The effect of hospital policy regarding trial of labor after cesarean (TOLAC) on primary cesarean delivery rates over time

OBJECTIVE: Many hospitals do not provide women with the opportunity to undergo a trial of labor after cesarean (TOLAC). We performed a study to examine how primary cesarean delivery (CD) rates change over time at hospitals with and without TOLAC bans. STUDY DESIGN: We conducted a cohort study of all low-risk nulliparous term singleton vertex (NTSV) births at California hospitals during 1999-2009 using the Birth Cohort File of linked birth certificates and maternal discharge diagnoses. We surveyed hospitals in 2012 to determine each hospital's TOLAC policy at that time, and, if a policy change had been made, the year it took effect. We fit a repeated measures mixed regression model to compare the rate of change in low-risk NTSV CD rates among three groups of hospitals 1) those with a stable policy of allowing TOLAC (“always”); 2) those which never allowed it (“never”); and 3) those which instituted a TOLAC ban at some point during the 11 year period (“stopped”). We controlled for patient and hospital characteristics as time-varying covariates. RESULTS: 1,294,569 births were evaluated at 239 hospitals. 131 hospitals (54%) allowed TOLAC for the entire study period, 48 (20%) never allowed it, and 60 (25%) banned TOLAC during the study period. Compared to “always” hospitals, and after adjustment for confounders, “never” hospitals had a 0.32% higher annual increase in primary CD rate (p=0.03) and “stopped” hospitals had a 0.25% greater increased rate (p=0.05) (Table). Hospitals that stopped TOLAC began the decade with CD rates similar to the “always” hospitals, and over time, they developed rates similar to the “never” hospitals. (Figure) CONCLUSION: Compared to hospitals that allowed TOLAC, hospitals that had policies banning TOLAC had higher primary CD rates and a faster rate of increase in CD among low-risk nulliparas. The national trend of decreasing access to TOLAC may also be contributing to the increasing incidence of primary CD and deserves further investigation. (Figure presented) .