Vaginal birth after cesarean section: a comparison of rural and metropolitan rates in Oklahoma

The rate of cesarean delivery has risen steadily over the past fifteen years from a rate of 17% in 1980 to 24% in 1995. In an effort to curb medical expenses and reduce the risk associated with operative delivery, many suggestions have been proposed to reduce the rate of cesarean sections. The most promising of these is to reduce the number of repeat cesarean deliveries through vaginal birth after cesarean section (VBAC). For fifteen years the American College of Obstetrics and Gynecology has proposed VBAC as a safe alternative to repeat C-section. VBAC carries a 1% to 2% risk of uterine rupture and is contraindicated in the presence of previous classical uterine incision, multiple gestation, and certain abnormal presentations. In the absence of contraindications, VBAC is as safe or safer than repeat C-section. This study shows that VBAC rates are lower in two rural hospitals than in two urban hospitals in Oklahoma. Data was collected from two rural and two urban hospitals for the years 1993 through 1996. This data indicates that in urban hospitals the rate of vaginal deliveries (81%) is higher and the rate of C-sections (19%) is lower than in rural hospitals (68% and 31% respectively). Also, the rate of attempted VBAC (46%) and successful VBAC (36%) is higher in urban hospitals than in rural hospitals (30% and 18% respectively). The lower rate of VBAC in rural hospitals can be explained by several factors, including lack of in-house physicians, anesthesia, and surgical crews; inadequate neonatal intensive care units; difficulty of transfer; economic factors; physician training or experience; and physicians' attitudes. This study points to a need for a larger scale study of VBAC practices among rural and urban physicians in Oklahoma.