title: Changing policies on vaginal birth after cesarean: impact on access.
abstract: BACKGROUND
  The issue of vaginal birth after cesarean (VBAC) has become highly visible and contentious. In 1999, the American College of Obstetricians and Gynecologists advocated a policy that surgical capability be "immediately available" for women in labor attempting VBAC.
  
  
  METHODS
  Every hospital in Colorado, Montana, Oregon, and Wisconsin was contacted by telephone at least once during the period 2003 to 2005. Using a semistructured interview, respondent hospitals were asked whether and when their policies for VBAC had changed and what was the availability of VBAC services before and after the 1999 policy was issued.
  
  
  RESULTS
  Of 314 hospitals contacted, 312 responded to the survey (response rate 99.4%). Babies were delivered at 230 (74%) respondent hospitals. Almost one-third, 68 of 222 (30.6%), of responding delivery hospitals that previously offered VBAC services had stopped doing so; seven hospitals had never allowed VBAC. Of the hospitals that still allowed VBAC, 68 percent had changed their VBAC policies since 1999, with the most frequent changes requiring the in-house presence of surgery (53%) and anesthesia (44%) personnel when women desiring VBAC presented in labor. Compared with hospitals that stopped allowing VBAC, those that currently permit VBAC were larger (156.6 vs 58.1 beds, t = 7.02, p < 0.001), closer to other delivery hospitals (20.9 vs 39.2 miles, t = 4.33, p < 0.001), annually delivered more babies (1009.9 vs 458.3, t = 4.41, p < 0.001), and annually had more cesarean deliveries (226.7 vs 105.7, t = 3.91, p < 0.001).
  
  
  CONCLUSIONS
  In the years following advocacy of the 1999 policy, the availability of VBAC services significantly decreased, especially among smaller or more isolated hospitals.
authors.affiliation: Department of Family Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin 53715, USA.
authors.forename: Richard G
authors.initials: RG
authors.lastname: Roberts
authors.forename: Mark
authors.initials: M
authors.lastname: Deutchman
authors.forename: Valerie J
authors.initials: VJ
authors.lastname: King
authors.forename: George E
authors.initials: GE
authors.lastname: Fryer
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Miyoshi
mesh_terms: D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D016134:Organizational Policy; D011247:Pregnancy; D016064:Vaginal Birth after Cesarean