Seeing dollar $igns

With all this talk about President Obama raising the "debt ceiling," you have to wonder where the spending cuts are being made (or if they're being made). Politics aside, I can't help but think of one way the government could definitely save money: reduce the cesarean rate.

It's estimated that the US could save $3.5 billion a year in healthcare costs if the number of medically unnecessary cesareans were reduced. I don't know if that's just for the surgery alone, so perhaps the figure is much higher when you account for everything that takes place up to the cesarean. Think about the way a typical birth unfolds in the US:
• Mom is approaching 39 weeks in an otherwise normal pregnancy. Since her doctor is telling her it's "dangerous" to go past her due date, she decides to go ahead with an induction. After numerous doses of Cervidil and Pitocin, her labor finally starts, but is slow and very painful. Perhaps pain relief from the epidural is spotty, or they just need to keep giving her boluses because her labor is so long. They finally agree to do a cesarean for fetal distress. After birth, they decide the newborn must spend time in the NICU because her dates were off and the baby is showing signs of prematurity. He spends a week in the NICU and then goes home. Oh, did we mention this mom was giving birth in a military hospital? 
• The mother has already had a prior cesarean, and is scheduled to have another "elective" repeat cesarean. 


(This is just based on some of the stories I hear from mothers. While it obviously doesn't always go this way, it's not that uncommon, either.) 

While it's been said that Medicaid won't pay for unnecessary cesareans, I'm sure they can find other reasons to do them. When you don't even know what constitutes "necessary" anymore, it's probably not all that hard.

As of 2009, certain states were working hard to eliminate any financial incentives for doing cesareans. Washington State was one of them, and saw a 14-48 percent c-section rate, which obviously alarmed some. Before the policy change:

On average, Medicaid pays $5,000 more for a C-section than for a vaginal birth, and private insurance pays a far greater premium. You don’t have to be a cynic to wonder if that could have something to do with the rise in unnecessary C-sections.

Because of that lack of incentive, there is probably more accountability when you are receiving money from a government agency. I won't say there still isn't some form of fraud going on, but it's no doubt easier to get away with if your patient is privately insured. Additional health care costs probably come from extra items tacked onto your bill. Didn't receive an epidural but it's on your bill? Your health insurance company will probably pay for it anyway, even though you've called to complain. One West Virginia OB faces up to 340 years in prison for her part in billing patients for things they never received. Those little "extras" can really add up.

Statistics have also shown that you are more likely to get a cesarean if you give birth in a for-profit hospital than a non-profit one. They have to make their money somehow, right?

While it's glaringly obvious, at least to birth advocates and those who simply want a choice in their births, lowering healthcare costs in this way would require the obstetrical community to basically change the way they practice medicine, which I don't think is going to happen anytime too soon. Our health care industry is increasingly moving away from focusing on the patient and rather seeing dollar signs every time you hop up onto the exam table, for a number of reasons. They have to make their time "worth it," both because of their own personal pursuits and because of rising insurance costs for them that otherwise wouldn't justify them continuing to practice medicine. You are just the little fish - albeit probably one of the most important ones - in the food chain.

More reading:
Take away the incentives for too many c-sections - Crosscut Seattle
"Whatever you try is just going to end in a cesarean section" - My OB Said What?!
"If a baby hasn't engaged by 37 weeks, we need to do a cesarean section" - "My OB Said What?! (same doctor)
Should OBs be investigated for insurance fraud? 
All about the Benjamins? TennCare's call for lower cesarean rates - The Unnecesarean 

Avoiding unnecessary inductions and c-sections: "Every week counts"

I was going to title this post "Sick of being pregnant? So what?!" but thought maybe that would come off as a little harsh.

I've written about this several times, as have a lot of others. Unfortunately, I'm not really sure who's listening (one woman decided that since the Huffington Post, whose link I've included below, was not an unbiased source of news, that perhaps the article wasn't true). I've been posting links ad nauseam to the March of Dimes website for months about Why the Last Weeks of Pregnancy Count, in hopes that someone out there is actually reading it. And this month, they and ACOG have teamed up in hopes of decreasing unnecessarily early births because of elective, non-medical inductions and cesareans.

Obviously there are some exceptions, as this article from the Huffington Post noted. While I was glad to see this subject go mainstream, I did have a problem with this paragraph:

“If a baby needs to be born for a medical reason, that baby should be born,” said Dr. George Macones, an OBGYN at Washington University’s School of Medicine in St. Louis. “But when I was practicing in Philadelphia, patients put pressure to deliver early for what I call ‘social purposes.’”

