Limited labor after c-section reported in most counties

Limited labor after c-section reported in most counties | Image Credit: © Regina - © Regina - stock.adobe.com.

Attempting labor after a previous cesarean section was only offered in 16% of US counties from 2016 to 2021, according to a recent study published in JAMA Network Open.¹

The Northeast and Western US regions had higher rates of counties where labor after cesarean section was offered, while access was extremely limited in many South and Midwest counties. Those with access had increased odds of reduced recovery duration and a decrease in future pregnancy complication risk.¹

“ACOG officially says that [vaginal birth after cesarean (VBAC)] is a reasonable option for most people with a prior cesarean,” said Laura Attanasio, PhD, associate professor of health policy and management in the University of Massachusetts Amherst School of Public Health and Health Sciences and senior author of the paper.¹

Defining and measuring LAC access

The cross-sectional study was conducted to assess county-level labor after cesarean (LAC) delivery trends.² Data from 2016 to 2021 were obtained from the Natality Restricted-Use Data Files, a database with all US births.

LAC access was reported as the primary outcome based on availability in at least 1 county. This outcome was assessed using previously established methods. Additional outcomes included LAC ending in VBAC, prior cesarean birth, and expected LAC count.²

Counties were categorized as having no LAC access if LAC counts were near 0 or less than expected. Investigators assessed LAC access by year and other factors, with an additional analysis limiting the data to counties with an obstetric hospital.²

Where access exists

There were 18,648 county-years between 2016 and 2021 included in the analysis, 15.9% of which had access to LAC. Rates were 30.5% and 7.4% in metro-adjacent counties and metro-nonadjacent counties, respectively. In comparison, LAC access was reported in 30.9% of counties with hospital-based obstetric service only.²

Bivariate and multivariate analyses did not indicate any significant differences in county-level LAC access between years. Additionally, similar magnitude, direction, and significance were observed in a subanalysis limited to counties with an obstetric hospital.²

These results indicated limited but stable access to LAC across US counties. The trial was limited by the quality of birth certificate items, but highlights how LAC and VBAC may be more concentrated among smaller sets of hospitals. Investigators recommended further research to assess how limited LAC access impacts perinatal care experiences and outcomes.²

Barriers to expanding access

Investigators noted hospitals having no obstetric services and hospitals having obstetric services that are unable to guarantee immediate cesarean surgery access as barriers.¹ Delays may also be caused by shifting clinical guidelines in the past few decades and a lack of comfort by providers and medical liability insurers.

According to Attanasio, a major shift toward not having VBAC was observed in the early 2000s. While data published around 2010 highlighted clinical benefits and improved outcomes in some patients through VBAC, many locations have not caught up to providing this option.¹

“Given that VBAC has increased over this time period, this suggests that VBAC rates are increasing in the places where VBAC is available rather than coming from more places offering labor after cesarean,” said Attanasio. “Access is not expanding, at least at the county level.”¹

References

1. Access to vaginal labor after C-section is limited to some 16% of U.S. counties. University of Massachusetts Amherst. August 26, 2025. Accessed September 2, 2025. https://www.eurekalert.org/news-releases/1095975.
2. Ranchoff BL, Geissler KH, Goff SL, Bertone-Johnson ER, Paterno MT, Attanasio LB. Trends in labor after cesarean delivery access in the US. JAMA Netw Open. 2025;8(8):e2526224. doi:10.1001/jamanetworkopen.2025.26224