Demographic and organizational factors fostering vaginal birth after caesarean section in Italy: A retrospective...

Caesarean section (CS) rates have increased worldwide, raising concerns about maternal and child health and healthcare costs. Although vaginal birth after caesarean (VBAC) is considered a safe alternative, its use remains limited and variable. We aimed to identify sociodemographic, clinical, and organizational factors associated with VBAC utilization in Tuscany, Italy, and to assess the impact of VBAC on perinatal outcomes.

We conducted a retrospective population-based study using administrative healthcare data (2021-2024), including women with one previous CS who delivered at term (n = 6,737). Single-level and multi-level logistic regression models were used to investigate independent determinants of VBAC utilization and its association with perinatal outcomes. Missing data were handled using multiple imputation.

Overall, 27% of women underwent VBAC. Older maternal age, unemployment, Italian nationality, assisted reproductive technologies, diabetes, private care pathways, and indicators of more intensive prenatal surveillance were associated with lower odds of VBAC, whereas antenatal class attendance and early initiation of prenatal care were associated with higher odds. VBAC rates increased from 2021 to 2022 to 2023-2024. The multi-level model showed that 25.4% of the variance in VBAC utilization was attributable to differences between hospitals. VBAC was associated with improved perinatal outcomes (higher Apgar scores; increased breastfeeding and skin-to-skin contact; lower neonatal ventilation) and reduced length of stay and hospitalization costs.

VBAC utilization in Tuscany remains below recommended levels. Hospital-level differences explain a substantial proportion of the observed variation, supporting the need to standardize VBAC practices at the regional level.