Matern Child Health J (2013) 17:1309–1314
DOI 10.1007/s10995-012-1132-6
Rates and Success Rates of Trial of Labor After Cesarean
Delivery in the United States, 1990–2009
Sayeedha F. G. Uddin • Alan E. Simon
Published online: 19 September 2012
 Springer Science+Business Media, LLC (outside the USA) 2012
Abstract This study compares rates of trial of labor after
Cesarean delivery (TOLAC) and rates of successful TOLAC
between 1990 and 2009. Serial cross-sectional analyses were
performed using the National Hospital Discharge Survey data
to compare rates of TOLAC and TOLAC success between
1990 and 2009. Joinpoint regression was used to assess trends
over time, and logistic regression with marginal effects was
used to examine the unadjusted and adjusted significance and
magnitude of trends. The rate of TOLAC reached a high of
51.8 % (95 % CI 47.8–55.8 %) in 1995 and a low of 15.9 %
(95 % CI 13.8–18.0 %) in 2006, declined, on average, 4.2
(95 % CI -4.8 to -3.9) percentage points per year between
1996 and 2005. Rates increased significantly from 1990 to
1996 and 2005 to 2009. TOLAC success was at its highest
rate in 2000, 69.8 % (95 % CI 65.2–74.3 %) and its lowest in
2008, 38.5 % (95 % CI 28.1–48.8 %). The rate of TOLAC
success increased significantly between 1990 and 2000, but
declined thereafter an average of 3.4 % points per year (95 %
CI -4.3 to -2.5). The rate of TOLAC in the US decreased
between 1996 and 2005 and the rate of successful TOLAC
has declined from 2000 to 2009.
Keywords Trial of labor
Trial of labor success

Vaginal birth after Cesarean delivery
Cesarean section
Introduction
Vaginal birth after Cesarean delivery (VBAC) has been
considered a means to reduce the rate of Cesarean deliveries
S. F. G. Uddin (&)
A. E. Simon
Division of Health Care Statistics, National Center for Health
Statistics, Centers for Disease Control and Prevention,
3311 Toledo Road, Room 6122, Hyattsville, MD 20782, USA
e-mail: suddin@cdc.gov
in the United States [1]. However, concern about the mor-
bidities, such as uterine rupture, associated with trials of
labor after Cesarean delivery (TOLAC) led the American
College of Obstetrics and Gynecology to release recom-
mendations [2, 3] in 1995 and 1999 that preceded decreases
in the rate of VBAC, from its peak of 28 % of live births in
1996 [4] to an estimated low of \9 % in 2007 [5].
Although the change over time in the VBAC rate [4] has
been well documented using national data, the rate of
TOLAC and the rate of successful TOLAC (both of which
determine the VBAC rate) have not been examined using
national data, nor tracked over time within a single study
[6–25] Indeed, in their consensus statement the NIH con-
ference panel on VBAC states that ‘‘little is known about
population-based rates and patterns of utilization of trial of
labor after previous Cesarean deliveries’’ [6]. As a result, it
is unknown whether the change in VBAC rate results from
a decrease in the rate of TOLAC, the rate of TOLAC
success, or both. Additionally, the rate of TOLAC more
accurately reflects practice patterns than the rate of VBAC
alone. Similarly, understanding trends in failed TOLAC is
important for patient decision-making about undergoing
TOLAC, as this outcome might be less desirable to some
patients than planned Cesarean. The purpose of this study
is to examine the rates of TOLAC, and TOLAC success in
the US from 1990 through 2009.
Methods
Data from the National Hospital Discharge Survey (NHDS)
were used to compare rates of TOLAC and TOLAC suc-
cess across time. NHDS, a nationally representative survey
of non-federal, non-institutional short-stay US hospitals
has been conducted by the National Center for Health
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Table 1 ICD-9-CM codes used
Category
for case identification
Delivered
Previous Cesarean delivery
Cesarean delivery
Labored
Hypertension
Diabetes
Placenta previa
Preterm delivery
Multiple gestation
Genital herpes
Breech presentation
Statistics (NHCS) since 1965. NHDS has provided
nationally representative data on inpatient hospitalizations
since 1965 and the data are used by researchers, policy-
makers, hospitals, and professional organizations among
others [26–29].
