Groundbreaking analysis of vaginal birth after cesarean section shows both risks and opportunities for maternal health care improvement in low-resource settings

By Vandana Tripathi and Sara Riese

When the MOMENTUM Safe Surgery project brought experts from around the world together to consider the most important questions requiring evidence in surgical family planning and obstetrics, the issue of vaginal birth after cesarean delivery (VBAC) jumped to the top of a short list of consensus priority topics.

Ensuring that pregnant women who have had a prior cesarean section (CS) have the opportunity for a supervised trial of labor (TOLAC) can help avoid unnecessary repeat CS and the potential risks of infection and other complications associated with major surgical procedures. However, unsupervised TOLAC and labor in a facility, or even the home, without immediate access to comprehensive emergency obstetric and newborn care (CEmONC) can be dangerous for women who have had a prior CS, bringing risks including ruptured uterus.

Despite the increases in CS in most countries around the world and the potential role of TOLAC/VBAC in supporting positive delivery experiences and reducing nonindicated surgery, little is known about population-level VBAC rates and trends in low- and middle-income countries (LMIC) or the settings in which such procedures occur.

The Demographic and Health Surveys (DHS) offered an unparalleled source of data to explore this question, and MOMENTUM Safe Surgery and DHS Program teams collaborated on an innovative analysis, using datasets from 59 LMIC over the past 30 years and using existing variables from detailed birth or pregnancy histories to create measures of VBAC. Although both the DHS Program and MOMENTUM Safe Surgery were terminated during the dismantling of USAID in early 2025, we continued to work on this analysis on a volunteer basis, along with our coauthors Farhad Khan and Renae Stafford, and were able to publish the results as one of the final DHS Working Papers in May 2025, on the EngenderHealth website.

Our analysis shows clearly that the highest levels of VBAC (as high as 68% in Niger) are happening in countries with the lowest population CS rates. Given the low levels of CEmoNC access and uptake in these settings, it is likely that VBAC is not planned and after a supervised TOLAC, but rather a reflection of continued lack of access to appropriate counseling, birth planning, and emergency referral and transport. We also show that VBAC is decreasing over time, and decreasing the most in countries with the highest population CS rates, likely driven by increasing CS rates globally.

While DHS data did not allow us to assess TOLAC or the capacity of the locations where women were having VBAC, our findings have clear implications for improving maternal health care services and systems. For example, ANC visits should be an opportunity for systematic identification of previous CS, and then preparing for a safe delivery, including either TOLAC if labor can begin in a facility with adequate capacity and staffing, or a planned CS.

In Rwanda, the MOMENTUM Safe Surgery team supported just such an initiative, working with local health facilities and community health workers to institute active identification and follow-up for women with previous CS scars (see Figure). Through this program, over 11,600 pregnant women with previous CS scars were identified during ANC visits and referred to health facilities. Of those, 82% reached the facility and received a clear delivery plan. Project-led implementation research just published by Josee Uwamariya and coauthors in the journal PLOS One showed that the intervention was associated with an 81% reduction in the odds of emergency CS – an important change in a setting where very few hospitals are able to provide safe, supervised TOLAC.

One woman who was supported by this intervention was Mukankotanyi Yvette, a 27-year-old mother of three from Rwanda’s Eastern Province. Yvette was regularly attending ANC appointments but had not been informed about the risks related to her previous CS. Identification and referral assistance from a project-supported CHW helped Yvette deliver a healthy baby safely.

We will be expanding on the Working Paper with journal articles that examine VBAC trends and location in greater depth. While our analysis leaves many questions that require further research, such as TOLAC capacity and women’s knowledge of and preferences regarding VBAC, this analysis provides a foundation for the targeting and expansion of interventions such as the model we piloted and evaluated in Rwanda. Health systems can leverage existing CHW, primary care, and referral platforms to support women who have had a prior CS in ensure a safe, planned delivery in their next pregnancy.

The standardized, comparable, and publicly available datasets generated by The DHS Program provided uniquely rich information, allowing us to explore this issue at a global scale and for trends over time. This is just one of the many ways that data from The DHS Program has been used as the evidence base to answer crucial questions and indicate priorities for improving population health. The fact that there will be no more DHS data is a serious loss for the governments, implementing partners, and other stakeholders who relied on this high-quality information.

We hope that global actors seize emerging opportunities to strengthen routine health management information systems and create more country-owned platforms for timely data, as well as consider how to support efforts to generate and share high-quality health and development data across countries.

Figure: Schematic of active follow-up intervention. Uwamariya J, et al. 2025. PLoS One. https://doi.org/10.1371/journal.pone.0325884