While I'm certainly not denying that mothers do pressure doctors to do inductions, let's not lay the onus of blame completely on the mother. Doctors are often notorious for scheduling for convenience, and so many women can testify to that in their birth stories. It's also not uncommon for a diagnosis of "failure to progress" to come hours before a physician has an important upcoming event to attend. And sadly, we hear of plenty of doctors who pressure moms into cesareans before their shift runs out at 5 p.m.

As far as 'medical reasons,' this is often another gray area. True medical problems are one thing, but we're also finding more and more that doctors are using questionable medical diagnoses - like big baby and low fluid, most frequently - to assess whether or not the baby should be born. In the case of a big baby, there is no definitive answer to that question, except weighing that child right after birth. Some estimates are more accurate than others, and some are way off. In this case, you need to ask yourself, do I want to risk having major surgery - for this baby and potentially all my children - if my child happens to weigh substantially less than estimated?

It probably sounds like I'm anti-physician. Not really. But I wish people who think that doctors are incapable of doing these things would pull their heads out of their butts for a moment and take a look around.

As far as the Every Week Counts campaign, I'm hoping it gains some serious traction. I am not completely sure what the best answer is - but I wish we'd see some disciplinary action on the part of hospitals and medical boards for those who do like to practice "9-5 obstetrics," or have a higher-than-usual rate of cesareans. Many are coming down on the WHO's recommendation that the optimal c-section rate be around 15 percent, because they consider it an outdated (circa 1985) standard and acknowledge that the ideal c-section rate is a figure no one is really sure of. While that may be true, I think we can argue that this is far from optimal.

I've blogged before about the myth of the emergency cesarean, and have come to realize that words like "medically necessary" are relative terms. When you start questioning what is truly necessary, there are those who quickly become defensive, and assume that you're trying to say you know more than their doctor. No one likes the feeling of being pinned into the corner about their choices, or to essentially be told that perhaps they had choices they didn't even know about. I remember one particularly heated exchange on a pregnancy forum of a mother asking for induction techniques because her baby was 35 weeks gestation and she didn't "want a 9-pound baby." Why, dear God, why?! 

When it comes to laying blame, it probably fits squarely in both corners, as the above quote suggests. There are no shortage of women who want it their way, for a number of reasons - that much is true. HufPo user Trillian4210 writes:

My second baby's tentative due date was 10/10/10. My OB/GYN laughingly told me he hoped I didn't go into labor that day because he was BOOKED SOLID with scheduled c-sections of women who had no medical reason for it but that they wanted that birthday for their kid. That's not a birthday, that's a vanity story. 

What I want to know is, what is this physician doing about it? Are you informing your patients the dangers and giving them a realistic outlook of what could happen? They complain so much about mothers demanding it, when really, you're just facilitating and enabling it to happen by not informing or counseling your patients adequately to stop this from happening. This would be a perfect opportunity to go over with your patients why it's unsafe, and stop the practice altogether, not give in to their whimsical demands.

If a mother's excuse of "I want my baby's birthday to be 10/10/10!" sounds frivolous, then a doctor saying, "Your baby might get too big and then die!" should be code speak for "I have vacation to the Bahamas coming up, and there is no way I'm waiting around for this baby to be born!"

And speaking of the etched in stone due date, those people who like to criticize women for wanting to deliver their babies early are also throwing stones at women who decide to go post-dates and let the baby pick its own day. You just can't win.

For generations we have had instilled in us the idea that every "large" baby will be difficult to birth, that every baby born past 40 weeks "will die," or that because the baby has reached that magic benchmark of 37 weeks, that "it's ready!," like some kind of turkey pop-up timer.

So while it sounds great to blame the mother for going Princess Renegade and wanting everything done according to her plans, the medical community has no one to blame but itself.

The myth of the emergency c-section

It seems like when you're talking about a c-section, it often comes down to a question of semantics. The word "emergency" gets thrown around an awful lot, and I can't help but wonder if there's any validity anymore to the "If I didn't have a cesarean, my baby and I would have died!" argument.

Nowadays it seems that everyone has had an "emergency" cesarean. Come to think of it, depending on who you ask, I've had two of them.

