Vaginal birth after cesarean in California

To estimate rates at which women were offered and consented to trial of labor in California hospitals with high and low risk-adjusted cesarean delivery rates.

From 267 nonfederal acute-care hospitals in California that performed more than 678 deliveries in 1992-1993, 51 hospitals were selected in a stratified sample. Hospitals in the sample were categorized as having high, medium, and low risk-adjusted cesarean rates using a logistic regression model based on data from the California Patient Discharge Data System. We reviewed medical records of women with previous cesareans for evidence of counseling regarding trial of labor, other clinical variables, and method of delivery. Differences in proportions between the three groups of hospitals were compared.

According to records of 369 women with previous cesareans, after excluding contraindications, 312 were potentially eligible for trial of labor. Hospitals with low risk-adjusted cesarean rates documented counseling women for trial of labor in over 99% of records reviewed, compared with 85% and 79%, respectively, of hospitals with intermediate and high rates (P <.001). Rates of completed vaginal births after cesarean were 71% in hospitals with low risk-adjusted cesarean rates, compared with 39% and 31% in hospitals with intermediate and high rates (P <.05).

California hospitals with high cesarean rates in 1992-1993 had markedly higher rates of repeat elective cesarean delivery without evidence of counseling regarding trial of labor. Informed patient choice is a critical element of the decision for trial of labor or elective repeat cesarean, and lack of documented counseling is cause for concern.