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.