Analyzing State and County Rates of Vaginal Birth after Cesarean (VBAC) before and after Revision of ACOG

Guidelines

Kylia Garver MPH(c), Allison Potter MPH(c),Christina Gebel MPH, Eugene Declercq, PhD

American Public Health Association Annual Meeting: New Orleans, LA

November 17, 2014

Overview

1. Changes in the VBAC clinical guidelines released by ACOG in 2010.

2. National, state and county trends in VBAC rates.

3. Regional patterns in overall rates and changes in rates before and after adoption of ACOG guidelines.

August 2010

VBAC Contraindications

• T shaped, vertical or unknown uterine scar

• Previous uterine rupture

• Placental previa • Non-vertex

presentation

VBAC Health Significance at the Population Level

Benefits (as stated by ACOG)1

• No abdominal surgery • Shorter recovery period • Lower risk of infection • Less blood loss • If you want to have more

children, VBAC may help you avoid problems linked to multiple cesarean deliveries. – Including: hysterectomy,

bowel or bladder injury, & certain problems with the placenta.

Potential Risks of Cesareans to Consider2,3

•Maternal Physical Effects

•Physical Effects in Babies

•Breastfeeding

•Development of Childhood Chronic Disease

•Psychosocial Effects

•Cost

Trivia

A cesarean birth without complications costs _____% more than a vaginal birth without complications?3

A. 25%

B. 35%

C. 50%

D. 70%

Hospital Charges by Mode of Delivery, 2012

Source: AHRQ. 2011. HCUPnet, Healthcare Cost & Utilization Project3

Calculation of VBAC Rates

# of VBAC(# of VBAC + # of repeat cesarean)

Changing Measurement

• method of delivery question asked if birth was vaginal after cesarean

• no data collected on number of previous cesareans

2003 Revision• added previous cesarean delivery as

a risk factor • number of previous surgical

deliveries for all patients

1989 Version

Update of birth certificate makes year to year analyses unreliable in some states

VBAC Rates by State 2009U.S. Averages4: Old BC, 6.8%; New BC, 8.4%

VBAC Rates by State 2011U.S. Averages4: Old BC, 6.7%; New BC, 9.7%

DC

Change in VBAC Rates by State 2009-2011U.S. Averages4: Old BC, 0.1 Percentage Point (PP) Decrease; New BC, 1.3 PP Increase

Regional Variation

Santa Fe County, New Mexico reported a 33% VBAC rate, compared to a 16% state average.

St Louis County, Missouri reported a 35% VBAC rate in 2011, compared to a 14% state average.

VBAC Rates*, US 1990-2011

Source4: NCHS Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm

* Number of VBACs among women with prior cesarean

NOTE: Rates for 2005-2011 are unofficial

% VBAC Lower Risk* Mothers, U.S., Monthly Rates, 1990-2012

* Full-gestation(37+ weeks), vertex presentation, singleton births

ACOG New VBAC Guidelines 10/98 & 7/99

Lydon-Rochelle & Greene 7/01

Sachs, NEJM 1/99

LandonNEJM 12/04

McMahon NEJM 9/96

ACOG guidelines encourage VBAC, 1/82 10/88 Reaffirmed 1991

Flamm Studies1988,’90, ‘94

Revised ACOG Guide-

lines 8/10

VBAC Rate Low Risk Births*, 28 States with revised Birth Certificate, 2009-2012

* Singleton, Vertex, Gest Age 37+ weeks, 1 cesarean.

ACOG RevisedVBAC Guidelines

VBAC Rate Low Risk Births*, 28 States with revised Birth Certificate, 2009-2012

* Singleton, Vertex, Gest Age 37+ weeks, 1 cesarean.

ACOG RevisedVBAC Guidelines

VBAC Rates, Selected Countries, 2010

Sources: Euro-Peristat project with SCPE and Eurocat. European Perinatal Health Report, U.S. Vital Stats.

Base: had cesarean in the past and for most recent birth LTMI

2000-02LTMII 2005

LTMIII2011-12

Was interested in the option of a vaginal birth after cesarean

n.a. 45% 48%

Did not have the option of a vaginal birth, or VBAC 42% 52% 56%

Mothers’ Interest in and Access to VBACs

New VBAC Guidelines

“The complications of having a C section needto be discussed more thoroughly with the patient

having one in my opinion.”

-LtM III6

“Looking back, I wish I would have tried more for a VBAC. We live an hour and a half away from

the hospital where I gave birth so that was a factor in deciding to schedule another C-Section.”

-LTM III6

“It meant a lot that I was always treated as the owner and decision maker for my body. “

-LTM III6

Summary•In August 2010 ACOG released guidelines that stated that most women who have had a previous cesarean with a low-transverse incision are candidates for and should be counseled about VBAC and offered a TOLAC.

•No significant change in US VBAC rates before and after the guideline (2009 & 2011).

•Regional variation is an important consideration.

•Two years after the guidelines were released there is no increase in VBAC rates. The minimal change in the US rate remains lower than in all other industrialized countries.

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References

1. Vaginal Birth After Cesarean Delivery - Deciding on a Trial of Labor After Cesarean Delivery – ACOG. Available from: http://www.acog.org/Patients/FAQs/Vaginal-Birth-After-Cesarean-Delivery-Deciding-on-a-Trial-of-Labor-After-Cesarean-Delivery#benefits

2. Childbirth Connection (2012). Vaginal or Cesarean Birth: What is at Stake for Women and Babies? New York: Childbirth Connection.

3. AHRQ. 2011. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov.

4. Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. 2013.

5. Vaginal Birth After Previous Cesarean Delivery – ACOG. Aug 2010.

6. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection, May 2013.

7. Euro-Peristat project with SCPE and Eurocat. European Perinatal Health Report. The health and care of pregnant women and babies in Europe in 2010. May 2013.