Birara and Gebrehiwot BMC Pregnancy and Childbirth 2013, 13:31

http://www.biomedcentral.com/1471-2393/13/31

RESEARCH ARTICLE

Open Access

Factors associated with success of vaginal birth

after one caesarean section (VBAC) at three
teaching hospitals in Addis Ababa, Ethiopia: a
case control study
Malede Birara* and Yirgu Gebrehiwot

Abstract
Background: Vaginal delivery after previous one cesarean section for a non recurring indication has been
described by several authors as safe and having a success rate of 6080%. Hence many centers are offering VBAC
for candidates leaving the century old dictum of once cesarean always cesarean. But predicting success of VBAC
after trial of labor (TOL) is still a difficult task due to the lack of a validated prediction tool. Studies on predictors of
success are few and most of them conducted in developed countries and difficult to generalize. Therefore
assessing factors associated with successful VBAC is very important to for counseling mothers while offering VBAC.
The aim of this study was to assess factors associated with successful VBAC in three teaching Hospitals in Addis
Ababa Ethiopia.
Methods: A case control study was conducted to compare the factors associated with successful VBAC in teaching
hospitals in Addis Ababa in one year period. The cases were those successfully delivered vaginally and the controls
were those with failed VBAC and delivered by caesarean section. The sample size of the cases was 101vaginal
deliveries and the controls were 103 failed VBAC patients which made the case to control ratio of 1:1.
Result: In this study independent factors determining successful VBAC were, history of successful VBAC in the past,
rupture of membrane at admission, and cervical dilatation of more than 3cm at admission. Presence of meconium,
malposition and history of stillbirth were associated with failed VBAC. Factors like maternal age, past caesarean
indications, inter delivery interval, and birth weight were not found to be significant determinants of success. The
most common reason for repeat cesarean section for after trial of labor was labour dysfunction because of absence
of a policy for augmentation on a scarred uterus in these hospitals.
Conclusion: It is possible to prepare a decision tool on the success of VBAC by taking important past and present
obstetric and reproductive performance history as predictor.

Background
Caesarean delivery is an operation done to deliver a baby
through an incision in the uterus. It is the most frequently
performed surgical procedure worldwide [1]. Even though,
variation exists in rates of caesarean delivery across countries; currently the rate ranges from 10% to 40% [1,2]. This
high caesarean section rate has put burden on the economy of nations and individuals.
* Correspondence: [email protected]
Department of Obstetrics and genecology, Addis Ababa University, Addis
Ababa, Ethiopia

Previous caesarean section has been found to be the

commonest cause of increased caesarean section rate in
many parts of the world [1]. Because of increased risk
of maternal complications with repeat caesarean section and safety of VBAC, trial of labour for selected
group of patients with previous scar has become a preferred strategy [3].
In1988 ACOG recommended that, in the absence of
a contraindication, a woman with one previous lowtransverse cesarean delivery be counseled to attempt
labor in a subsequent pregnancy [1,4].

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Vaginal birth after cesarean section (VBAC) is associated

with shorter maternal hospitalizations, less blood loss and
fewer transfusions, fewer infections, and fewer thromboembolic events than cesarean delivery. Several reports have
indicated that the absolute risk of uterine rupture attributable to a trial of labor is about 1 per 1000 [1-4].
A 60 to 80% success rate of vaginal birth after previous
caesarean section has been reported by many authors if
the primary caesarean was done for nonrecurring indications [2]. Some of the non recurring indications for caesarean section are: poor labour progress, foetal distress,
placenta previa, transverse lie, breech presentation, oblique lie, pregnancy induced hypertension and twins [5].
The VBAC rate of hospitals in sub-Saharan Africa is between 37 to 97%. A Meta analysis done, in sub-Saharan
countries showed a VBAC success rate of 6375% [6].
There is considerable variation in the proportion of
women who are offered and attempt VBAC across centres.
British figures indicate that among women with a prior caesarean section, 33% will successfully achieve vaginal birth
in the subsequent pregnancy. Again there was considerable
variation across institutions, ranging from 6% to 64% [7].
One study in Lahore reported Successful vaginal delivery in 70% of the patients and repeat emergency caesarean
section in 30% of the patients. The leading indications for
the repeat caesarean sections were: failure to progress,
fetal distress and scar tenderness. There were no maternal
and foetal complications occurred. They concluded that
VBAC is a safe practice [8].
Caesarean rate is increasing in Ethiopia because of the
flourishing private hospitals in major towns. Even though
teaching hospitals offer trial of labour for mothers with
one scar, there is no study done which shows the rate of
VBAC acceptance and success in Ethiopian Hospitals.
A study conducted in Brazil from1985 1995, the rate
of TOL was found to be 11%. The factors significantly
associated with vaginal delivery were monthly family income below 5-fold the Brazilian minimum monthly
wage, reliance on the Brazilian national health system
for healthcare, low maternal age, and first cesarean section indicated because of fetal breech or transverse presentation, or twin pregnancy [9].
Mothers choice on mode of delivery is the most important single factor in offering trial of labour. Womens
expectations for birth and mode of birth preferences are
influenced not only by knowledge of the potential benefits and risks but also demographic, obstetrical and social factors. This knowledge would help while counseling
mothers for VBAC [4].
The crucial questions are how to reliably predict successful vaginal birth after Caesarean section, and how to
determine and quantify the magnitude of the risk of failure that is acceptable to women. Many studies have
addressed methods for identifying women at low and