To some, it seems like if labor has started and it's obvious a vaginal delivery won't take place, it suddenly becomes an emergency. I read one comment on a birth forum about a woman asking what happens when you go into labor before a scheduled cesarean, and the response - from a labor and delivery nurse, no less - was, "Your scheduled cesarean becomes an emergency cesarean. No big deal." Aren't emergencies usually a big deal? And what about this is indicative of an emergency?

In my situation, I went into labor before a scheduled cesarean. I came to the hospital in plenty of time, and was 4 cm upon arrival. Even if they had left me sitting there for a few hours, I probably would have been just fine. Was this an emergency? Not really.

Even after my second cesarean, when a nervous soon-to-be-new dad asked me if it was an emergency after hearing the hairy details of the birth, I sort of shrugged. "Yeah, I suppose you could say it was emergent," with an air of hesitation. I was already fully dilated when I got there, but had no urge to push and no little feet were sticking out. Emergency? Probably not.

Nothing confirms my suspicions about the true nature of emergency cesareans more than this comment from My OB Said What?!?:

“It’s extremely urgent we do the cesarean now before your baby goes into stress and it becomes life-threatening. Let me just deliver the woman across the hall and then we can get things ready.”

Seriously? If you have that much time to wait, then it must not be an emergency. If this comment had come from anyone else (assuming that most contributors to MOBSW "get it" and see it for what it really is), I'd probably smile and nod and walk away muttering something. It seems like once you throw the word "emergency" in there, suddenly everything comes to a grinding halt and "your baby would have died had you not had that cesarean!" Are you sure about that?

I've heard countless comments like that from so many people and wonder what the real back story was. I wasn't there, obviously, but the minute they mention the words "induction" or "Pitocin," I cringe inside. They don't even realize their "emergency" was likely brought on by the actions of their physician, who either meant well or was deliberately putting them at greater risk for his or her own purposes. Putting on a sympathetic face and frowning while saying "You're going to need an emergency cesarean!" sounds better than, "I need to catch a plane and I need you to push out this baby." (Although some physicians no doubt don't bother to cloak it in concern and just tell it like it is.)

I read one such account from someone commenting on a blog post about a teenager who was in labor, and the doctor was pressuring her to consent to a cesarean. As the physician walked out, this person overheard her say, "Thank God she finally consented. Now I have just enough time to catch my flight." Unfortunately, because of this experience, this young mother will forever have the word "emergency" emblazoned on her mind and think her body failed, and it was the only way. Which is a lie.

It's hard, as a birth advocate, to hear these stories. I think for some, it's a mixture of several things: pride, ignorance or misinformation, and a blind trust in their physician. They do not want to admit that they believed their doctor would tell them everything and that he lied. They do not want to admit that perhaps they made a decision that could have turned out better had they only known more. Or they just had no idea that things could be different. Birth stories are something that are shared between women, even strangers, who otherwise have little if any connection to each other and yet are willing to talk about those intimate moments with a woman they don't even know. And thus not only is the birth of a child talked about, but the birth of a myth is, as well.

One mom I know told me that when she delivered her only child in the 1980s, she was induced. Her baby went into distress and she had a cesarean. Another mom had AROM with her first, which produced cord prolapse and an emergency cesarean. (She was, however, able to VBAC twice after that with the same doctor.) Still another talks about how a friend is going in for an "emergency" cesarean at 37 weeks because the baby is "small" (estimated at five pounds, three ounces by an ultrasound, which can be a pound off, either way). (What baby isn't small with three to five weeks to go?!) This mom tried to birth vaginally after being induced, but her doctor, from the looks of it, rushed her into a cesarean after she was dilated to 8 cm after only two hours with a posterior baby. Now she feels like a failure and that her body is "defective." How can you explain to someone that perhaps your "emergency cesarean" was an "iatrogenic emergency cesarean"? That sounds a bit clunkier and hard to pronounce, and still few are ready to listen when told their doctor might have been the initiator.

I posted these terrific articles recently about a hospital in Minnesota that has a very low c-section rate because they use midwives. They show a mom laboring in a tub, without pain medication, and also talk about midwives repositioning a mom in order to birth her baby vaginally. Yet, based on the comments from some people, they still don't get it. Another article - this time from England - talks about the "myth of too posh to push," and still others don't understand. Most are probably in denial that their doctor, the person they have trusted, could ever do something to hurt them or their babies. Many like to put the onus of elective cesarean on the mother and her choices, and to some extent, we can't discount that. But I can't stand the mentality that no doctor will ever do an unnecessary cesarean in the US, because that's obviously not true. If only we could better discern which ones were true emergencies versus those in which the doctor only said they were, for dramatic effect in encouraging you to make your decision faster (i.e. the "Catch my plane" cesarean mentioned above).

