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Original Research

Early elective delivery and vaginal birth after cesarean in rural US maternity hospitals

Submitted: 18 March 2016
Revised: 23 August 2016
Accepted: 29 August 2016
Published: 15 November 2016

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Author(s) : Heinrich D, Vogel RI, Kozhimannil KB.

Demetra HeinrichRachel VogelKaty Kozhimannil

Citation: Heinrich D, Vogel RI, Kozhimannil KB.  Early elective delivery and vaginal birth after cesarean in rural US maternity hospitals. Rural and Remote Health (Internet) 2016; 16: 3956. Available: (Accessed 17 October 2017)


Introduction:  The purpose of this study was to describe policies on early elective delivery (EED) and vaginal birth after cesarean (VBAC) in rural US maternity hospitals and to measure whether hospital policies differ by staffing, facilities, or birth volume.
Methods:  Data came from a telephone survey, conducted among all rural maternity hospitals in nine US states from November 2013 to March 2014, to report on EED and VBAC at the hospital level. The associations between EED and VBAC and hospital characteristics were analyzed using χ2 and Fisher’s exact tests.
Results:  Most rural maternal hospitals (70.1%) had a ‘hard stop’ EED policy, whereby elective delivery before 39 weeks gestation was prohibited. Less than half of the rural hospitals surveyed allowed VBACs (38.1%). Rural hospitals with a higher birth volume (p=0.001), with a dedicated obstetric operating room (p<0.001), and where obstetricians and certified nurse-midwives attended deliveries (p=0.010 and p=0.030, respectively) were more likely to allow VBAC deliveries. Hospitals where family physicians and general surgeons attended deliveries were less likely to allow VBAC deliveries (p=0.002 and p=0.040, respectively).
Conclusions:  Most rural US maternity hospitals have a hard stop EED policy, consistent with evidence and guideline recommendations. Access to VBAC varies across rural settings, possibly owing to capacity limitations to provide this option. Further research is needed to determine whether and how best to safely implement national recommendations for EED and VBAC policies across a range of rural settings.

Key words: elective delivery, hospital policy, maternal and child health, rural obstetric care, USA, vaginal birth after cesarean delivery.

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