Although vital statistics data do contain information on
births in the US, these data do not include information for
the selected time periods from all states on whether a
woman labored, making it impossible to evaluate national
TOLAC and TOLAC success rates using vital statistics
data. Although vital statistics data have included informa-
tion on VBAC since the 1989 revision of the birth certifi-
cate, even trend analysis on VBAC is problematic as data
on VBAC ‘‘are not comparable between the 2003 and 1989
revisions of the US Standard Certificate of Live Birth’’[5].
Indeed ‘‘Results for the limited reporting area using the
2003 certificate are not generalizable to the country as a
whole because they are not a random sample of all births…
(additionally) trend analysis is compromised by the
changing composition of the reporting areas using the 2003
and 1989 revisions’’[5]. Furthermore, until the 2003 birth
certificate revision, the data did not capture information on
trial of labor. As of 2009, only 28 states have adopted the
new birth certificate with information on trial of labor.
Therefore, NHDS is preferred for this analysis.
Data from 1990 through 2009, the most recent 20 years
of the survey, were analyzed. For 1990 through 2007,
NHDS collected data on an average of 309,000 hospital
discharges per year from an average of 459 hospitals and,
for 2008 and 2009, data from 164,000 discharges from 206
hospitals. NHDS has a 3-stage sampling design and pro-
vides national data on inpatient hospital utilization. These
data were weighted by National Center for Health Statistics
(NCHS) to produce nationally representative estimates of
inpatient hospitalizations. The weights were calculated
based on the reciprocal of the selection probability and
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Matern Child Health J (2013) 17:1309–1314
ICD-9-CM codes Procedure codes
Diagnosis code
V27 72, 74.0–74.2, 74.4, 74.9
654.2 –
– 74.0–74.2, 74.4, 74.9
650, 653.4–653.5, 653.8–653.9, 72.0–72.4, 73.01, 73.09, 73.1, 73.3–73.6,
658.2, 658.3, 659.0–659.3, 73.93–73.99, 75.32, 75.38, 75.6
660–662, 664, 665.1
642.0–642.9
648.0, 648.8, 250
641.0–641.1
644.2
V27.2–V27.7, 651
054.1
652.1–652.2
adjusted for non-response. Details of survey methodology
and weighting procedures have been previously described
[30]. NHDS has received approval by the NCHS Research
Ethics Review Board.
Assessment of whether the patient had a prior Cesarean
delivery, a trial of labor during the current delivery, vaginal
or Cesarean delivery, or had other clinical conditions used
in the analysis during the current discharge was determined
by examining each discharge for International Classifica-
tion of Diseases-9th Revision Clinical Modification (ICD-
9-CM) codes listed in Table 1. Deliveries with labor were
identified using a modified list of codes used in previous
studies (as listed in Table 1) [31, 32].
Cases with a diagnosis code for previous Cesarean
delivery and any code used to identify labor were consid-
ered to have had a TOLAC. Although regression analyses
were conducted using unrounded estimates, the weighted
estimates presented were rounded to the nearest 1,000
cases to be consistent with NCHS practice. NCHS rec-
ommends presenting national estimates rounded to the
nearest thousand from NHDS in order to imply an appro-
priate level of precision for a survey of this nature [33].
The TOLAC rate was calculated for each year. Delivered
TOLAC cases with no procedure codes for Cesarean
delivery were classified as having a successful TOLAC.