When looking at cesarean rates over the last few decades, they have increased steadily just within the last 20 years, in which time we've still had "modern" obstetrics to save us from ourselves in case of just such an emergency. Considering the rates are continuing to climb, what does that mean? That we're evolving into a species that suddenly can't give birth vaginally? That suddenly birth is much more dangerous than it used to be only two decades ago? I wonder, if people bother to look at the stats, if they even for a moment think about the absurdity of what they're saying. And can we quit blaming the mother for everything - from her "preference" to her weight and stature - and for once look at how her labor and delivery are managed by her doctor?

We use the term "emergency" so casually - paralleling the casual attitudes towards surgical birth in general - and water down its meaning until we don't even know what is normal and what isn't, or how to define a life-threatening situation. These attitudes, myths and misconceptions have totally changed not only our attitudes about what constitutes a real reason to have a cesarean, but clouded our view of birth as a whole.

Technology and birth: Should a robot perform your cesarean?

I don't think Bill Gates realized he was about to open a huge can of worms when he recently speculated, among other things, that robot technology could be used to perform c-sections. The birth nerd community responded, horrified, and the general consensus among my FaceBook friends was that it would basically dehumanize the birth process even more than it sometimes already is.

I think we can all agree that sometimes, technology in giving birth is a lifesaver. And then there are those gray areas, like electronic fetal monitoring, that have a shady, somewhat dubious past, and yet are used constantly even though they have actually been shown to lead to more cesareans, instead of fewer. In some cases, the very thing that's supposed to detect cases of cerebral palsy actually fails to do so, thus also failing to identify which babies are truly in distress and do need to be delivered immediately. In the other half, it leads to more cases of distress that are questionable , oftentimes producing a newborn who is quite pissed off to be so violently thrust into this new world.

I think, therefore, that we need to be vary of our use of technology, especially in surgical births. Having a robot do your c-section might sound cool to Bill Gates, until it's you lying on the table, already feeling like a slab of meat and having that inanimate object hovering over you. If you are distressed or emotional about the birth ending in a cesarean, the robot cares even less than your physician might. It doesn't care if you're crying, upset, or having birth trauma. It can't hold your hand throughout or ask how you're doing. It can only, with another machine, check your vitals, see that you're doing okay, and proceed as usual, completely disregarding any emotional or psychological aspects that can't be registered with a machine.

When I had my first cesarean, their routine choice of medication administration was a PCA (patient-controlled anesthesia) pump. This requires an IV be inserted and the patient then decides when to inject herself with pain medication. According to nursing guidelines in the hospital where I gave birth, I was allowed no more than 10 doses in a one-hour period.

This might be all fine and good, and I can understand why a PCA pump can be helpful, if used properly: it allows the patient to determine her level of pain, while the nurse can tend to other patients. But shortly after being wheeled into recovery - probably the minute the spinal wore off - I noticed that I was in increasing pain, and the PCA pump didn't seem to be doing anything about it. Off and on throughout the middle of the night, the pump would routinely beep at me - and I knew, from my experience calibrating pumps as a pharmacy tech - that that meant there was a problem. The nurse would come in every so often, adjust something, tut about this and that, and then leave the room. A half hour or so later, she'd come back for a repeat.

After the first full day, I had tried injecting myself and nothing happened - except a horrible burning sensation up the length of my arm, which had been happening since I was in recovery - and the nurse scolded me that I had reached my maximum number of doses for medication per hour and couldn't have anymore. The pump had counted the number of doses, and it told her I had already had enough, and that was that. No doubt everything else looked good, and she didn't bother asking me why I was still in pain, even with that much medication supposedly flowing through my veins.

Finally, after my hand swelled up like a blown-up latex glove, the nurse noticed and quickly remarked how they 'had to get that thing out of there.' I had told them, numerous times, that it wasn't working, and that I felt more pain from injecting myself than anything else, at this point. I repeatedly asked, "Is it supposed to burn when I do this?" after another dose of Demerol. It was only after that that I realized the line had infiltrated at the injection site and the painkillers were leaching into my tissues, which offered little, if any, pain relief. No explanation, no apology - I only managed to figure out later that that's what happened.

I consider this episode a major technology fail. A machine can give you so many doses of something and then tell the nurse, in a nice digital printout, how much you've had, when you're due for another, and so on and so forth. It cannot, however, tell the nurse why you're in pain, or that there might be a problem. Only she can do that. And she can only do that if she listens to you as a patient.

