Vaginal Birth After Cesarean Rates Are Declining Rapidly in the Rural State of Maine

Abstract

Cesarean delivery became the most common major operation in the United States in the 1980s. The rate rose from 5.5% in 1970 to 24.7% in 1986. In the late 1990s, the American College of Obstetricians and Gynecologists (ACOG) began requiring the presence of a surgeon, anesthesiologist, and operating personnel throughout the trial of labor for patients having a past cesarean delivery. This study reviewed birth certificate and hospital data for the state of Maine from 1998 to 2001 to estimate the change in rate for vaginal birth after cesarean (VBAC) and to detect possible reasons for the change. Hospital-specific rates were determined for primary, repeat, and total cesarean deliveries and for VBAC. Present providers of obstetric care were asked about the reasons for any change in VBAC rates at their hospitals. The study was limited to women giving birth at 20 or more weeks gestation. Statewide rates of VBAC delivery decreased by 56% between 1998 and 2001 based on birth certificate data and by 62% based on hospital-reported data. The respective relative risk figures for VAC in 1998 versus 2001 were 2.8 and 3.5. In 2001, but not in 1998, some hospitals reported no VBAC deliveries. According to hospital-reported data only, smaller hospitals performed significantly fewer VBACs. The rate of primary cesarean delivery increased by 1% to 2.6% during the period under review. Total cesarean deliveries increased from 19.4% to 24.0%. A survey disclosed that a large majority of those practicing at hospitals doing VBACs reported meeting the ACOG guidelines. Many family practice physicians stated that a lack of backup from the obstetric service was the most common reason for declining VBAC rates. Some patients refused VBAC after counseling, and some institutions failed to meet the ACOG guidelines. These findings, demonstrating a marked drop in VBAC after the change in ACOG guidelines, probably apply to rural states other than Maine. It is important to continue monitoring national VBAC rates so as to better define risk factors for fetal death and uterine rupture.