The association between hospital volume of labor after cesarean and outcomes in California



Labor after cesarean (LAC) is an alternative to planned repeat cesarean delivery. The effect of hospital-level factors on LAC frequency and vaginal birth after cesarean (VBAC) has been relatively understudied. It was our goal to determine if hospital frequency of LAC (number of women undergoing LAC/number of women with previous uterine scars) is associated with increased VBAC and associated outcomes among women undergoing LAC.


We analyzed 43,331 term, singleton births to women who experienced LAC in California from 2007 to 2010. We conducted multivariable logistic regressions of infant and maternal outcomes for women at hospitals with high LAC frequency (≥median) compared with low LAC frequency (<median), adjusting for maternal and hospital characteristics. We stratified analyses by overall hospital birth volume (categories 1, low; 2, medium; 3, high).


We did not observe an association between high LAC frequency and VBAC in any category of hospital birth volume in regression models. We found that women in hospitals with high LAC frequency had higher odds of infection in category 1 (low) and 2 (medium) hospitals (category 1 hospitals adjusted odds ratio [aOR], 1.61; 95% confidence interval [CI], 1.04-2.48; category 2 hospitals, aOR, 2.12; 95% CI, 1.34-3.35) and postpartum hemorrhage in category 2 and 3 hospitals (category 2 hospitals: aOR, 2.49; 95% CI, 1.57-3.94; category 3 hospitals: aOR, 1.83; 95% CI, 1.24-2.70). We observed that high LAC frequency was associated with more adverse outcomes (e.g., infection, severe perineal lacerations, decreased Apgar scores) in category 2 than in category 1 and 3 hospitals.


We did not find that high LAC frequency was associated with more VBAC, nor with many perinatal complications in category 1 and 3 hospitals. The associations between high LAC frequency and both infection and postpartum hemorrhage are concerning and require further investigation. There may be a sensitive balance between increasing LAC access and determining appropriate LAC candidate selection.

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Dissanayake, Mekhala & Bovbjerg, Marit & Tilden, Ellen & Snowden, Jonathan. (2020). The Association between Hospital Frequency of Labor after Cesarean and Outcomes in California. Women’s Health Issues. 10.1016/j.whi.2020.07.005.