Access to Vaginal Labor After C-section is Limited to Some 16% of U.S. Counties

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Laura Attanasio

Only 16% of all counties in the U.S. offered pregnant people the opportunity to attempt labor after a previous cesarean section between 2016 and 2021, according to new research from Laura Attanasio that provides the most recent national look at this trend.

“Our findings confirm the difficulty individuals have expressed in accessing LAC [labor after cesarean],” concludes the research published recently in JAMA Network Open.

Counties with access to labor after cesarean were more prevalent in the Northeast and Western regions of the country. Large swaths of counties in the South and Midwest had “extremely limited access.” 

Though having labor with the goal of vaginal delivery is not the best choice for some pregnant people with a prior cesarean birth, vaginal birth after cesarean (VBAC) offers a shorter recovery and lower risk of infection, as well as a lower risk of complications in future pregnancies and maternal death, according to the American College of Obstetricians and Gynecologists (ACOG). 

“ACOG officially says that VBAC is a reasonable option for most people with a prior cesarean,” says Attanasio, associate professor of health policy and management and senior author of the paper.

Metropolitan areas were most likely to offer LAC due to the availability of one or more hospitals staffed with the required specialists. Even then, the research notes, access may be hindered by other barriers, such as a lack of health insurance and transportation.

When limiting to counties that have a hospital offering obstetric services, LAC access rose to 30%. “So even when we’re looking only at counties that have obstetric care, less than a third of them offer access to labor after cesarean,” Attanasio says.

The rate of access to labor after cesarean held steady across the nation at 16% of counties from 2016 to 2021, according to the research. Yet the national VBAC rate actually increased — from 12.4% in 2016 to 14.2% in 2021, according to the March of Dimes Perinatal Data Center. 

“One major finding was that access was pretty low and was not increasing over this time period,” Attanasio says. “Given that VBAC has increased over this time period, this suggests that VBAC rates are increasing in the places where VBAC is available rather than coming from more places offering labor after cesarean. Access is not expanding, at least at the county level.”

Attanasio was the advisor to lead author Brittany Ranchoff, a graduate of the Ph.D. program in health policy and management who worked on the paper as part of her dissertation. Other co-authors are Dr. Sarah Goff, professor and chair of health promotion and policy, and Elizabeth Bertone-Johnson, professor of epidemiology.

The researchers used birth certificate data to examine all births in every county in the U.S. from 2016-21. Birth certificates include information on mode of delivery. Attanasio and team point to several reasons that access for LAC is so low despite the current ACOG guidelines. 

In addition to hospitals with no obstetric services, another impediment occurs in hospitals with obstetric services that can’t guarantee immediate access to a cesarean surgery, which is the appropriate setting for LAC, according to ACOG guidelines.

Other big barriers may be the results of shifting clinical guidelines in the past few decades and the comfort, or lack thereof, of providers and medical liability insurers.

“There was a swing in the early 2000s to not having a vaginal birth after cesarean and then a recognition around 2010 that for a lot of people there might be clinical benefits and better outcomes to having a vaginal birth after cesarean, so it should be an option for more people,” Attanasio says. “But there’s been a lag in access catching up with this.

One of the concerns for providers and hospitals is around liability—if there’s someone attempting a vaginal birth after cesarean and it ends in a negative outcome.”