hard to get at this because people are taking their doctor’s advice and may not realize until later, until the second baby or the third baby or when they read an article,” she said. “People learn later about risks that might not have been explained to them at the time.”

Steiner said it’s also fairly difficult for patients to win lawsuits on these issues.

“They end up with a healthy baby and the woman ends up with no visible, physical injury and it’s hard to recover money in a case where you can’t show that,” she said.

‘Patient Safety’

Despite her bad experience, Brown herself has not filed a complaint.

“I don’t have the resources to hire an attorney to take on a hospital. They could tie me up for longer than my resources would sustain to have the attorney fight it,” Brown said.

DeKalb Medical Center said it wouldn’t comment on Brown or any specific patient’s case.

“Patient safety is our first priority, and we routinely review our policies, and our policies are currently aligned with the accepted standard of care,” spokesperson Cheryl Iverson said.

Leslie Wolf, a professor of law and medical ethics at Georgia State University, said ideally, hospitals’ policies are based on evidence about what is best for patients, “but the hospitals are also driven on some level by safety and litigation.”

She said the American College of Obstetricians and Gynecologists tends to say if there are risks involved in any procedure or delivery, women should be the ones choosing in consultation with their doctors, but that’s not always the way it shakes out.

“There has been a history in obstetrical care of taking the more conservative route and of pressuring women into cesareans out of concern for the infants, perhaps much more conservatively than has been necessary,” Wolf said.

She said whatever the obstetrics community’s guidelines are, hospitals are businesses that could be on the hook for millions if something goes wrong.

“Here the hospitals are saying essentially, ‘it’s not a reasonable risk, or certainly not one we’re willing to take within our hospital,’” said Wolf.

The Risks

When DeKalb Medical changed its policy on VBACs last year, it left patients like Brown feeling like they had nowhere to go. It’s kind of a rare service, and some traveled from out of state just to find a facility where VBACs are offered.

“I think what is tricky and confusing about vaginal birth after cesarean in general is that labor in a woman with a prior C-section carries with it risks,” said Aaron Caughey, who leads the Department of Obstetrics and Gynecology at Oregon Health and Science University. “And you say, well gosh, it’s got risks, why don’t we just do another C-section. But honestly, labor in everybody, even those without a prior C-section, carries with it risks.”

Caughey works on policy recommendations for the American College of Obstetricians and Gynecologists, which decided almost a decade ago that vaginal birth after two cesareans is a safe delivery option.

“After one C-section we have a ton of data, and so we can really give people very good estimates of their risks,” Caughey said.

After two C-sections? He says there’s some data on the risks.

“And after three C-sections, we have much, much, much less data, and so that’s when people get nervous when they don’t have a large amount of data to be able to counsel people,” he said.

Caughey said from what he’s seen, if a patient and her doctor are comfortable with a VBAC after two cesareans, pushing it to three isn’t that big a leap.

It’s also in line with a larger goal of many major medical groups, including the World Health Organization, of finding a safe way to try to lower the number of cesareans doctors perform.

There’s a lot of disagreement about how to do that though. And in the meantime, mothers like Ashley Brown are getting caught up in the battle between hospital policy and what their doctors say is safe, which can be traumatic.

“I have to keep it pushed really far down to function. On days that I allow my mind to go back to that place or on mornings when I wake up with nightmares remembering that experience, it’s all-consuming,” said Brown, her voice cracking.

She says she hasn’t been able to share her pain with her husband for fear that he’ll feel guilty about not having been able to intervene.