What do we know?
One of the strongest predictors of a woman’s likelihood of having a cesarean delivery is whether she has had one with a previous pregnancy. Vaginal birth after cesarean (VBAC) has been a contentious area in medicine for decades. Studies have demonstrated an association between VBAC and ruptured uterus and neonatal morbidity. However, repeat cesarean delivery also carries increased risks of complications such as placenta accreta in future pregnancies.
When done in an appropriate context with the necessary resources in place, VBAC can have high rates of success. Evidence suggest that the relative risks associated with VBAC and repeat elective cesarean delivery are comparable among low-risk women. In addition to clinical risk factors, there are several elements that can influence a woman’s decision to attempt a VBAC including providers’ beliefs and practices, hospital-level and national policies, limited resources, lack of information, health insurance reimbursement and concerns about malpractice litigation.
Clinical guidelines related to VBAC decision-making and management are inconsistent across hospitals and countries, and most of the research on the safety of and indications for VBAC has been conducted in high-income countries (HICs).
Expanding the conversation
Over the past few decades, cesarean section rates have increased dramatically in virtually every part of the world—including in low- and middle-income countries (LMICs). As global cesarean rates rise, more and more women will be faced with a dilemma: “Do I attempt a VBAC or choose a repeat cesarean?” Weighing the risks and benefits of these choices becomes even more complicated in health facilities that do not meet basic requirements for safe surgery.
More evidence from diverse settings is needed to understand the complexity surrounding VBAC in the global context. Very few studies on this topic have been conducted in LMICs, and findings from HICs may not always apply to different populations and health systems. For example, in some cases, the process of assessing whether a women is a good candidate for VBAC might incorporate facility-level factors such as the availability of safe anesthesia, a sterile operating room and a properly trained surgeon. In HICs, these issues are often not considered relevant in conversations about VBAC.
Obstetricians, midwives and other maternal health care providers around the globe must be trained and equipped to safely conduct cesarean deliveries when needed, carefully monitor attempted VBACs to prevent complications and help women to make informed decisions about which option is best for them and their babies.
Read the report from a technical meeting that the MHTF hosted with the Fistula Care Plus Project, “Cesarean Section Safety and Quality in Low Resource Settings.”
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