Page 2 of 6

high risk of failure of an attempted vaginal birth after a

prior caesarean but none of them have resulted in a validated result. Even those factors found to be associated
with successful VBAC vary from centre to centre. Currently, therefore, there is no single validated tool which
holds true for all to predict successful vaginal birth
among women with a prior cesarean delivery.
The purpose of the present study was to identify maternal demographic, past and present obstetric determinants
of successful VBAC in teaching hospitals in Ethiopia. This
is of great help for physicians in the joint physician-patient
decision while offering TOL.

Methods
Study area

The study was conducted in three hospitals in Addis

Ababa, Ethiopia; namely, Tikur Anbesa (TAH) Hospital,
St. Pauls (SPH) Hospital and Ghandi Memorial Hospital
(GMH). These are teaching hospitals for Addis Ababa
University which provide a 24 hr specialty care. Most of
the deliveries and evaluations are made by residents with
a specialist or faculty supervision. All hospitals offer trial
of labour (TOL) with patient consent if the following conditions are fulfilled: the mother has one previous lower
uterine segment scar, non recurring previous indications,
singleton pregnancy, cephalic presentation, estimated fetal
weight less than or equal to 4 kg, and no current indication for caesarean section.
Study period

The study included mothers accepted a trial of labour

(TOL) and delivered in the time period between May,
2009 and May, 2010.
Study design

A case control study was conducted to identify factors

associated with successful VBAC among mothers with one
previous cesarean section and offered trial of labor. Cases
were all deliveries with only one previous scar, allowed
VBAC according to the hospitals protocol, started labour
spontaneously and delivered by vaginal route. Controls
were those who delivered by caesarean section after trial of
labour.
Sample size and sampling technique

A double proportion sampling technique was used using

EPI6 stat-calc. The sample size was calculated to get a
minimum OR of 2 among cases over controls with 95%
confidence interval; and power of 80%. The sample size
was 204 of which 101 vaginal deliveries were taken as cases
and 103 mothers who had failed VBAC and delivered by
caesarean section were included in the control group.
The primary sources of the data were the admission
log books at outpatient department (OPD) where the

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card numbers of patients admitted with previous caesarean scar was traced. Then those offered VBAC were
identified from delivery log books and ward discharge
summaries. Cases and controls were selected from the
available charts in the study period until the minimum
sample size was fulfilled.
Case ascertainment was done with clear inclusion and
exclusion criteria. The inclusion criteria for the cases was
patients with one previous lower uterine segment caesarean section scar who came with spontaneous labour or
leakage of liquor, with no contra indication for VBAC and
allowed to undergo trial of labour by the managing physician as documented on the patient chart and delivered
through the vaginal route. The inclusion criteria for the
controls were caesarean delivery after trial of labour.
Data collection methods

Ethical clearance was obtained from Addis Ababa university department of OB-GYN research and publication committee and submitted to the hospitals medical directors.
The data was collected from patients charts after tracing by patients number. Data was collected by residents
after orientation on the data collection tool. The information was collected using a structured questionnaire
which includes maternal socio demographic, past and
present obstetric experience, mode of delivery and birth
outcomes variables.

