S1 Ep1: What are my chances of having a VBAC with founder April Austin

You’re listening to The VBAC Hub Podcast and I’m your host, April Austin. I’m a doula and antenatal teacher, VBAC mum and the founder of The VBAC Hub CIC. This podcast is here to dig into the messy, complicated and deeply human side of birth after caesarean. We’re going to talk about the evidence, the guidelines, share birth stories, give context and talk about the realities of navigating the maternity system. We’ll be having respectful conversations, discussing all of the nuances and hopefully having a bit of companionship along the way. If you’re ready to get informed and feel less alone in this journey, you’re in the right place. Make sure you follow along so you never miss an episode.

Hello my loves and welcome back to The VBAC Hub Podcast. We’ve got a solo episode today with me, April Austin, and we are going to be looking at the question: what are my chances of having a VBAC?
Now, in theory it should just be a straightforward question, right? As humans, we love black and white answers. But sadly, the human body is a little bit more complicated than that, and this answer is really nuanced. I can’t give you a nice little figure that you can hang your hat on, but we are going to break it down as best we can today.

We’re going to talk about the brand new data that we got from the National Maternity and Perinatal Audit, which looks at birth across all areas for 2023. We’ve been able to pull the VBAC statistics so we can have a look at those. We’re going to look at what they tell us and what they don’t tell us, which to be honest is most of the story. Then finally, we’re going to look at some things that you can do that can tilt the chances in your favour so that you could increase your chances of having a VBAC.

There is no magic guaranteed success, but it’s always nice to have things that you know you can influence.

Just to be clear, this is just information. It is not a substitute for medical advice. Take what helps, leave the rest, and make sure that you bring any questions you have about your own care to your care providers.

The data

So first off, we are going to look at the data and try and make sense of the numbers. The National Maternity and Perinatal Audit looked at births across Great Britain and there was a section just about VBACs, looking at information for VBAC in 2023. We’re also going to compare this to the previous audit, which was done in 2016.

There are a few things we need to understand about this data. It is only looking at people who are having their second baby after their first birth was a caesarean. So it’s not including people who are on their third or fourth births. It’s only looking at singleton pregnancies, so anyone having twins or multiples is not included. It only looks at gestations from week 34 up to 42 weeks and six days, so anyone who gave birth outside that gestation is not included. It tells us nothing about people who have had more than one previous caesarean.

So it’s a really narrow picture, but it is the most up-to-date data that we have about VBAC in the NHS.
There were a lot of confusing statistics within this that I want to try and break down, and some of the language used was also quite confusing.

We’ve got three different statistics they were looking at.

Attempt rate. This is simply the number of people who attempted to have a VBAC. In England, that was 25%. So 25% of people who had had a previous caesarean for their first birth went on to try to have a VBAC in their second pregnancy.

Success rate. I don’t love this word, but people who did attempt a VBAC and had a vaginal birth, that was pretty much 50-50, roughly 52%. So half of people that tried to have a VBAC went on to have one, and the rest had a repeat or in-labour caesarean.

Overall VBAC rate. This is the thing that’s confused people the most. It has come out at 14.2%. But what this was, was an accumulation of everybody who had had a caesarean for their first pregnancy and then went on to have a vaginal birth for their second pregnancy.

So to humanise this data a little bit, let’s just consider 100 people. If we imagine 100 people whose first baby was born by caesarean, and now they are pregnant with their second child, 25 of them would go on and attempt to have a VBAC. Of those 25, 13 of them would have a vaginal birth. The other 12 would end up with an emergency or in-labour caesarean. The remaining 75 would go on to have a planned repeat caesarean.

So the overall VBAC rate being 14.2% isn’t that VBAC doesn’t work, it’s just that the number of people who attempted to have a VBAC in the first place is actually really low.

Comparing to 2016

We can compare this data to 2016, where the overall VBAC rate was 24.5%. It has dropped over 10 percentage points in a decade to 14.2.

I know that if you’re pregnant and you’re considering having a VBAC, seeing that can feel a bit like a gut punch and like your chances have just evaporated.

But I really want you to hear this. This isn’t about physiology. Your physiology and your ability as a human to birth has not changed in the last decade. What has changed is the system.

