Vaginal birth after cesarean in California

OBJECTIVE: To estimate rates at which women were offered and consented to t rial of labor in California hospitals with high and low risk-adjusted cesar ean delivery rates. METHODS: From 267 nonfederal acute-care hospitals in California that perfor med more than 678 deliveries in 1992-1993, 51 hospitals were selected in a stratified sample. Hospitals in the sample were categorized as having high, medium, and low risk-adjusted cesarean rates using a logistic regression m odel based on data from the California Patient Discharge Data System. We re viewed medical records of women with previous cesareans for evidence of cou nseling regarding trial of labor, other clinical variables, and method of d elivery. Differences in proportions between the three groups of hospitals w ere compared. RESULTS: According to records of 369 women with previous cesareans, after e xcluding contraindications, 312 were potentially eligible for trial of labo r. Hospitals with low risk-adjusted cesarean rates documented counseling wo men for trial of labor in over 99% of records reviewed, compared with 85% a nd 79%, respectively, of hospitals with intermediate and high rates (P < .0 01). Rates of completed vaginal births after cesarean were 71% in hospitals with low risk-adjusted cesarean rates, compared with 39% and 31% in hospit als with intermediate and high rates (P < .05). CONCLUSIONS: California hospitals with high cesarean rates in 1992-1993 had markedly higher rates of repeat elective cesarean delivery without evidenc e of counseling regarding trial of labor. Informed patient choice is a crit ical element of the decision for trial of labor or elective repeat cesarean , and lack of documented counseling is cause for concern. (C) 2001 by the A merican College of Obstetricians and Gynecologists.