Page 3 of 6

101 cases who delivered vaginally after undergoing trial

of labour. The 103 mothers for whom repeat caesarean
section done after undergoing trail of labour were taken
as controls
The exposure variables which were studied in this research were: demographic variables, reproductive history,
past obstetric performance, and current obstetric variables
like Status of membrane, Presence of meconium, cervical
status, Duration of labour, Birth weight and outcome of
the baby (see Table 1).
In the analysis only those variables which are documented on the patients charts and logbooks were included.
Therefore factors like, education, and medical illness were
not documented on the data sources and taken off.
The majority of the study units were from Addis
Ababa (93.1% of cases and 92% of controls) and few
have come from nearby towns. Most of the mothers had
their antenatal care at other health centres before they
came for delivery to the hospitals.
The mean age of the cases and controls were 28.4
years and 28.6 years respectively. The mean parity and
gestational age for cases was 2.4 and 39.8 weeks respectively. In this study significant association was not found
Table 1 Summary of exposure variables initially
considered for the study
I-Demographic Variables
Maternal age

Variables

Socio demographic variables: Maternal age, marital status, Parity, Gestational age, booking status, Address.
Past Obstetric variables: Indication for the primary C/S,
inter delivery interval, Prior successful VBAC and Spontaneous vaginal delivery (SVD), history of still birth.
Current obstetric and foetal factors : Status of membrane at admission and duration rupture, presence of
meconium, cervical dilatation at admission and position
of the presenting part, duration of labour, birth weight
and outcome of the baby.

Marital status
Address
Education
II-Reproductive Variables
Parity
ANC booking
Gestational age
Presence of co morbid medical illness
III-Past Obstetric variables
Indication for past caesarean section

Analysis

Inter delivery interval

Data was entered after checking completeness, cleaning

and coding into computer SPSS version 15 software. A bivariate analysis was done using chi square test for difference of proportions between cases and controls for
categorical variables and results showed in OR and respective confidence intervals. A multivariate analysis was run
using logistic regression backward conditional model to
control the confounding effect independent determinants.

Presence of successful VBAC

Past spontaneous vaginal delivery
History of still birth
IV-Current obstetric variables
Membrane status at admission
Cervical dilation at admission
Duration of labour
Presence of me conium

Results
The total number of mothers with one previous caesarean section who were offered trial of labour (TOL) and
included in the study was 204. This number includes

Position
Mode of delivery
Birth weight

Birara and Gebrehiwot BMC Pregnancy and Childbirth 2013, 13:31

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between vaginal delivery and maternal age, gestational

age, parity and place of ANC follow up.
It was not possible to know the indications for the past
caesarean section for the Twenty percent of cases and
ten percent of controls. Some of the indications for the
last caesarean sections were fetal distress, malpresentations, big baby, failed induction and CPD. Of these
indications fetal distress and failed induction were associated low success. The other indications were not found
significant determinants.
Mothers who had experienced successful VBAC after
the past caesarean section had a higher chance of success with significant statistical association. History of
stillbirth in the past was found to be related with failed
VBAC. We didnt find significant relationship between
success and past vaginal delivery before the previous
caesarean section.
Regarding the current delivery, those mothers who
were admitted after rupture of membrane, at active first
stage of labor and having occipito-anterior position were
having a higher chance of vaginal delivery which was
found to be strongly statistically significant. Presence of
meconium stained liquor and labour stay more than four
hours after admission were associated with higher failure
rate of VBAC which was also statistically significant.
There was no association between the birth weight of the
baby and success of VBAC. There were four still births
among the cases but they were all intra uterine deaths.
Regarding the mode of delivery, 65 (64.5%) of the
cases had spontaneous vaginal deliveries while the rest
were instrumental deliveries. Among the controls the
common indications for the cesarean section up on
failed VBAC were slow progress (43.7%), arrest disorders
(23.3%), none reassuring foetal heart pattern (NRFHRP)
and CPD. There were 6 complications in the group of
cases like perineal tear, episiotomy infection, and 16 in
control group like wound infection, extensions and PPH.
There was one cesarean hysterectomy.
Generally the independent factors found to be associated with successful VBAC by the multivariate analysis
with logistic regression were history of stillbirth, history
of successful VBAC, admission at active first stage of
labor, and occipto-anterior positions (see Table 2).