Since 2016, we’ve seen the caesarean rate climb, induction rates continue to rise, staff shortages, newly qualified midwives not being able to get jobs despite the fact that we’ve been told by the government that we are short by 2,500 midwives within the NHS alone. There is less continuity of care, we have the legacy of COVID restrictions being left over, and there’s always been very risk-averse policies within the NHS across the board, but specifically when you have pregnancy complications such as having had a previous caesarean.

So what’s dropping here is not women and birthing people’s ability to birth vaginally, it’s living in a system that is under much more strain and has been stripped of funding and resources continually for the last two decades.

The Royal College of Obstetricians and Gynaecologists guidelines state that you have a 75% chance of having a VBAC if you try for one, but the data has shown something different over the last two decades. In 2016, the chances of having a VBAC if you tried was 62%. That’s now dropped to 52%, so it’s pretty much 50-50 at the moment.

What the data doesn’t tell us

What we’re not knowing within these stories is we’re just looking at numbers. They’re not telling us who had an induction and what methods of induction they had. We know from data that induction increases your chances of having another caesarean. We don’t know who laboured spontaneously and who laboured spontaneously to begin with and then might have had the syntocinon drip added to their labour later on, or might have had their waters broken.

We don’t know whether people had the freedom to move, whether they chose to remain on continuous monitoring, had one of the wireless ones, or chose intermittent monitoring. We don’t know if people were in water. Of those that did have a vaginal birth, we don’t know what was instrumental or what was spontaneous.

We also don’t know how people were counselled. People who wanted to have a VBAC when they were attending their antenatal appointments and having these discussions with their midwives, consultants and doctors, we don’t know what language was used, what risks they were presented with, what was emphasised, and what options they might have asked for that were then shut down.
All of this information doesn’t include anything to do with anybody who’s had more than one caesarean.
So on the face of it, it might look like at the moment that half succeed and half have a repeat caesarean, but behind all of those births are completely different labours. We also know that induction after caesarean carries a greater risk of uterine rupture, whereas spontaneous labour carries the lowest. But that’s one example of nuance that isn’t included in this data.

What this means for you

I know that all of these numbers can seem really bleak, but I want to speak directly to anybody who’s felt their stomach drop when they’ve heard that the VBAC rate is 14%.

This is population data. It does not equal your personal odds of having a VBAC.

This audit is a service-wide average. It’s basically the system talking about itself. It’s not talking about you as an individual. Your own chances depend on your own story, your own choices, and the support that you get.

When you look at these numbers, I want you to use them as a mirror for the system, not as a mirror for your own body.

What you can do to tilt the odds in your favour

So if you do want to have a VBAC, what can you do to tilt the odds in your favour? We can’t give magic guarantees, but there are definitely things you can do to influence your own chances.
Debrief your previous birth experience. You can get hold of your labour and birth notes. Contact your local hospital or where you had your baby and ask for them. You might have to pay for them but you can get access to them yourself. You can then ask to have a debrief either with a midwife within the NHS or privately with an independent midwife, and you can go through your notes and find out what happened clinically in your labour.

This can help you marry up the picture between what was happening from a clinical perspective and what was happening to you. Your own experience of the story is also really important, and it can be really useful feedback for the NHS to hear how your experience might differ to what was on paper. It starts giving you a blueprint for understanding what happened and the things you can start doing in your next pregnancy to increase your chances of having a vaginal birth.

You don’t even have to be pregnant to do this. If you are considering having a baby in the future or you’ve had a caesarean recently, you can go back and find out what happened in your birth so you can make sense of it.

Think about continuity of care. Research and all maternity reviews that have happened pretty much since 1993 have all come out and said that continuity of care improves outcomes. It increases the spontaneous vaginal birth rate, it reduces interventions and caesarean sections, but it is something that the NHS still struggles to provide.

It is still something you can talk about with your care providers. You don’t know if you don’t ask. When you become pregnant and start seeing your community midwife, you can say that you want to have continuity of care. You’d like to know the team that’s potentially going to be looking after you. Is there a caseloading team at your local hospital? There might not be one, but you don’t know unless you ask.
Other ways you can have continuity of care is to hire a doula. That is a professional birth partner who supports you physically and emotionally through labour and through pregnancy. They can attend your birth and that can be really supportive and helpful. Doulas are also evidence-based. They also reduce interventions and increase the vaginal birth rate.