TOLAC and TOLAC success rates, as well as associated
standard errors were estimated for each year from 1990
through 2009 using Stata 11.0 SE [34] and adjusted for the
complex design of the survey using Taylor series linear
approximation [34]. Resulting estimates of yearly TOLAC
rates as well as standard errors for each estimate were
entered into a Joinpoint regression using the National
Cancer Institute’s Joinpoint 3.4.3 software [35] using year
as the independent variable and TOLAC rate as the
dependent variable. Joinpoint was used to identify time
points (joinpoints) where linear trends changed during the
Matern Child Health J (2013) 17:1309–1314
time period examined. The software fits the simplest linear
model with no joinpoints (a straight line) and, using a
series of Monte Carlo permutation tests, tests whether 1 or
more joinpoints (changes in linear trend) are statistically
significant and should be added to the model. Similarly,
TOLAC success rates (and associated standard errors) were
entered into a second Joinpoint regression as a dependent
variable with year as an independent variable. Results were
considered significant if p values were \0.05.
To further investigate the significance and magnitude of
linear trends identified in Joinpoint, we conducted 2 sets of
logistic regressions using Stata, with dependent variables
of TOLAC for the first set and TOLAC success for the
second. For each dependent variable, regressions were
conducted for each time period identified as a separate
trend by the Joinpoint regression. For each time period
identified by Joinpoint, two models were conducted: an
unadjusted model was conducted with only year as the
independent variable and an adjusted model that also
included maternal age, hospital bedsize, US census region,
expected source of payment and the following clinical
factors that may influence the decision for trial of labor
(preterm delivery, multiple gestation, hypertension, diabe-
tes, placenta previa, genital herpes, breech presentation) or
success of trial of labor (preterm delivery, multiple gesta-
tion, hypertension, diabetes) as independent variables. For
each regression, marginal effects were calculated for the
independent variable representing survey year. This
allowed us to calculate adjusted and unadjusted percentage
point changes per year. Additionally, this analysis was
repeated with only singleton, term deliveries in order to
assess unadjusted and adjusted trends over time in more
homogeneous population of births.
Results
From 1990 to 2007 there were 338 to 400 hospitals that
contributed discharges with deliveries in the NHDS, in
2008 and 2009 there were 162 and there were 160 hospi-
tals, respectively. The estimated number of total deliveries
for each year ranged from 3,738,000 in 2000 to 4,144,000
in 2008.
Estimates for deliveries with previous Cesarean deliv-
eries between 1990 and 2009 ranged from 429,000 in 1990
to low of 413,000 in 1995 and rose to a peak of 645,000 in
2008. Of deliveries with a previous Cesarean delivery,
estimates for deliveries undergoing TOLAC ranged from
137,000 in 1990 and rose to a peak of 235,000 in 1998 then
declined to a low of 97,000 in 2006.
The TOLAC rate reached a high of 51.8 % (95 % CI
47.8–55.8) in 1995 and a low of 15.9 % (95 % CI
13.8–18.0) in 2006 (Fig. 1). The Joinpoint regression
1311
Fig. 1 Percent of births with trial of labor among all deliveries with
prior Cesarean delivery in the United States, 1990–2009. Changes in
linear trend lines identified using Joinpoint analysis. Source CDC/
NCHS, National Hospital Discharge Survey, Annual files 1990–2009
identified two significant joinpoints, 1996 and 2005. The
trend between 1990 and 1996 showed a 3.3 % point (95 %
CI 2.6–4.0) increase per year (p \ 0.0001). The rate of
TOLAC declined an average of 4.2 % points per year
(95 % CI 3.9–4.8) between 1996 and 2005 (p \ 0.0001).
The trend between 2005 and 2009 showed an increase of
1.6 % point (95 % CI 0.4–2.9) increase per year
(p = 0.011).
TOLAC success was at its highest rate in 2000, 69.8 %
(95 % CI 65.2–74.3 %) and its lowest was in 2008, 38.5 %
(95 % CI 28.1–48.8 %). (Figure 2) The Joinpoint regres-
sion identified a single significant joinpoint, in 2000. The
rate of TOLAC success increased significantly between
1990 and 2000 at 0.6 % points per year (95 % CI 0.1–1.1,
p = 0.013), but declined significantly thereafter approxi-
mately 3.4 % points per year (95 % CI 2.5–4.3,
p = \0.0001).
