Social Vulnerability is Associated with Greater Risk of Cesarean Delivery Following a Trial of Labor After Cesarean

Following calls to reduce the prevalence of non-medically indicated cesarean deliveries (CD), there has been increased focus on trials of labor after cesarean (TOLAC). TOLAC requires a risk-benefit analysis, as unsuccessful TOLAC resulting in CD may compound morbidity. Prior work has attempted to develop risk prediction models that guide TOLAC counseling and account for sociostructural barriers. This study examined associations between social vulnerability and birth outcomes among patients with a history of one prior CD.

This retrospective case-control study included patients who attempted a TOLAC at term from 2016 - 2020. We divided patients into two groups: vaginal birth after cesarean (VBAC) and CD. We analyzed social disparities including race and ethnicity, health insurance type, and Social Vulnerability Index (SVI). Chi-squared tests examined proportional differences between groups and multivariable logistic regressions examined adjusted odds ratios of a CD.

We included 976 births. There were significant sociodemographic disparities in VBAC success. Greater rates of morbidity were observed in the CD group. Multivariable regression models revealed that patients with high vulnerability had a 1.2 (1.1, 1.5) greater adjusted odds ratio (aOR) of CD. Patients who identified as Black had a 2.0 (1.1, 3.3) greater aOR of CD compared to White patients. Patients with public (0.6 [0.4,0.9]) or no (0.3 [0.1,0.9]) health insurance coverage had lower aOR of CD.

Our findings suggest that socially vulnerable patients may be more likely to have a CD, and social disparities persist in TOLAC outcomes. This suggests inclusion of social measures be considered with VBAC risk prediction.