I had tried speaking up and no one really listened. If they had been listening, perhaps they would have pulled the entire thing out from the beginning and tried again. Another technology fail lies in the fact that, with increased technology, nurses are then able to spend more time tending to other patients, and thus take on a greater caseload. Additionally, when someone does need something that only a human can respond to, they often become resentful or irritated when you do speak up and express a need that the machine failed to address. Perhaps this is why some OB's are perceived - whether for right or wrong - as cold and callous, because they expect the machine to do their jobs, to some extent: to give them results so they don't have to. In many situations, technology - as we see in the case of EFM - has replaced human judgment, which is an art form that is dying quickly, it seems, when it comes to birth. As a result, greater technology has helped patients, while at the same time, hurt them - by destroying the nature of the one-on-one patient-caregiver relationship. No robot can take the place of that.

More reading:
Bill Gates and Robot Cesareans - The Unnecesarean 

I wish all doctors thought like this ...

I suppose, if I have another child, it would be considered impractical to give birth across the country with this guy. But I wish more doctors thought like he does. This YouTube video features obstetrician Dr. Stuart Fischbein talking about the risks and benefits of having a VBAC.

Key points that Dr. Fischbein makes include the importance of knowing the risks and benefits of VBAC and how much risk you're willing to accept. After all, he says, getting out of bed in the morning is riskier than staying in bed, but we're all perfectly willing to accept that risk and go on with our day. How is having a VBAC any different?

According to Dr. Fischbein, the risks of having repeat c/s over and over again - especially in the (rare) event that a couple wants to have a large family - can include thinning of the uterus, possible uterine rupture prior to labor in subsequent pregnancies, scarring, pain from adhesions, potential risk of increased blood loss and damage to the bladder, bowel obstruction, and the placenta growing into the uterine wall, which could lead to hysterectomy after the birth. Some of these risks, like blood loss, uterine thinning and rupture, bladder damage and adhesion pain can happen even after one or two c-sections, depending on the person. During my second section, my doctor apparently removed scar tissue that had built up after my first section five years prior. And maybe I'm crazy, but I think the pronounced discomfort I feel at certain times of the month is definitely scar adhesion pain. 

But after all those possible risks, Dr. Fischbein makes one very interesting and important point: that "these risks are usually not mentioned to women. All you hear is that 'your uterus could rupture and your baby could die.'" I call this lying by omission - because if you haven't done your research and believe everything your doctor is (or isn't) telling you, then your choice has really been made for you. Which is unfortunate. 

The biggest obstacles for pregnant women are their doctors - whether unintentionally or intentionally - misinforming them or omitting important facts about the risks and benefits; other women who have a negative story about this that and the other that often discourages women from even wanting to attempt a VBAC; and themselves. Yes, sometimes we are our own worst enemies - because we don't act enough as our own advocates and find out every detail and kernel of information that could weigh in our favor against this medical professional we practically see as God.  After all, he/she was the one who went to med school, right? They know way more about my body than I do, right? 

Dr. Fischbein notes that it's unfair to women to get skewed counseling from their doctors based on lies and misinformation. He does say that ACOG (The American College of Obstetricians and Gynecologists) still supports VBAC in their literature, but I'm willing to bet that if any doctor has that pamphlet in his office, it's probably carefully hidden or sitting at the bottom of a trash can.

One take-home point worthy of remembering: "The choice ultimately belongs to the patient herself." Dr. Fischbein, you rock. 

The Fight To Give Birth in the Age of Fear-Based Obstetrics

As I quickly approach the 40-week mark in my pregnancy, I am thankful for many things: namely the fact that my body has essentially "proven" itself to not only me but to my OB's. I am preparing for my second VBAC (Vaginal Birth after Cesarean) and while my journey has been fairly uneventful thus far (I won't say totally uneventful, because that's not the truth), it is nothing less than a tooth-and-nail fight for thousands of women to do the same all over the US. 

I am also thankful that my only reason for having a c-section was breech presentation of my first child - not failure to progress, a "small pelvis," or failed induction of labor. I went into labor on my own even then, and had already progressed well despite the fact that we knew the baby had to be delivered via cesarean. With my second pregnancy, to my OB's credit he did offer me the choice to do a VBAC initially (which I declined, knowing nothing about it) and I think he was secretly relieved when I said no. But as I approached 37 weeks, my baby was heads down - something I wasn't even sure my children could do because of a physical defect of my uterus - and realized quickly that I really didn't want to go through the painful recovery of another c-section. 