Moreover, the linear trends in both TOLAC rate and
TOLAC success rate persisted after adjustment for those
available confounding factors. For both sets of regressions,
the marginal yearly effect after accounting for additional
independent variables was similar to the yearly decline
estimated from the unadjusted regression (Table 2). For the
singleton, term deliveries, the Jointpoint regression iden-
tified joinpoints identical to those of the larger population
of all deliveries.(data not shown) Additionally, the rates of
change and levels of significance for both the unadjusted
and adjusted regressions among the singleton, term deliv-
eries were similar to the larger population of all deliveries.
(data not shown).
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contraction during labor, may be torn apart, resulting in

Fig. 2 Percent of successful trials of labor among all TOLAC
deliveries in the United States, 1990–2009. Note Changes in linear
trend lines identified using Joinpoint analysis. TOLAC is trial of labor
after previous Cesarean section. Source CDC/NCHS, National
Hospital Discharge Survey, Annual files 1990–2009
Comment
The rate of TOLAC in the US decreased between 1996 and
2005 and the rate of successful TOLAC has declined from
2000 to 2009. The decrease in TOLAC rate mirrors the
changes in guidance from ACOG regarding requirements
for labor and delivery units offering TOLAC in order to
minimize the occurrence of negative sequleae of TOLAC
such as uterine rupture [2, 3]. The area of the uterus that is
scarred from previous cesarean delivery is weaker than the
rest of the uterine muscle and under the strain of
catastrophic maternal and fetal consequences.
The reasons for the decline in TOLAC success are
unclear as it has not been previously studied and therefore
causes for this finding have not been evaluated. Two
potential contributors to the finding are the possibility that
providers managing TOLAC in later years convert to
Cesarean delivery earlier in labor than in previous years, or
that despite known clinical factors associated with success
[36, 37], patient selection for TOLAC has not been
optimal.
Changes over time in many clinical and structural
variables may have contributed to the changes in TOLAC
rate and TOLAC success rates over time, but the NHDS
does not provide sufficient data to analyze many of these
variables. However, the declines presented did persist after
accounting for those variables that we were able to
examine (age of women giving birth, bed size of hospitals,
region of country, payment source, and rates of diabetes,
hypertension, multiple gestation and preterm delivery for
TOLAC success with rates of genital herpes, placenta
previa and breech presentation for TOLAC additionally).
The similarity of the marginal yearly effects estimated
from the unadjusted regression and after accounting for
additional independent variables, suggests that the changes
in TOLAC rate or TOLAC success rate over time were
independent of changes in the distribution of these vari-
ables. We were unable to examine the effect of race and
ethnicity, or other clinical factors such as maternal weight,
parity, number of previous Cesarean deliveries, indication
for previous Cesarean delivery or fetal size. However, data
from the vitals statistics system [38] regarding changes in
fetal weight suggest that there is no increase over time in
the number or percent of births in the highest birthweight

Table 2 Yearly percentage point change in TOLAC and TOLAC success rates 1990–2009
Time period Yearly percentage point change in rate
Unadjusted (95 % CI) Adjusteda (95 % CI)

TOLAC
1990–1996 3.3 (2.6–4.0) 3.7 (3.0–4.4)
1996–2005 -4.2 (-4.5 to -3.8) -4.4 (-4.9 to -4.0)
2005–2009 1.6 (0.4-2.9) 1.2 (0.0–2.3)

TOLAC success
1990–2000 0.6 (0.1–1.1) 0.8 (0.3–1.4)
2000–2009 -3.4 (-4.3 to -2.5) -3.4 (-4.3 to -2.5)
All rate changes in table were statistically significant
a
Change in rate adjusted for maternal age (greater than or \35 years), hospital bedsize (\50, 50–99, 100–199, 200–299, 300–499, 500–999 or
1,000 or more beds), Census geographic region (Northeast, Midwest, South and West), expected source of payment (private insurance, Medicare,
Medicaid, uninsured, other/unknown). TOLAC adjusted for preterm delivery, multiple gestation, hypertension, diabetes, placenta previa, genital
herpes, breech presentation. TOLAC success adjusted for preterm delivery, multiple gestation, hypertension, diabetes

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categories. Further research in clinical settings may allow
for assessment of clinical factors (maternal weight, parity,
number of previous Cesarean deliveries, indication for
previous Cesarean delivery, fetal weight, gestational age,
inter-pregnancy interval). Other unmeasured factors such
as provider and patient attitudes regarding TOLAC and its
risks may have influenced the rate of TOLAC and TOLAC
success. Assessment of these attitudes may also be sur-
veyed in order to gauge their effect on the decision for
TOLAC and the threshold for Cesarean delivery after
labor.
