Without any examination of my body, the doctor told me that I was likely “not a good candidate for a VBAC.” In shock, but not wanting to come off as an asshole, I responded “that’s interesting because my doctors at Kaiser said I’d be an excellent candidate. I’m concerned that the physicians here are generally unsupportive of VBACs and—”
“Well, we’ll let you do what you want. We won’t force you.” She cuts me off.
Yes they will.
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VBAC stands for “Vaginal Birth After Cesarean.” Cesarean deliveries (or c-sections) are medically necessary in some circumstances, but in the U.S., birth workers (including some physicians) are concerned that medically unnecessary c-sections are occurring too often. After much thought...and a lot of reading and reflecting, I really believe my c-section was unnecessary.
Photo of me trying to rest after being told my labor failed to progress and that the best option was to go into surgery for a c-section.
The birth of my first child was filled with mixed emotions. I’ve not shared publicly about it yet but it was traumatic. It included 38 hours of back labor, excruciating spinal pain, an epidural, dilating to 8cm (with the ultimate goal of 10cm), and an unexpected c-section. After all my preparation and that hard work during labor, I felt absolutely defeated. A c-section is a major abdominal surgery. My recovery was long and painful. Picking up my newborn, sitting up, bending over, and showering were all challenges for me in those early weeks.
The saving grace for me was that my OBGYN said that I shouldn’t worry about a repeat c-section if I chose to have additional children because, given my history, I’m an excellent candidate for VBAC. So how did this other physician who I’d never met before get the idea that I’m not likely a good candidate just by looking at me?
Well, it seems like the US is the only country that uses ‘race’ to predict VBAC success rates or the likelihood that a woman will successfully have a VBAC. I found this nifty calculator online.
The problem is that, baked into the VBAC calculator, there is an underlying assumption that something is biologically different about Black people’s bodies that makes us less capable at having a VBAC than other people.
According to this calculator, a Black person has a “predicted chance of vaginal birth after cesarean” 28% lower than a white person with the same characteristics. It’s important to note that they are developing a new calculator without race and ethnicity variables. But what work—what damage—has the calculator already done?
Screenshot of VBAC calculator. Grobman WA, Lai Y, Landon MB, Spong CY, Leveno KJ, Rouse DJ, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM; National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU), "Development of a nomogram for prediction of vaginal birth after cesarean delivery," Obstetrics and Gynecology, volume 109, pages 806-12, 2007.
We know that there are racial disparities in cesarean deliveries. People of color and especially Black birthing people are given unnecessary c-sections more often than white people. So to include race in the calculation not only normalizes the disparity, it actually perpetuates it if practitioners are using such tools to determine whether or not women are eligible to attempt to deliver vaginally. It’s a circular self-fulfilling prophecy. You give Black people more c-sections, then when they want to VBAC, you tell them the success for VBAC is less likely because you give them more c-sections — thus, resulting in more c-sections.
The VBAC calculator can be situated in a long history of racialized medical tools. On their face, these tools “adjust for race” to support decision-making processes for physicians and other healthcare providers. However, most were developed with the premise that race tells us something about our biological makeup—or genes. It does not. But because they are designed by humans in the social world, these tools reflect the social and political inequities that determine our relative risk for disease. So, VBAC calculators tell us more about our society’s racist propensity to give Black birthing people repeat sections than it does about Black people’s ability to deliver vaginally.
VBAC disparities have broader implications for maternal health as Black individuals are much more likely to die during and after childbirth and repeat c-sections increase the risk of death over time. One jarring example is the story of Kira Johnson who, after her second c-section was allowed to bleed internally for hours leading to her death. Her husband tells the story of how the medical staff ignored his calls for immediate attention and by the time they finally came in to help, it was too late. When Kira was finally taken in for surgery, she died immediately.
Again, there are medical reasons to undergo a c-section. But there are also a lot of complications that can arise from repeated c-sections. None of the doctors I’ve seen so far cared to talk about any of those risks but spent a great deal of time warning me about the risk of uterine rupture if I attempt a VBAC.
After that infuriating visit with the “you’re not a good candidate” OBGYN, I spoke to a friend of mine who is studying to become a midwife. She recommended that I ditch the OBGYNs at the clinic I was attending and instead make the midwives my primary prenatal providers.
My first visit was fantastic. When I asked the midwife about VBAC support, she was not only supportive but enthusiastic. She checked my medical record from my first delivery to see if I had a particular type of incision. I did.
She said “Yep! That’s all I needed to see, we’re happy to support you on your VBAC journey. What other questions do you have?”
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We have to stop using race and other proxies for race (e.g., education, neighborhood, etc.) in these medical tools and assessments because they are more harmful than they are informative. If we’re interested in health equity as a goal, these “race adjustments” are in our way.