For many people who have delivered their first child via cesarean section, the prospect of a subsequent pregnancy brings a critical question: is it possible, and safe, to deliver the next baby vaginally? While medical guidelines often support this path for low-risk patients, the actual likelihood of attempting and achieving a vaginal birth after cesarean (VBAC) often depends less on a patient’s health and more on the culture of the hospital where they deliver.
New research led by UCLA suggests a surprising trend in this landscape: vaginal birth after cesarean more common at Black-serving hospitals than at facilities that treat fewer Black patients. The study, published in the peer-reviewed journal Obstetrics &. Gynecology, indicates that hospitals serving predominantly Black populations may be more willing or better equipped to support labor after a previous cesarean, challenging long-held assumptions about the quality of care at these institutions.
The findings come at a pivotal moment for maternal health in the United States. Black women continue to experience disproportionately higher rates of cesarean deliveries and face significantly higher risks of severe pregnancy complications and maternal death. By identifying pockets of success in VBAC rates, researchers hope to uncover institutional practices that can be scaled to improve outcomes for all patients.
The study analyzed data from 2017 to 2019 sourced from the U.S. Department of Health and Human Services‘ National Inpatient Sample, covering more than 1.7 million patients who had previously undergone cesareans. To ensure the data reflected clinical willingness rather than medical necessity, the researchers focused exclusively on low-risk deliveries, grouping hospitals into high, medium, and low “Black-serving” categories based on their patient demographics.
Measuring the Gap in VBAC Attempts
The disparity in how hospitals approach labor after a cesarean was stark. Patients at high Black-serving hospitals (BSHs) were 25% more likely to attempt labor than those at facilities serving few Black patients. Approximately 75% of those attempts at high BSHs resulted in successful vaginal births, with particularly strong results seen at urban teaching hospitals.
In contrast, the willingness to attempt a VBAC was significantly lower at facilities with fewer Black patients. Only about 18% of patients at low BSH hospitals attempted labor, and of those who did, about 70% were successful.
While the overall success rates for those who attempted labor were relatively similar, the “gatekeeping” aspectโwho is actually encouraged to tryโvaried wildly by institution. For Black patients specifically, the hospital type played a measurable role in their success: those at high BSHs had a 72% likelihood of a successful VBAC, compared to a 67% probability for those at low BSH facilities.
| Hospital Category | Labor Attempt Rate | Success Rate (Approx.) |
|---|---|---|
| High Black-Serving (BSH) | 25% more likely than low BSH | 75% |
| Low Black-Serving (BSH) | ~18% | 70% |
The Medical Stakes of Repeat Cesareans
As a physician, it is vital to emphasize why these statistics matter beyond the delivery room. While cesarean sections are life-saving interventions, they are major abdominal surgeries. Avoiding unnecessary repeat cesareans is a primary goal for improving long-term maternal safety and reducing healthcare costs.
Dr. Max Jordan Nguemeni, the study’s lead author and an assistant professor of medicine at the David Geffen School of Medicine at UCLA, noted that the risks associated with surgical births are cumulative. “Cesarean births carry higher risks of complications like infection, bleeding, and future pregnancy complications like placenta accreta, which is on the rise,” Nguemeni said. “These risks accumulate with each repeat cesarean.”
Placenta accreta, a serious condition where the placenta grows too deeply into the uterine wall, is more common in patients with multiple previous uterine scars. This can lead to life-threatening hemorrhage during delivery, making the ability to successfully navigate a VBAC a critical factor in a patient’s future reproductive health.
Culture Over Resources
Historically, research has often painted a bleak picture of Black-serving hospitals, frequently citing them as under-resourced or providing inferior care. However, this UCLA-led study adds a necessary layer of nuance. It demonstrates that BSHs can actually outperform other hospitals in specific outcomes, such as supporting labor after a cesarean.
One of the most telling findings involved teaching hospitals. The researchers found that even when resources and technology were similar, teaching hospitals showed large differences in VBAC rates depending on the number of Black patients they treated. This suggests that the driver of these outcomes is not necessarily the budget or the equipment, but rather the institutional culture, clinical norms, and the comfort level of the providers.
“This suggests that culture, norms, and clinical comfort, and not just technology and resources, play an important role,” Nguemeni said. He argued that these findings challenge simplistic narratives about hospital quality and suggest that positive lessons already exist within the system.
Persistent Disparities and Next Steps
Despite the higher attempt rates at BSHs, the study highlighted a sobering reality: Black patients remained less likely to achieve a successful VBAC than their white counterparts, regardless of the type of hospital they attended. This indicates that while institutional willingness to attempt labor is higher at some facilities, systemic racial disparities in health outcomes persist across the board.
The researchers acknowledged certain limitations in the data, including an inability to distinguish between patients who had one previous cesarean versus multiple, as well as the cross-sectional nature of the data, which prevents the determination of direct causation.
Moving forward, the research team aims to dig deeper into the “how” and “why” behind these differences. Future studies will examine specific staffing models, labor management protocols, the use of operative vaginal delivery, and how clinical decision tools are applied in real-time. By understanding the specific institutional cultures that foster higher VBAC success, the medical community can work toward a standard of care that prioritizes patient safety and autonomy regardless of race or zip code.
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Patients should consult with their healthcare provider to determine the safest delivery plan for their specific medical history.
The research team will continue to analyze institutional culture and training protocols to identify scalable models for improving VBAC access. Official updates on these staffing and protocol studies are expected as the researchers move into the next phase of their analysis.
Do you have experience navigating VBAC or thoughts on maternal health disparities? Share your perspective in the comments or share this article to join the conversation.
