INTRODUCTION
Globally, caesarean section rates have increased to 21.1% of all births in 2018 (1, 2). Although caesarean sections can be lifesaving, many are not performed on medical indication despite the procedure being associated with increased maternal and perinatal risks(1-7). The World Health Organization (WHO) aims to reduce such non-indicated caesarean sections (4, 8). Although the greatest benefit is expected from performing the first caesarean section only on strict medical indication, reducing the second by offering women a chance to attempt vaginal birth after caesarean (VBAC) is another strategy proposed by the WHO and in most guidelines(4, 9-11).
While a successful VBAC has the lowest rate of maternal complications at no increased perinatal risk, an unsuccessful intended VBAC results in an unplanned caesarean section, associated with increased risk of adverse maternal and perinatal outcomes (12, 13). Moreover, trial of labour may result in uterine rupture (0.16-0.80% after one previous caesarean section(14)), a severe complication with considerable associated maternal and perinatal risk(12, 15, 16). At the same time, repeated caesarean sections substantially increase the risk of placenta praevia, abnormally invasive placenta and postpartum haemorrhage in subsequent pregnancies(13, 17-20) and are associated with increased risks of maternal mortality in the Netherlands compared to vaginal birth(6).
There is considerable variation in VBAC rates between European countries, with relatively high rates occurring only in countries with relatively low overall caesarean section rates (e.g., Sweden, Finland, the Netherlands). Inversely, relatively low VBAC rates occur in countries with high overall caesarean section rates (e.g., Italy, Greece, Ireland) (1, 2, 21, 22). In the Netherlands, VBAC is generally still considered a safe option for women with one previous caesarean section in presence of continuous foetal monitoring, immediate access to an operating room and staff competent to perform neonatal resuscitation (11). Mode of birth is decided based on individual counselling with considerations of risks and benefits, and a prediction model is often used to estimate the individual likelihood of a successful VBAC (11, 23).
In the Netherlands, neither changes over time in women intending VBAC versus those who opt for planned caesarean section, nor changes in perinatal outcomes in both groups have recently been comprehensively analysed. Our primary aim was to describe changes over time in mode of birth among women with a previous caesarean section between 2000 and 2019. Our secondary aims were to describe VBAC success rates and adverse perinatal outcomes among women with one previous caesarean section in the same time frame.