VBAC in Kentucky: What the Data Tell Us- and What Comes Next?

For decades, vaginal birth after cesarean (VBAC) has been recognized as a safe, evidence-based option for many people with a prior cesarean birth. Yet, in Kentucky, access to VBAC remains limited, uneven, and often dependent on where someone lives, which hospital they deliver in, and which provider they see. Two recent briefs led by Dr. Melissa Eggen, PhD, MPH at the University of Louisville School of Public Health and Information Sciences offer a rare and powerful opportunity to examine this issue from both sides of the bedside: the experiences of women who sought birth after cesarean, and the perspectives of the providers who care for them.

Taken together, these findings tell a clear story. Kentucky's low VBAC rate is not driven by lack of interest from birthing people, nor by the lack of concern from providers. Instead, it reflects deep structural, institutional, and policy barriers - many of which are modifiable. If Kentucky is serious about improving maternal health outcomes, reducing unnecessary surgery, and honoring patient-centered care, VBAC access must be part of the conversation.

Why VBAC Matters in Kentucky

Kentucky consistently ranks among states with the highest cesarean delivery rates in the country. While cesarean birth can be lifesaving and medically necessary, repeat cesareans carry increasing risks for hemorrhage, infection, abnormal placentation, surgical complications, and longer recovery times. From a public health perspective, increasing access to VBAC is one of the most effective strategies for reducing overall cesarean rates and improving maternal outcomes.

Nationally, VBAC rates have risen modestly in recent years, but Kentucky continues to lag behind the U.S. average. The research led by Dr. Eggen shows that this gap is not accidental—it is the predictable outcome of how maternity care is organized, regulated, and reimbursed in the Commonwealth.

Listening to Kentucky Women: Experiences After Cesarean Birth

The statewide survey of women who had given birth after a previous cesarean offers critical insight into what families actually experience when navigating their options. One of the most striking findings is that most women who ultimately had a repeat cesarean were interested in a VBAC. The desire was there—but the support often was not.

Many respondents reported that their provider did not allow VBAC or that hospital policy explicitly prohibited a trial of labor after cesarean (TOLAC). Others described never being told that VBAC was even an option. This lack of information had real consequences. Women shared that they assumed repeat surgery was inevitable, felt afraid to ask questions, or worried that advocating for a VBAC would label them as “difficult” or irresponsible.

Just as important as the outcome of birth was the experience of care. Women who felt respected, informed, and included in decision-making reported more positive birth experiences—even when the birth ended in a repeat cesarean. Conversely, women who felt pressured, shamed, or dismissed described long-lasting emotional harm and loss of trust in the healthcare system.

A consistent theme throughout the survey was the importance of the patient–provider relationship. When providers engaged in shared decision-making, discussed risks and benefits honestly, and supported patient autonomy, women felt empowered. When providers relied on fear-based counseling or rigid policies, women felt coerced.

The Midwifery Difference

One of the clearest findings from the women’s survey was the difference in experiences between those who received midwifery care and those who did not. Women cared for by midwives were significantly more likely to report:

• Being informed of all available birth options

• Feeling that their preferences were respected

• Having autonomy in decision-making

• Describing their VBAC or TOLAC experience positively

  
  

Many women reported seeking midwifery care specifically because they could not find an obstetric provider willing to support a VBAC. Some traveled long distances; others chose out-of-hospital births not because they preferred that setting, but because it was the only place they felt supported. This should give policymakers pause. When families leave hospital care to access autonomy, it signals a system-level failure—not a patient one.

What Providers Are Saying

The companion survey of Kentucky birth providers adds essential context. Contrary to common assumptions, most providers surveyed expressed support for VBAC in principle. Many cited professional satisfaction, alignment with evidence-based care, and a desire to reduce unnecessary cesareans as reasons they want to offer VBAC.

Yet a significant proportion reported that they could only “sometimes” or “rarely” accommodate patient requests for VBAC. The reasons were overwhelmingly systemic:

• Hospital policies that ban or strongly discourage TOLAC

• Lack of 24/7 anesthesia coverage, particularly in rural hospitals

• Liability insurance costs and malpractice concerns

• Administrative resistance rooted in outdated interpretations of clinical guidelines

  
  

Providers described frustration with being unable to offer care they believe is appropriate and safe. Some noted that while national guidelines have evolved to support VBAC in a wider range of settings, hospital policies have not kept pace. Others highlighted inequities, pointing out that patients with financial means can travel or self-pay for care, while those relying on Medicaid often have no options at all.

A Rural and Equity Issue

These findings make clear that VBAC access is also a rural health and equity issue. Hospitals in smaller or more remote communities are less likely to offer VBAC due to staffing and resource constraints. As labor and delivery units continue to close across Kentucky, the distance to VBAC-supportive care grows even farther for many families.

The result is a two-tiered system: those who can travel, pay out-of-pocket, or navigate complex healthcare systems may access VBAC, while others are left with repeat surgery as their only option. This disparity undermines both equity and informed consent.

From Research to Action: What Kentucky Can Do

The research led by Dr. Eggen does more than diagnose the problem—it points toward solutions. Providers themselves offered concrete, actionable recommendations, including:

• Expanding interdisciplinary VBAC training and simulation opportunities

• Revising hospital policies to align with current evidence

• Increasing access to midwives and collaborative care models

• Addressing malpractice insurance structures that penalize VBAC

• Improving patient education about birth options after cesarean

  
  

One possible compelling next step is the creation of a statewide maternal health task force focused solely on reducing primary cesarean births and expanding safe, equitable VBAC access. Such a task force should include:

• Midwives, obstetricians, nurses, and anesthesiologists

• Hospital administrators and insurers

• Public health experts

• Medicaid representatives

• Community advocates and people with lived experience

  
  

Reducing primary cesareans is essential to improving VBAC rates. Every first cesarean sets the stage for future risk. A coordinated, statewide approach would allow Kentucky to address prevention, access, training, and policy together rather than in silos.

A Call to Do Better

Kentucky families deserve maternity care that is evidence-based, respectful, and responsive to their needs. The voices captured in these surveys—both women and providers—are calling for change. They are not asking for reckless care or ignoring risk. They are asking for transparency, autonomy, and systems that support safe choices.

The data are clear. The expertise is here. The question now is whether Kentucky will act.

Honoring VBAC as a legitimate, supported option is not about promoting one mode of birth over another. It is about restoring trust, reducing harm, and ensuring that every family has access to the full spectrum of safe, informed choices. That is a goal worthy of collective effort—and long overdue.