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Research ArticleOriginal Research

Vaginal Birth After Cesarean in California: Before and After a Change in Guidelines

John Zweifler, Alvaro Garza, Susan Hughes, Matthew A Stanich, Anne Hierholzer and Monica Lau
The Annals of Family Medicine May 2006, 4 (3) 228-234; DOI: https://doi.org/10.1370/afm.544
John Zweifler
MD, MPH
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Alvaro Garza
MD, MPH
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Susan Hughes
MS
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Matthew A Stanich
MPH
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Anne Hierholzer
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Monica Lau
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  • Figure 1.
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    Figure 1.

    Singleton births in California hospitals by California residents, 1996–2002.

    VBAC = vaginal birth after cesarean.

  • Figure 2.
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    Figure 2.

    Successful vaginal births in women with previous cesarean section delivery: California, 1996–2002.

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    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 Characteristics1996 – 19992000 – 2002Decrease (%)
    *χ2 test; P <.001 for difference between time frames.
    Overall*24.013.544
    Age, years*
        <2026.611.756
        20–2925.213.945
        30–3923.313.442
        40–4919.311.242
    Race/ethnicity*
        White25.614.045
        Hispanic22.612.644
        Black21.614.334
        Asian29.517.541
        Other25.614.743
    Education*
        Less than high school22.612.445
        High school23.313.144
        Some college25.214.542
        College degree27.215.244
    Hospital status*
        Rural27.314.846
        Urban23.813.444
    Pregnancy complication*
        Yes28.118.036
        No22.812.545
    • View popup
    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 g1,500– 2,499 g2,500–4,000 g>4,000 g
    Delivery MethodStudy Periodn*Rate (95% CI†)nRate (95% CI†)nRate (95% CI†)nRate (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 VBAC1996–1999316253.2 (197.7–308.6)1,5891.8 (0.4–5.5)42,2480.3 (0.2–0.5)6,5170.3 (0.0–1.1)
    2000–2002190336.8 (254.3–419.4)8387.2 (2.6–15.6)19,6820.4 (0.1–0.7)2,8630.0 (0.0–1.3)
    Successful VBAC1996–1999292267.1 (207.8–326.4)1,3872.2 (0.4–6.3)35,5280.3 (0.2–0.6)4,7540.0 (0.0–0.8)
    2000–2002178359.6 (271.5–447.6)7388.1 (3.0–17.7)16,6720.1 (0.0–0.4)2,1350.0 (0.0–1.7)
    Failed VBAC1996–19992483.3 (10.1–301.0)2020.0 (0.0–18.3)6,7200.3 (0.0–1.1)1,7631.1 (0.1–4.1)
    2000–2002120.0 (0.0–307.5)1000.0 (0.0–36.9)3,0101.7 (0.5–3.9)7280.0 (0.0–5.1)
    Repeat CS1996–19991,94759.1 (48.3–69.9)6,4074.7 (3.3–6.7)128,4170.4 (0.3–0.5)23,5590.1 (0.0–0.4)
    2000–20021,60460.5 (48.4–72.5)6,0726.9 (5.0–9.3)124,2240.3 (0.2–0.4)19,4620.5 (0.3–0.9)
    • View popup
    Table 3.

    Multiple Logistic Regression Analysis of the Association Between Delivery Characteristics and Neonatal Death in California from 1996–2002

    CharacteristicOdds 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, 2000–20021.00-
        Pre-ACOG revision, 1996–19990.82 (0.69–0.97).022
    Birth weight
        2,500–4,000 g1.00-
        <1,500 g273.61 (215.70–347.07)<.001
        1,500–2,499 g15.63 (11.66–20.95)<.001
        >4,000 g0.88 (0.51–1.52).65
    Delivery method
        Repeat cesarean1.00-
        Attempted VBAC2.84 (2.35–3.45)<.001
    Pregnancy complication†1.54 (1.28–1.86)<.001
    Hospital location‡
        Urban1.00-
        Rural1.21 (0.76–1.95).425
    • View popup
    Table 4.

    Maternal Deaths by Delivery Method and Study Period, California, 1996–2002

    Maternal Death Rate per 100,000 (95% CI*)
    Delivery Method1996–19992000–2002
    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 VBAC2.0 (0.1–11.0)8.5 (1.0–30.6)
    Repeat cesarean8.7 (4.8–14.6)11.9 (7.0–18.8)

Additional Files

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  • 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.
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The Annals of Family Medicine: 4 (3)
The Annals of Family Medicine: 4 (3)
Vol. 4, Issue 3
1 May 2006
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Vaginal Birth After Cesarean in California: Before and After a Change in Guidelines
John Zweifler, Alvaro Garza, Susan Hughes, Matthew A Stanich, Anne Hierholzer, Monica Lau
The Annals of Family Medicine May 2006, 4 (3) 228-234; DOI: 10.1370/afm.544

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Vaginal Birth After Cesarean in California: Before and After a Change in Guidelines
John Zweifler, Alvaro Garza, Susan Hughes, Matthew A Stanich, Anne Hierholzer, Monica Lau
The Annals of Family Medicine May 2006, 4 (3) 228-234; DOI: 10.1370/afm.544
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