The trial of labor rate reported from vital statistics data
in 2008 among the 28 states using the 2003 revision of the
birth certificate (which includes 65 % of all births) is 27 %
[5]. This is similar to the rate of 25.2 % (95 %CI
18.3–32.0 %) found in this study, adding validity to our
estimates. A recent study by Zhang et al. [39] examined the
overall TOLAC and TOLAC success rates for the years
2002 through 2008, although they did not examine the
trend across these years. Zhang et al. [39] found a rate of
TOLAC success of 57.1 % during their study period. This
rate is comparable to the rate for the same time period in
our study (53.9 %, 95 % CI 50.4–57.4). However, the
combined TOLAC rate found by Zhang et al. [39] was
28.8 % during their study period, higher than our estimate
of 21.0 % (95 % CI 19.5 %–22.4 %) for the comparable
years 2002 through 2008. No standard errors were pre-
sented for their estimates, however, preventing detailed
comparison. Any difference in the rates between our
analysis and Zhang’s might be in part explained by the
overrepresentation of academic centers in the Zhang study.
Previous studies [6, 22, 24, 25, 37] suggest TOLAC
success rates of 60–87 %, higher than our estimates from
this time period, although data from those studies were not
nationally representative and may not represent the popu-
lation of women undergoing TOLAC. The literature [6, 22,
24, 25, 37] also suggests that the success rate is consistent
over time, however, in our data, the rate varied over time
especially during the last 10 years of our study from
69.8 % (2000) to 38.5 % (2008).
The strengths of our study are that our data source is
nationally representative and reflects actual practice. Also,
it allows for trend analysis over time. Our study is limited
by the use of administrative data to identify women who
underwent TOLAC. Our study might miss women whose
labors ultimately resulted in Cesarean delivery if labor-
associated diagnoses (Table 1) were omitted or not recor-
ded correctly. Similarly, patients intending to undergo
repeat Cesarean delivery who present in early labor or with
premature rupture of membranes followed by repeat
Cesarean delivery could artificially inflate the rate of true
TOLAC, and artificially reduce the rate of TOLAC suc-
cess. However, the ICD-9-CM diagnosis codes used in our
1313
study to identify labor were specific and include codes
likely to have been coded with intentional TOLAC such as
those associated with delayed delivery after rupture
(658.2–658.3), obstructed or abnormal labor/dystocia
(653.4–653.5, 660) and failed induction of labor
(659.0–659.1), but not those such as premature rupture of
membranes (658.1). Furthermore, although sensitivity of
labor-associated diagnoses to identify labor has not been
specifically validated, Henry et al. [31]. found good con-
cordance between clinical indication and ICD-9 coded
indication for repeat Cesarean delivery (85 %), which
included labor-associated codes. Additionally, although no
studies have examined the possibility, it is conceivable that
coding practices for TOLAC could have changed over
time.
This study is the first to track TOLAC and TOLAC
success over time and provides important national data for
consideration for any future refinements to VBAC practice
policy. The decrease in TOLAC success rates over time
and its effects on other outcomes warrant further study.
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