Think about the onset of labour. Whether you are going to have an induction or not. VBAC success rates are higher with spontaneous labour, as induction after caesarean is possible but it does carry higher risks of uterine rupture. Induction carries a higher risk of ending in caesarean itself anyway, particularly if you’re using prostaglandins.

If induction is suggested, it’s always good to ask why, when would you be having one, how would it be done, would they be using prostaglandins, could they use a balloon catheter instead, would you need to have the syntocinon drip, and what changes for you for monitoring, for mobility. How can you still keep your chances as high as possible for having a vaginal birth if you choose to have an induction?

Redo full antenatal education.
I know it sounds weird, particularly if you’ve already done it with your first pregnancy, but when you’ve already been through the system once and you’re coming back to antenatal education again, you’re looking at it with fresh eyes and a totally different experience. Suddenly you start noticing things that you haven’t clocked before and the information is going to settle within you differently.

Finding antenatal education that supports physiology and can help you understand your rights and how you can access evidence-based information can be really valuable, even if you’ve done it in your first pregnancy. It’s also going to remind you what our bodies need for physiology to work, for our bodies to feel safe enough, calm enough to be able to labour undisturbed.

Find your allies. I’ve seen this one time and time again in birth stories. Finding people who are in your care circle who can support your informed choices wholeheartedly. That might mean finding people who understand physiology, how the body works, who respect your autonomy, and who feel comfortable if you’re going to make choices outside of guidance.

For example, if you turn up at a midwife appointment and you say, “yes, I want to have a VBAC and I’d like to have a home birth,” and their reaction is to dismiss it immediately, that is not a midwife for you to continue having those discussions with. I’m sure that midwife is absolutely lovely and gives amazing care to people they feel comfortable giving care to. But they have highlighted in that discussion that this is not something they are comfortable supporting, and that’s okay.

You can ask to talk to other people who are comfortable supporting you in those choices. That might mean talking to a consultant midwife, seeing a different community midwife, or talking to a different obstetrician or consultant. You’ll be surprised who you find as your allies, but never fear going to ask to speak to somebody else. You are not being difficult. It’s really not personal and it’s not about the midwife or obstetrician being awkward either. It’s just where they’re comfortable and where their preferences are, and it works best for everybody when we have people in our space who feel comfortable and confident caring for us in the way that we need to be cared for.

There are many other things you can do as well, like researching optimal fetal positioning, ensuring your baby is in the best type of position, having some body work done, ensuring your hips are in alignment. Are you having any issues with back pain or hip pain? It’s always good to go and get it looked at. To be honest, this is just the tip of the iceberg of things you can do, but it’s a good list to get you started if you’re thinking about having a VBAC.

Bringing it all together

So to bring this back to the question we asked at the beginning: what are my chances of having a VBAC?

I’m hoping, and keeping all of my fingers crossed, that you have come to the conclusion that actually there is no magic number. It’s really individual.

The data that we have dissected today gives us a much bigger picture of what’s happening within the system, but that is still really valuable. It gives us a pathway and information to know how to navigate it so that we can increase our own chances, so we know how to go and find our allies, so we know how to go and find the bits of information that we need, so we can make decisions that feel good for us.
Your chances of having a VBAC are much more determined by you being an active participant in the decision-making and you feeling comfortable with the decisions that you are making. But these are just the first steps, the first little tools that you can start thinking about to set you off on that journey if you are planning on having a VBAC.

Thank you so much for listening to The VBAC Hub Podcast. If this episode helped you make sense of the numbers, please share it with someone else who might need to hear it. You’ll also find links in the show notes to our crowdfunder and to all of our socials. If you have time, I’d really love it if you could leave us a review, that helps us to climb in the podcast charts. I’d love to hear your reflections over on Instagram. You can follow us at The VBAC Hub. Remember, you deserve autonomy, dignity and to be fully informed whatever path your birth takes, and I’ll see you in the next episode.