Availability of Trial of Labor after Cesarean among California Hospitals: Understanding Predictive Factors and Possible Racial and Ethnic Disparities

The cesarean section rate in the United has risen to nearly one in three births (from 21% in 1996 to 32% in 2007). This rise is of concern since it has not been accompanied by improved maternal and neonatal outcomes but instead by increased maternal short and long-term morbidity. The increase in the cesarean rate since 1996 is due in part to the rapid decline in the rate of women undergoing a trial of labor after a cesarean (TOLAC) who deliver vaginally from 28% to 8% during the same timeframe. A reason to focus on this rate is that during the early to mid-1990’s when the rate was increasing, there was a decrease in both repeat and primary cesareans. There is good evidence that for selected women, the option of having a TOLAC is less risky than having a planned repeat cesarean. Two national policy recommendations were issued in 2010 encouraging hospitals and obstetric providers to make TOLAC more widely available. The purpose of this study is to develop and pilot test of a survey on TOLAC policies in California’s 257 birth hospitals. We seek to find out if recent policy recommendations have influenced hospitals to change their policies since 2007, the most recent data on TOLAC rates by hospital ,and identify factors that promote or discourage this policy. We will also test an innovative strategy using geographical information system software to link hospital data characteristics, their TOLAC policies, and community variables to determine potential ethnic/racial or economic disparities in communities offering and not offering TOLAC, and also be able to determine distances women desiring TOLAC would have to travel to receive this delivery option. These objectives will address two of the critical knowledge gaps identified in the recent NIH Consensus Conference recommendations: to further understand the racial/ethnic, geographic, and socioeconomic differences in rates of TOLAC and VBAC and to identify the nonmedical factors affecting availability and management of TOLAC.


Additional Members:
Elena Gates, MD
Jennifer Dunn, JD