Abstract
BackgroundIn 2010, the NIH and ACOG recommended increasing women’s access to trial of labor after cesarean (TOLAC). This study explored access to TOLAC in California, change in access since 2007 and 2010, and characteristics of TOLAC and non-TOLAC hospitals.MethodsBetween November 2011 and June 2012, charge nurses at all civilian California birth hospitals were surveyed about hospitals’ TOLAC availability and requirements for providers. VBAC rates were obtained from the California Office of Statewide Health Planning and Development (OSHPD). Distance between hospitals was calculated using OSHPD geocoding.ResultsAll 243 birth hospitals that were contacted participated. In 2010, among the 56% TOLAC hospitals, the median VBAC rate among TOLAC hospitals was 10.8% (range 0-37.3%). The most cited reason for low VBAC rates was physician unwillingness to perform them, especially due to the requirement to be continually present during labor. TOLAC hospitals were more likely to be larger hospitals in urban communities with obstetrical residency training. However, there were six (11.3%) residency programs in non-TOLAC hospitals and 5 (13.5%) rural hospitals offering TOLAC. The majority of TOLAC hospitals had 24/7 anesthesia coverage and required the obstetrician to be continually present if a TOLAC patient was admitted; 17 (12.2%) allowed personnel to be 15-30 minutes away. TOLAC eligibility criteria included one prior cesarean (32.4%), spontaneous labor (52.5%), continuous fetal monitoring and intravenous access (99.3%), and epidural analgesia (19.4%). The mean distance from a non-TOLAC to a TOLAC hospital was 37 mi. with 25% of non-TOLAC hospitals more than 51 mi. from the closest TOLAC hospital.In 2012, 139 hospitals (57.2%) offered TOLAC, 16.6% fewer than in 2007. Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change.ConclusionsDespite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44% of California hospitals do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer than 3% VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California.
Highlights
In 2010, the National Institutes of Health (NIH) and ACOG recommended increasing women’s access to trial of labor after cesarean (TOLAC)
Since 1996 the number of women undergoing a trial of labor after cesarean (TOLAC) has dropped sharply, due in part to two sets of guidelines issued by the American College of Obstetricians and Gynecologists (ACOG)
In response to the rising cesarean rate, the decline in vaginal birth after cesarean (VBAC), and the intense focus on a rare outcome (0.5% for uterine rupture among TOLAC women) [9], the National Institutes of Health (NIH) convened a Consensus Development Conference Panel in March 2010 to address key questions surrounding the practice of TOLAC
Summary
In 2010, the NIH and ACOG recommended increasing women’s access to trial of labor after cesarean (TOLAC). Following a widely publicized study [1] and increasing malpractice concerns around TOLACs [2,3,4], ACOG in 1998 revised its guidelines for women desiring a vaginal between 1996 and 2010 [7] and the vaginal birth after cesarean (VBAC) rate (per 100 women with a prior cesarean) dropped from 28% to 8% [8]. The Panel concluded that TOLAC “is a reasonable option for many pregnant women” and that efforts are needed to ensure that women with a prior cesarean are supported in making informed decisions about trial of labor versus an elective repeat cesarean [11]. “When [TOLAC] and elective repeat cesarean delivery are medically equivalent options”, the Panel’s statement encourages a shared decision-making process that, whenever possible, allows the woman’s preference to be honored [11]
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