Why women with previous caesarean and eligible for a trial of labour have an elective repeat caesarean delivery? A national study in France

Abstract

Objective: To identify the characteristics of women and maternity units associated with elective repeat caesarean delivery (ERCD) in women eligible for trial of labour after caesarean (TOLAC). Design: Cross-sectional study. Setting: France. Population and sample: Using data from the 2010 French National Perinatal Survey, a representative sample of births in France (n = 14 681 women), we studied two groups of women with prior caesarean section: (i) women eligible for TOLAC according to guidelines (n = 1179) and (ii) a subgroup of these women without any medical characteristics that might indicate ERCD (n = 575). Methods: Associations were analysed by multilevel logistic regression. Main outcome measures: Adjusted odds ratios. Results: Among the 1584 women with a previous caesarean, 1179 (74.4%) were eligible for TOLAC according to guidelines (group 1); 490 (41.6%) had ERCD. Risk of ERCD increased with increasing maternal age and body mass index, pre-existing condition and suspected macrosomia and decreased with previous vaginal deliveries. Among the unit characteristics, private status (aOR = 2.3, 95% CI 1.3–4.1) and low level of care (aOR = 2.5, 95% CI 1.4–4.5]) were independently associated with a higher risk of ERCD after adjustment on patient/pregnancy characteristics. The variability of ERCD rate between hospitals was mainly (78%) explained by the status and level of care, and not (0%) by patient/pregnancy characteristics. Associations with unit characteristics were similar for group 2. Conclusion: For women eligible for TOLAC, the rate of ERCD is high and not in agreement with guidelines. Some characteristics of women are associated with ERCD, but the main determinants are at the unit level, which suggests that non-medical reasons are involved in the decision process. Tweetable abstract: Elective repeat caesarean in women eligible for trial of labour mainly depends on maternity unit characteristics.