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 National, state and county trends in VBAC rates. 1.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 Consider 2,3 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 HCUPnet, Healthcare Cost & Utilization Project 3

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 2009 U.S. Averages 4 : Old BC, 6.8%; New BC, 8.4%

VBAC Rates by State 2011 U.S. Averages 4 : Old BC, 6.7%; New BC, 9.7%

DC Change in VBAC Rates by State U.S. Averages 4 : 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 Source 4 : NCHS Vital Stats. * Number of VBACs among women with prior cesarean NOTE: Rates for are unofficial

% VBAC Lower Risk* Mothers, U.S., Monthly Rates, * Full-gestation(37+ weeks), vertex presentation, singleton births ACOG New VBAC Guidelines 10/98 & 7/99 Lydon-Rochelle & Greene 7/01 Sachs, NEJM 1/99Landon NEJM 12/04 McMahon NEJM 9/96ACOG guidelines encourage VBAC, 1/82 10/88 Reaffirmed 1991 Flamm Studies 1988,’90, ‘94 Revised ACOG Guide- lines 8/10

VBAC Rate Low Risk Births*, 28 States with revised Birth Certificate, * Singleton, Vertex, Gest Age 37+ weeks, 1 cesarean. ACOG Revised VBAC Guidelines

VBAC Rate Low Risk Births*, 28 States with revised Birth Certificate, * Singleton, Vertex, Gest Age 37+ weeks, 1 cesarean. ACOG Revised VBAC 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 LTMII 2005 LTMIII 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 need to be discussed more thoroughly with the patient having one in my opinion.” - LtM III 6

“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 III 6

“It meant a lot that I was always treated as the owner and decision maker for my body. “ -LTM III 6

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: 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 HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. 4.Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats Vaginal Birth After Previous Cesarean Delivery – ACOG. Aug Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection, May Euro-Peristat project with SCPE and Eurocat. European Perinatal Health Report. The health and care of pregnant women and babies in Europe in May 2013.