The Availability of Trial of Labor After Cesarean among California Hospitals

The Availability of Trial of Labor After Cesarean among California Hospitals: Understanding predictive factors and possible racial and ethnic disparities

PIs: Mary Barger CNM, PhD

Other Collaborators: Elena Gates, MD; Jennifer Dunn, JD

Funders: UCSF’s Resource Allocation Program (Multidisciplinary Research Project Planning Awards)

Project Objective: Experts in law, nursing and obstetrics from UCSF and UC Hastings Law are collaborating to examine the legal and clinical implications of provider restrictions on trial of labor after cesarean (TOLAC) and hospital bans on vaginal birth after cesarean (VBAC). The Availability of Trial of Labor After Cesarean Among California Hospitals is the collaboration’s first project. The researchers intend to have the California project serve as a pilot for a larger national study.

Project Description: 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 this rate is due in part to the rapid decline of women undergoing TOLAC and delivering vaginally (down from from 28% to 8% during the same timeframe). This decrease in the rate of TOLAC results in a decrease in the rate of vaginal birth after cesarean and increase in the overall rate of cesarean surgeries. 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 survey will ask whether TOLAC is available at a given hospital; what factors influenced the hospital’s decision to offer or not offer TOLAC; and what type of obstetrical providers, emergency services, and anesthesia the hospital provides. The investigators will also use data available from the California Office of Statewide Health Planning and Development to classify hospitals by ownership, geography, and size; to characterize patients’ sociodemographic information; and to determine how far women must travel to receive TOLAC if the hospital in their community does not offer that option. These objectives will address two of the critical knowledge gaps identified in the recent NIH Consensus Conference recommendations: 1) to further understand the racial/ethnic, geographic and socioeconomic differences in rates of TOLAC and VBAC and 2) to identify the nonmedical factors affecting availability and management of TOLAC.

UPDATE: The study has recently been published in BioMed Central: http://www.biomedcentral.com/1471-2393/13/83

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