I consulted with my OB, whom I thought was going to stutter himself into oblivion at my choice. I had since done lots of research, lots of praying, and lots of reading of very positive birth outcomes that I felt was essential to the preparation process. I couldn't believe what I was about to embark on, but with God's help and my husband's support, I could get through this. And I did. Beautifully!

I'm not totally against c-sections: of course I think there are instances where they are totally necessary. Breech presentations, multiple births (although not necessarily with twins alone, as long as they present correctly), severe prematurity, dangerous pre-eclampsia, and fetal distress are all obvious red flags, at least to me. But with a c-section rate of roughly 30 percent in this country, you have to wonder if those reasons are really why women are having c-sections?

More common reasons that the c-section rate is so high is because OB's want to practice "daylight obstetrics" - they want the baby out in time for dinner, essentially. With the ability to control so many facets of our lives, why not birth? Anymore if you go one day past your due date, you seem to be a candidate for induction. Pitocin-happy doctors willingly try and induce (more like coerce) a baby out even if it's not ready. Unfortunately it seems that fewer and fewer women are sent home as a result and are almost definitely candidates for c-section. Pitocin can bring with it a cascade of interventions that can sometimes alter or stop labor completely - increased use of epidurals because of harder, stronger contractions is not uncommon, which can, in turn, stall labor - leading to an increased number of c-sections. 

Insufficient pelvis size is another common reason many women are encouraged to have a c-section. Scores of women are even told their babies are too big to deliver vaginally just by an estimate on ultrasound, which further scares them away from attempting a vaginal delivery. Sadly, there is no definite way to know how big a baby will be until they're born and put on the scales - and ultrasound measurements can be off by as much as a pound either way. Many, many petite women give birth vaginally to "large" babies (according to the March of Dimes, anything between six and nine pounds is considered average) and do just fine. Even many babies deemed to be "stuck" can be birthed vaginally provided the medical practitioner knows to instruct the woman to change positions to facilitate further widening of the pelvis (known as the "Gaskin Maneuver," named for renowned midwife Ina May Gaskin). 

Because of the high rate of c-sections in the US, many women are faced with a two-fold problem: if they want more children, do they deliver them via cesarean too? 

Not necessarily. The mantra "once a c-section, always a c-section" is thankfully being disproved by women everyday in this country, although we still have to fight for the right to do so. But unfortunately few women choose this option - whether because they're uneducated about the risks, their doctors scare them out of it, or they have no interest - which is their right. I would never advocate a woman do a VBAC if she really doesn't want to, but neither should I think women should be scared into repeat c-sections for no reason, either. 

One reason many women are scared away from VBACs is the phrase "uterine rupture." It is possible, but is rare, provided you have a low, transverse incision (bikini incision). Also, your chances of receiving Pitocin to induce labor are less - because it can increase your risk of rupture. To many women, the risks of a c-section, if they even know what they are, are somehow more acceptable than the risks of a VBAC, even though the percentage of complications is about the same. 

Risk of VBAC, with non-induced labor, include:

• uterine rupture - this is rare, and the rate is around 1 percent, depending on which source you site

• risk of needing emergency c-section, should the same complications arise as in the first birth

• if you can't go into labor on your own, induction is not recommended 

Risks of cesarean section include:

• increased blood loss and chance of infection

• respiratory complications in the infant because of spinal anesthesia

• increased risk of scar tissue adhesion, especially after several c-sections (which can cause pain and sometimes infertility)

• premature birth because due dates are off 

• risk of uterine rupture (without even going into labor) (although small, still a risk)

It all boils down to which risks you are more comfortable in taking - because don't kid yourself that a repeat c-section isn't without significant risks, too. Neither of them are decisions that should be taken lightly, but unfortunately many women shrug it off as though it's nothing. This unwittingly affects birth outcomes and choices for thousands of women they don't even know, because they either don't care or aren't willing to fight their doctor for the right to give birth. And if you don't fight it, nothing will change. 

http://www.ynhh.org/healthlink/womens/womens_11_01.html

http://www.vbac.com

http://www.vbacfacts.com

http://www.mothering.com/articles/pregnancy_birth/birth_preparation/inducing.html

http://www.buffalonews.com/248/story/573154.html

http://www.msnbc.msn.com/id/17796664/