Hospital bans on trial of labor after cesarean and antepartum transfer of care

Abstract

Background: Hospital policies restricting access to trial of labor after cesarean (TOLAC) are prevalent. Many women with a previous cesarean birth are affected by these bans, but there are limited data on the effect of these bans and whether women would consider changing delivery hospitals in the setting of a real or hypothetical TOLAC ban. Methods: This was a survey of TOLAC-eligible women receiving prenatal care at four hospitals where TOLAC is available, and 1 non-TOLAC site. Participants were asked about their likelihood of switching hospitals to pursue TOLAC if it were unavailable. Women at the non-TOLAC site had their medical records reviewed to ascertain final location and approach to delivery. Results: A total of 297 women were interviewed, 48 from the non-TOLAC site. 162 (54%) participants indicated they would transfer care if TOLAC were unavailable. Among women at the non-TOLAC site, 57% who indicated an intention to switch hospitals did so. In a multivariable logistic regression model, variables associated with transferring care included race/ethnicity other than Latina (aOR 25.20 [95% CI 2.23-284.26]), being unaware of the TOLAC ban (19.81 [1.99-196.64]), and perceiving that a close friend/relative thought they should undergo TOLAC (17.31 [1.70-176.06]). Conclusions: More than half of women with prior cesarean would consider transferring care if TOLAC became unavailable, and more than 1 of 3 of women at a non-TOLAC site transferred care. More research is needed on the impact of TOLAC bans and how to facilitate transfer for those who desire TOLAC. K E Y W O R D S hospital policy, trial of labor after cesarean, vaginal birth after cesarean | 575 ROSENSTEIN ET al.

Access to maternity and prenatal care services in rural Michigan

“…Historically, the decline in TOLAC/VBAC services, especially in rural communities, has been attributed to a lack of available hospital resources to meet previous ACOG guidelines with respect to VBAC, malpractice concerns, and lack of knowledge about this option on the part of both patients and practitioners. 38 With new ACOG guidelines supporting careful selection of TOLAC candidates, individual decision making with patients who are informed about delivery options, and TOLAC at facilities capable of emergency cesarean births, 23 rural hospitals have an opportunity to reevaluate their ability to offer this service. Strategically identifying those rural maternity hospitals in the state that are not currently providing TOLAC services, yet could potentially operate as rural regional centers for TOLAC births, would increase delivery options for rural women who are currently without local options.…”

“…22 VBAC availability also prevents risks associated with multiple repeat cesareans and affords an important choice to women who are otherwise at low risk of birthing complications. 17,23 However, unsuccessful TOLACs sometimes result in an emergency cesarean, which increases maternal and perinatal morbidity and mortality, 24 risks that deter rural hospitals from offering TOLAC as a delivery option. This has contributed to an overall decrease in TOLACs and an increase in the rural cesarean birth rate over the last several decades.…”

Barriers to labor after cesarean: A survey of United States midwives

“…In interviews with women planning LAC, over half said they would transfer care if VBAC became unavailable at their hospital. 20 There is evidence that as access to LAC in hospitals declines, LAC and VBAC in out of hospital settings 12,21 increase, elevating neonatal morbidity associated with LAC. 22 The purpose of this study was to measure certified nurse-midwives' (CNM's) and certified midwives' (CM's) perceptions of select barriers to LAC in practices, which offer LAC care.…”

“…Other evidence suggests public displeasure with barriers to VBAC. In interviews with women planning LAC, over half said they would transfer care if VBAC became unavailable at their hospital 20 . There is evidence that as access to LAC in hospitals declines, LAC and VBAC in out of hospital settings 12,21 increase, elevating neonatal morbidity associated with LAC 22 …”

Hospital factors associated with maternal and neonatal outcomes of deliveries to patients with a previous cesarean delivery: an ecological study

“…The current ACOG guideline states that a trial of labour can be attempted in a level 1 maternity care facility (i.e., a hospital providing basic obstetric services), which has “the ability to begin emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits.” 17 Similarly, the current SOGC guideline states that hospitals providing trial-of-labour services should have “the resources to perform an emergency cesarean section.” 18 This change in recommendations has led to an increase in the number of hospitals that offer trials of labour, though concerns about inadequate access to such delivery options persist. 19 , 20 …”