Estimating the prevalence of vaginal birth after cesarean section and repeat cesarean section: An analysis of nationally representative household surveys in 59 low- and middle-income countries.

objectiveLittle is known about the birthing patterns of patients having experienced a prior cesarean section (CS) in low- and middle-income countries (LMICs). We sought to estimate the prevalence of and characterize trends relating to vaginal birth after cesarean section (VBAC) and repeat CS in LMICs.

methodsWe analyzed 107 nationally representative surveys across 59 LMICs. For countries with population CS rates above 8%, we analyzed repeat CS trends across two or three consecutive surveys and estimated the association between repeat CS and facility level and facility type.

resultsThe prevalence of VBAC ranged from 0.5% in Turkey (95% CI: 0.1, 3.5) to 67.6% in Niger (95% CI: 53.4, 79.2). We observed an inverse association between the population CS rate and VBAC prevalence. Of the 33 countries with CS rates below 10%, 26 countries had VBAC prevalence estimates ranging from 20% to 50% with the prevalence of six countries exceeding 50%. Of the 26 countries with CS rates at or above 10%, 19 had VBAC prevalence estimates below 20%. We observed strong associations between repeat CS and births in private facilities or hospitals, and we found that repeat CS also increases over time across multiple countries. However, many of these associations were not statistically significant across multiple countries.

conclusionVBAC prevalence is greatest in countries with the lowest population CS rates, indicating that unplanned, unmonitored, and unsafe VBACs are occurring, necessitating shifts in birth planning and preparedness strategy. Repeat cesareans predominate where population CS rates are already high.