Article Figures & Data
Figures
- Figure 1.
Singleton births in California hospitals by California residents, 1996–2002.
VBAC = vaginal birth after cesarean.
- Figure 2.
Successful vaginal births in women with previous cesarean section delivery: California, 1996–2002.
Tables
- Table 1.
Women With a Previous Cesarean Section Delivery Who Attempted Vaginal Birth, by Maternal Demographic Characteristics and Study Period, California, 1996–2002
Attempt VBAC (%) Maternal Characteristics 1996 – 1999 2000 – 2002 Decrease (%) *χ2 test; P <.001 for difference between time frames. Overall* 24.0 13.5 44 Age, years* <20 26.6 11.7 56 20–29 25.2 13.9 45 30–39 23.3 13.4 42 40–49 19.3 11.2 42 Race/ethnicity* White 25.6 14.0 45 Hispanic 22.6 12.6 44 Black 21.6 14.3 34 Asian 29.5 17.5 41 Other 25.6 14.7 43 Education* Less than high school 22.6 12.4 45 High school 23.3 13.1 44 Some college 25.2 14.5 42 College degree 27.2 15.2 44 Hospital status* Rural 27.3 14.8 46 Urban 23.8 13.4 44 Pregnancy complication* Yes 28.1 18.0 36 No 22.8 12.5 45 - Table 2.
Neonatal Death Rates by Birth Weight, Delivery Method, and Study Period, California, 1996–2002
Neonatal Deaths per 1,000 Live Births <1,500 g 1,500– 2,499 g 2,500–4,000 g >4,000 g Delivery Method Study Period n* Rate (95% CI†) n Rate (95% CI†) n Rate (95% CI†) n Rate (95% CI†) Note: Neonatal death rates calculated for singleton births delivered in California hospitals by California residents with a previous cesarean delivery, 1996–2002. Numbers bolded show significant differences (CIs do not overlap) within the birth weight category. CI = confidence interval; VBAC = vaginal birth after cesarean; attempted VBAC = successful VBAC + failed VBAC; CS = cesarean section. * Total number of births in each category. † 95% Poisson CIs. Attempted VBAC 1996–1999 316 253.2 (197.7–308.6) 1,589 1.8 (0.4–5.5) 42,248 0.3 (0.2–0.5) 6,517 0.3 (0.0–1.1) 2000–2002 190 336.8 (254.3–419.4) 838 7.2 (2.6–15.6) 19,682 0.4 (0.1–0.7) 2,863 0.0 (0.0–1.3) Successful VBAC 1996–1999 292 267.1 (207.8–326.4) 1,387 2.2 (0.4–6.3) 35,528 0.3 (0.2–0.6) 4,754 0.0 (0.0–0.8) 2000–2002 178 359.6 (271.5–447.6) 738 8.1 (3.0–17.7) 16,672 0.1 (0.0–0.4) 2,135 0.0 (0.0–1.7) Failed VBAC 1996–1999 24 83.3 (10.1–301.0) 202 0.0 (0.0–18.3) 6,720 0.3 (0.0–1.1) 1,763 1.1 (0.1–4.1) 2000–2002 12 0.0 (0.0–307.5) 100 0.0 (0.0–36.9) 3,010 1.7 (0.5–3.9) 728 0.0 (0.0–5.1) Repeat CS 1996–1999 1,947 59.1 (48.3–69.9) 6,407 4.7 (3.3–6.7) 128,417 0.4 (0.3–0.5) 23,559 0.1 (0.0–0.4) 2000–2002 1,604 60.5 (48.4–72.5) 6,072 6.9 (5.0–9.3) 124,224 0.3 (0.2–0.4) 19,462 0.5 (0.3–0.9) - Table 3.
Multiple Logistic Regression Analysis of the Association Between Delivery Characteristics and Neonatal Death in California from 1996–2002
Characteristic Odds Ratio (95% CI*) P Value CI = confidence interval; ACOG = American College of Obstetricians and Gynecologists; VBAC = vaginal birth after cesarean. * 95% Poisson CI. † Pregnancy complication is a composite variable based on codes noted in the California Department of Health Services Certificate of Live Birth Medical Data Supplemental Work Sheet, Item 29, and excludes mothers with electronic fetal monitoring or ultrasound. ‡ Hospital location based on California Office of Statewide Health Planning and Development designation of “small/rural” during years 1996–2002. Date of delivery Post-ACOG revision, 2000–2002 1.00 - Pre-ACOG revision, 1996–1999 0.82 (0.69–0.97) .022 Birth weight 2,500–4,000 g 1.00 - <1,500 g 273.61 (215.70–347.07) <.001 1,500–2,499 g 15.63 (11.66–20.95) <.001 >4,000 g 0.88 (0.51–1.52) .65 Delivery method Repeat cesarean 1.00 - Attempted VBAC 2.84 (2.35–3.45) <.001 Pregnancy complication† 1.54 (1.28–1.86) <.001 Hospital location‡ Urban 1.00 - Rural 1.21 (0.76–1.95) .425 Maternal Death Rate per 100,000 (95% CI*) Delivery Method 1996–1999 2000–2002 Note: Maternal death within 72 hours of delivery; maternal death rates calculated for singleton births delivered in California hospitals by California residents with a previous cesarean. CI = confidence interval; VBAC = vaginal birth after cesarean. * 95% Poisson confidence interval. Attempted VBAC 2.0 (0.1–11.0) 8.5 (1.0–30.6) Repeat cesarean 8.7 (4.8–14.6) 11.9 (7.0–18.8)
The Article in Brief
Vaginal Birth After Cesarean in California: Before and After a Change in Guideline
John Zweifler, MD, MPH, and colleagues
Background In 1999, the American College of Obstetricians and Gynecologists adopted more-restrictive guidelines for vaginal birth after cesarean delivery (VBAC), requiring a physician to be immediately available to perform emergency care, if needed. This study looks at trends in VBAC in California before and after the 1999 guideline revision.
What This Study Found The percentage of women attempting vaginal birth after cesarean delivery fell significantly, from 24 percent before the guideline revision to 13.5 percent after guideline revision. This decline, however, seems to continue a national trend that began in 1997. Although rates of repeat delivery by cesarean section increased during the years following the guideline revision, death rates among infants and mothers did not improve.
Implications
- The 1999 guideline revision reflects concern for the safety of VBAC deliveries and may have accelerated the trend away from VBAC and toward repeat cesarean deliveries, particularly at rural hospitals.
- This study found that, in delivery of normal or large birth weight infants, the infant death rate for VBAC was similar to the death rate for repeat cesarean delivery.
- The authors recommend that, when counseling pregnant patients who have had a previous cesarean delivery, physicians offer a balanced presentation of risk and inform them of the encouraging outcomes found in this study.