Discussion
This study was conducted with the main objective of identifying factors associated with successful vaginal delivery
on mothers offered trial of labour after previous lower segment caesarean section. Significant Determinants found
were history of still birth, history of successful VBAC, past
indication of past C/S, presence of meconium, cervical
dilatation at admission, rupture of membrane at admission
and its duration and position of the presenting part. In
this study parity, maternal age, gestational age, medical

Page 4 of 6

Table 2 Bi variate analysis of cases and controls by

selected present and past obstetric factors
Cases

Controls

CRUDE OR

95% CI

<25

32

20

2.25

1.07, 4.73

26-30

42

59

Maternal age

Parity
I

65

78

0.83

0.3, 2.31

II

26

15

1.73

0.51, 5.89

III and above

10

10

Gestational age in weeks

<40

31

32

1.03

0.56, 1.97

40

18

20

1.13

0.53, 2.39

>40

52

51

Inter delivery interval

<2yrs

17

2.1-4

14

22

0.34

0.1,1.08

4-6

24

30

0.42

0.14,1.23

>6

46

42

0.58

0.21,1.58

yes

10

21

No

91

82

2.46

1.03,5.98

0.16, 0.92

History of stillbirth

PAST C/S INDICATION

Known

79

93

0.39

Unknown

22

10

Indication of the past cesarean section

Fetal distress
Malpresentation
Big baby
Failed Induction

16

25

0.29

0.1,0.86

17

19

0.41

0.13,1.22

10

11

0.41

0.11,1.40

10

14

0.32

0.09,1.12

CPD

12

14

0.39

0.11, 1.38

Others

14

10

0.64

0.18, 2.2

Unknown

22

10

1.01, 8.77

Health of baby of past C/S

Live

95

87

2.91

Dead

16

Prior successful VBAC in the past

Yes

20

3.39

No

81

96

Yes

22

18

1.32

No

79

85

Yes

52

40

1.67

No

49

63

1.27, 9.34

SVD before c/s

0.62, 2.79

ROM at admission
0.92, 3.03

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Page 5 of 6

Table 2 Bi variate analysis of cases and controls by

selected present and past obstetric factors (Continued)

the bivariate analysis didnt show that. Similar findings

have also been reported by other authors [9]. Gestational
age was not found a significant predictor of success in
this study. There are reports which found that gestational age above 40 weeks is associated with poor success [4,9]. In our case the finding could also be
confounded by high number of unknown dates and ascertainment of correct date was not possible.
History of still birth was one parameter which was
associated with poor success in this study. This could be
arising from the assumption that the cesarean route of
delivery would give the mother a higher chance of having alive baby. Inter delivery interval was not associated
with success of delivery. On other reports it was found
that interval of less than 2 years was associated with
poor success but not in our case [3]. This could be partly
due to difficulty of case ascertainment and recall bias.
Those mothers with unknown indications for past
cesarean section have been found amazingly associated
with high success. From known indications fetal distress,
malpresentations and failed induction were associated
with poor success. Breech presentation was not found
significant determinant as opposed to other reports
which consistently reported favoring successful vaginal
delivery because of its less recurrence [3,6,7,9].
Prior successful VBAC was found to be associated
with success which is similar to other reports [1,3,8,9].
Many authors reported history of prior spontaneous vaginal delivery as important determinant for success in
VBAC. But our study failed to show that.
Status of membrane at admission was found to be important factor in predicting success of VBAC. Mothers
admitted with rupture of membrane had a higher likelihood of success. But those whose liquor was stained
with meconium have poor success.
The strongest factor determining success in this study
was cervical dilatation at admission. Those who were admitted with cervical diameter greater 3 cm (Active first
stage of labour) had a strong likelihood of vaginal delivery than those admitted at cervical diameter of less than
or equal to 3 cm (latent first stage of labour). This is due
to high frequency of false labour and slow progress in
the latter. This is also supported by the finding that the
mean cervical diameter at the time of cesarean section
for failed VBAC group 4cm. The other important factor
determining success was the position of the presenting

Duration of ROM
<12hrs

40

25

6.4

>12 hrs

12

1.46, 32.1

Presence of Meconium
Yes

11

27

No

90

76

2.19

1.28, 6.72

Cervical Dilation at admission in cm

3

28

70

>3

73

33

5.53

2.91,10.56

Position of presenting part

OA

38

21

OP/PT

10

18

0.31

0.11, 0.86

UK

53

64

0.46

0.23, 0.92

Duration of labour after admission in Hours

<4 hrs

56

42

>4 hrs

45

61

1.81

1, 3.28

Birth weight in grams

<2500

5.83

0.48, 93.2

2500-4000

92

95

2.42

0.4, 18.5

>4000

illness, HIV status, inter delivery interval, history of SVD,

and birth weight were not found significant determinants.
The strengths of this study were the methodology, the
use of inclusion and exclusion criteria. The case ascertainment and analyzing variables with less missing value
has added to the strength.
There were some limitations in this study the study
might be affected from small sample size effect because
of errors made on the assumptions while calculating the
sample size. There could also be a possibility of recall
bias at reporting the inter delivery interval and indications of past cesarean section. Documentation on important variables, like occupational status, educational
status, Apgar score, blood loss, post delivery hematocrit
and medical illness was not good which has made these
variables to be excluded from analysis.
Young maternal age and primiparity were associated
with high success rate with vaginal delivery even though

