Ahhh....the PERFECT example of the impact of legal issues and financial issues on medicine.
Believe me, this issue has NOTHING to do with a repeat C/S being more "lucrative" to Physicians, and EVERYTHING to do with safety.
In the modern era, with the almost universal use of regional anesthesia (Spinal or Epidural anesthesia) for C/S that are non-emergent, the true incidence of major morbidity and/or mortality from elective C/S has become negligent or non-existent. With attempted VBAC, there is a CERTAIN risk that approaches 1% by most estimates of a potential CATASTROPHIC outcome for either the mother, fetus or both.
In the current medicolegal environment, as a physician, which route would you choose?
The primary problem with VBAC is COVERAGE IN HOUSE when women are in labor...the ONLY way I would let my wife labor as a VBAC is if BOTH the obstetrician AND Anesthesia provider (preferably and Anesthesiologist) were IMMEDIATELY AVAILABLE... and that means IN HOUSE, and NOT OTHERWISE OCCUPIED.
No one in medicine presently gets reimbursed by insurance carriers for "being available", or staying "in house"...if it's 0200, and your wife comes in to the facility as a VBAC in labor, am I expected to come in to the facility and stay there FOR NOTHING so you can have the choice to attempt VBAC to ensure it's safe? If it's in the middle of the day, am I supposed to cancel elective OR cases to make an anesthesia provider IMMEDIATELY available to respond to the mother attempting VBAC who has an emergency? Who pays for that? Who pays for the immediately available scrub tech and circulating RN?
Legally, as a physician if I know that elective C/S is inherently safer (regardless of the patients feelings) than VBAC, and if I am legally liable for a potential lawsuit in the multiple millions of dollars for a bad outcome secondary to a catastrophic UNANTICIPATED, and UNPREVENTABLE event such as uterine rupture, am I obligated to acquiesce to the patients wishes?
Listen folks...anyone that is anticipating VBAC that is reading this thread, I encourage you to ask the following questions:
1. Will the obstetrician be IN HOUSE and immediately available?
2. Will there be an anesthesia provider IN HOUSE and immediately available?
3. Does the hospital make provisions to have immediate OR availablity with proper staffing 24/7/365?
If the answer to any of these questions is no, then you are rolling the dice.
The big issue here -- and its an issue in a number of other legal liability areas as well -- is that our legal system has no provision whatsoever for waiver of liability concerning injury to children. You can make the parents sign a waiver so that THEY can't sue if a baby is harmed during delivery, or a child is seriously injured participating in an organized sport. But these waivers do not prevent the child, or some other entity purporting to act on behalf of the child, from suing and winning multimillion dollar judgements.
IMO we need a federal law giving full legal weight to liability waivers signed by parents on behalf of their children. More children are being harmed by the lack of such waivers, than would be harm by parents who sign them thoughtlessly. Not only are many babies being born in cars on the way to distant hospitals, with no medical help at all in the event of a problem, because all the nearby obstetricians have been put out of business. But children across the country are being prevented from being physically active by liability-conscious schools and play facilities that have eliminated a huge range of activities and equipment on the grounds that someone might get hurt and sue. Workplace based daycare centers, where parents could actually keep an eye on how their children are being cared for, and informal home daycare opportunities, where children can be cared for by a trusted friend or neighbor, are very rare, because of the massive liability issues that can't be contracted out of.