A recent comprehensive study conducted by researchers at the University of Massachusetts Amherst sheds new light on the availability of labor after cesarean (LAC) opportunities across the United States. Their findings indicate a strikingly low accessibility, with only 16% of all U.S. counties offering pregnant individuals the chance to attempt labor following a previous cesarean section during the years spanning 2016 to 2021. This investigation presents the most up-to-date national perspective on this crucial trend in maternal health care.
Labor after cesarean, or LAC, refers to the option for individuals with a prior cesarean delivery to attempt vaginal birth in a subsequent pregnancy. While vaginal birth after cesarean (commonly referred to as VBAC) is not suitable for every patient, it generally offers substantial benefits, including reduced recovery time, lower infection risks, and decreased chances of complications in future pregnancies as well as maternal mortality. These clinical advantages have been underscored by prominent professional bodies such as the American College of Obstetricians and Gynecologists (ACOG), which affirms that VBAC is a reasonable and often preferable option for most eligible individuals.
Geographic disparities emerged prominently in the study’s analysis: counties in the Northeastern and Western United States were more likely to provide access to labor after cesarean, while vast areas in the South and Midwest demonstrated limited or negligible availability. This uneven distribution points to systemic factors influencing access that transcend individual patient choice, emphasizing structural and institutional constraints within healthcare delivery systems.
Importantly, metropolitan regions exhibited the highest likelihood of offering labor after cesarean, often attributable to the presence of hospitals staffed with necessary specialists capable of managing both labor and emergency cesarean surgeries. However, even in urban centers equipped with appropriate facilities, barriers such as inadequate health insurance coverage and transportation challenges can restrict practical access for many pregnant individuals. These socioeconomic factors interplay with clinical infrastructure to shape the real-world feasibility of choosing VBAC.
When researchers narrowed focus exclusively to counties hosting hospitals with obstetric services, they observed that approximately 30% offered labor after cesarean opportunities. Though this represents an increase compared to the overall figure, it highlights a critical shortfall: even in locales where obstetric care is available, the majority lack the capacity or protocols to support LAC safely and effectively. This gap calls attention to the complexities involved in meeting clinical guidelines formulated by ACOG and others.
Notably, while access to LAC remained steady at the 16% threshold nationwide from 2016 through 2021, data revealed a concurrent rise in VBAC rates, inching upward from 12.4% to 14.2%. This paradox indicates that vaginal births after cesarean are becoming more frequent in regions where LAC options exist but are not spreading geographically to new areas or increasing overall availability at the county level.
This disconnect suggests that improvements in VBAC outcomes and uptake are localized phenomena rather than markers of a broader systemic expansion of labor after cesarean accessibility. It also implies that, despite evolving clinical guidelines, the infrastructural and procedural adoption needed to support wider LAC opportunities is lagging behind patient desires and professional recommendations.
Delving into the causes of persistently limited LAC access, the study points to several interrelated factors. Historically, the early 2000s witnessed a shift away from advocating VBAC due to safety concerns, leading many hospitals and practitioners to restrict or discourage this option. Around 2010, recognition grew that VBAC might yield favorable clinical outcomes for many patients, prompting ACOG to reconsider and recommend broader availability. Despite these changing guidelines, healthcare providers’ adoption of LAC protocols has been uneven and sluggish.
Moreover, a major impediment to expanding labor after cesarean services involves the inability of some hospitals with obstetric care to guarantee immediate access to emergency cesarean surgery—a requirement established by ACOG to ensure patient safety during LAC attempts. Without the assurance of prompt surgical intervention, hospitals are reluctant to offer labor after cesarean due to potential risks.
Liability concerns also weigh heavily on institutional decisions. Medical providers and insurers remain cautious and risk-averse because adverse outcomes in VBAC cases can lead to significant malpractice litigation. This environment fosters conservative clinical practices that often prioritize repeat cesarean deliveries over labor trials, limiting patient choice despite evidence supporting VBAC’s safety when correctly managed.
The research team, led by Laura Attanasio, associate professor of health policy and management, utilized a national dataset encompassing birth certificate information for all U.S. counties from 2016 to 2021. Birth certificates document delivery methods, enabling a comprehensive analysis of where LAC is accessible and how VBAC rates correspond to geographic availability. Beyond quantitative metrics, the study contextualizes findings within broader social, medical, and policy frameworks influencing maternal health services.
This nuanced understanding emphasizes that enhancing LAC access requires multifaceted strategies. These may involve expanding hospital capacity to provide emergent cesarean surgeries, modifying institutional policies to better align with updated clinical guidelines, addressing insurance and transportation hurdles faced by pregnant individuals, and fostering provider education to reduce liability fears and increase comfort with VBAC management.
By revealing that labor after cesarean remains limited to a small fraction of U.S. counties, this study underscores a significant public health challenge. Ensuring equitable, safe access to VBAC for individuals desiring it has implications for maternal morbidity reduction, healthcare cost containment, and empowerment of pregnant people to make informed reproductive choices aligned with their clinical needs and personal preferences.
This research advances the conversation around obstetric care disparities and calls for targeted interventions to close access gaps, expand informed patient options, and promote best practices in maternal health nationwide. As VBAC rates improve in current-access regions, scaling these benefits broadly remains an urgent task for clinicians, policymakers, and healthcare institutions alike.
Subject of Research: Access to labor after cesarean (LAC) and vaginal birth after cesarean (VBAC) availability across U.S. counties.
Article Title: Access to Labor After Cesarean in U.S. Counties Remains Low Despite Increased VBAC Rates.
Web References:
- JAMA Network Open: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2837371?resultClick=1
- American College of Obstetricians and Gynecologists (ACOG) VBAC FAQs: https://www.acog.org/womens-health/faqs/vaginal-birth-after-cesarean-delivery
- March of Dimes Perinatal Data Center: https://www.marchofdimes.org/peristats/data?lev=1&obj=1®=99&slev=1&stop=90&top=8
Image Credits: UMass Amherst