Table 3 Multivariate analysis of independent variables associated with successful VBAC

Successful VBAC

Failed VBAC

CR OR (95% CI)

AOR (95% CI)

No History of still birth

Variable

10/101

21/103

2.46 (1.03,5.98)

2.54 (1.03,6.27)

Prior successful VBAC

20/101

7/103

3.39 (1.27, 9.34)

3.40 (1.12, 9.48)

Cervical dilatation at admission > 3cm

28/101

70/103

5.53 (2.91,10.56)

6.63 (3.36,13.01)

OP/OT positions

10/101

18/103

0.31 (0.11, 0.86)

0.36 (0.14, 0.96)

Birara and Gebrehiwot BMC Pregnancy and Childbirth 2013, 13:31

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part. Those having occipito anterior position were associated with higher success than those with occipito posterior and occipito transverse positions or unknown positions.
There was no difference in the birth weight of both groups
even though there are reports that macrocosmic babies
have poor success. No difference in the neonatal outcome
observed in both groups.
66% of repeat caesarean sections (66%) for the failed
VBAC group were for reasons of slow progress of labour
and arrest of cervical dilatations. This is because, oxytocin augmentation for scarred uterus is not allowed in
these hospitals.
Generally the independent variables found to determine
success of VBAC found with multivariate analysis were
history of absence still birth, history of successful VBAC,
cervical diameter at admission more than 3cm, and occipito anterior position of the presenting part (Table 3).

Page 6 of 6

6.

7.
8.

9.

Boulvain M, Fraser WD, Brisson-Carroll G, Faron G, Wollast E: Trial of

labor after caesarean section in sub-Saharan Africa: a meta-analysis.
BJOG 1997, 104:13851390.
Jodie MD, Caroline AC, Janet EH, Ross RH, Jeffery SR: Vaginal birth
after caesarean. BMC Childbirth and Pregnancy 2007, 7:17.
Taj G, Sohail N, Cheema SZ, Zahid N, Rizwan S: Review of Study of
Vaginal Birth After Caesarean Section (VBAC). Annals 2008,
14(1):1316.
Cecatti JG, Pires HMB, Fandes A, Duarte Osis MJ: Factors associated
with vaginal birth after previous cesarean section in Brazilian
women. Rev Panam Salud Publica 2005, 18(2):107113.
doi:10.1186/1471-2393-13-31
Cite this article as: Birara and Gebrehiwot: Factors associated with
success of vaginal birth after one caesarean section (VBAC) at three
teaching hospitals in Addis Ababa, Ethiopia: a case control study. BMC
Pregnancy and Childbirth 2013 13:31.

Conclusion
This study revealed that successful vaginal delivery after
one previous cesarean scar was associated with past
obstetrics performance and mainly to the current labor.
The main determinants include history of stillbirth, history of successful VBAC in the past, rupture of membrane, absence of meconium, cervical stage of labor at
admission, position of the presenting part, duration of
labor, and knowledge of the previous indication for the
past cesarean section.
VBAC is a safe practice as long as it is offered with
proper selection of candidates with factors having a high
success rate. Physicians need to be based on knowledge of
factors having good outcome before counseling mothers
so that failure rates decrease.
Competing interests
We declare that there is no competing interest with anyone.
Authors contributions
Both authors contributed equally to the study. MB developed the initial
manuscript and YGH reviewed critically and approved for submission.
Acknowledgements
We Thank the Ethiopian society of obstetricians and Gynecologists (ESOG)
for financial assistance.
Received: 10 April 2012 Accepted: 21 January 2013
Published: 1 February 2013
References
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Practice Bulletin: vaginal birth after previous cesarean delivery:
Clinical management guidelines. Int J Gynecol Obstet 2004, 54:197204.
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McGraw-Hills; 2007.
3. Up-to-date version 16.3, vaginal birth after cesarean delivery: 2008.
4. Ugwumadu A: Does the maxim once a caesarean, always a
caesarean still hold true? PLoS Med 2005, 2(9):e3053.
5. What is Vaginal Birth after Cesarean Section? HealthwiseW Knowledgebase,
19952005. P.O. Box 1989, Boise, Idaho 83701: Health wise, Incorporated.

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