The VBAC calculator ACOG references in some of its bulletins and guidelines is a hot topic in the birth world. There is outdated evidence, updated evidence, and conflicting evidence surrounding its accuracy and use for those attempting a trial of labor after Cesarean (TOLAC).
Even ACOG seems to contradict itself in its current VBAC guidelines.
If you are preparing for a VBAC and your provider has never referred to your VBAC score or how likely you are to have a VBAC, consider yourself lucky! The VBAC success calculator uses statistics from 7,000 VBAC attempts in the United States to determine how likely YOU are to have a VBAC.
If you have listened to our VBAC podcast at all, you know I have a strong opinion on the VBAC score provided by these calculators. Today, I will explain why I have such strong feelings about the VBAC calculator and what ACOG says about its use.
I will share the essential things you need to know about the VBAC success rate, and what else to consider when calculating your personal chances of success.
Factors included in your VBAC score
One of the biggest reasons I am not a fan of the VBAC calculator is that it is inherently racist, against women of size, and reduces your score based on medical factors that might not even be true.
In a nutshell, your “chances” drop if you:
- Are Black or Hispanic
- Have a BMI over 30
- Are over 35 years old
- Have not had any prior vaginal deliveries
- Have a Cesarean that was labeled failure to progress or failure to descend
This calculator has limitations and should not be the sole decision-maker regarding a woman’s decision to attempt a VBAC.
A more important thing to do is to have an educated conversation with your provider about your medical history, past birth experiences, your incision type, and plans for your family size.
One of my favorite VBAC stories is of my first doula client, who was given a 4% (yes FOUR) chance of success by her provider using the VBAC calculator. She ended up pushing her baby out in twenty minutes.
Curious to see what your success rate is? Play around with the VBAC calculator and adjust different variables to see how it impacts your “chances” of VBAC.
ACOG and the VBAC Calculator
ACOG Practice Bulletin 205 discusses using the VBAC calculator for providers when counseling patients who want a VBAC:
A VBAC calculator may be used to provide more specific information about the chance of VBAC, which can be used to further the process of shared decision making.” (emphasis added)
The ACOG bulletin also focuses on how population-based statistics cannot accurately predict an individual’s VBAC success odds. It goes on to say:
It is ill-advised to use statistics as a primary indicator when making VBAC decisions.
A predicted success rate of less than 70% is not a contraindication to TOLAC. The decision to attempt TOLAC is a preference-sensitive decision, and eliciting patient values and preferences is a key element of counseling.
Is my VBAC score accurate?
In 2019, a cohort study was performed to see if predicted rates for VBAC were accurate. Are prediction models for vaginal birth after cesarean accurate?.
While I know the calculators were more likely to predict those who WOULD achieve a VBAC vs. those who would not, I was surprised to see the data. Let’s break it down. Your VBAC score can either be a number (0-25) or, a percentage (out of 100%).
I absolutely love these charts from the AJOG journal, which break down the numbers from the study referenced above using both the score-based and percentage-based calculators. As you look at the numbers, pay close attention to the “Calculated VBAC Score” and compare it to the “Actual VBAC Success Rate.”
While the number of participants is small, and more research still needs to be done, you can see how inherently flawed these numbers can be. It saddens me to think that many parents have not been given a chance for TOLAC because of a lower VBAC score.
Putting VBAC score in perspective
One critical conclusion is that there is no single right answer on estimating the probability of any individual attempting VBAC. Even people with similar predicted success rates will make different decisions, have different providers, and face different birth circumstances.
The most critical factors to consider when choosing between VBAC or repeat Cesarean are:
- A VBAC friendly doctor or midwife who truly supports you
- A supportive birth location
Some providers promise to support your VBAC, and as the due date approaches, they change their tune, restrict your options, or come up with reasons to schedule a repeat Cesarean. They may suggest reasons such as your baby being too big, testing positive for gestational diabetes, not going into labor by 40-weeks, or any other non-evidence-based reason.
Having a supportive provider and birthing at a VBAC friendly location makes a more significant impact on your VBAC success chances than any other factor.
VBAC Calculator FAQ’s
The VBAC calculator can be difficult to wrap your head around if you have a lower than expected score. For my first VBAC, I had a 42% VBAC score. I had a VBAC, then two more after that. Even now, my predicted success rate is just 72% because I am older and slightly fluffier around the edges.
How accurate is the VBAC calculator?
While VBAC calculators attempt to predict your odds of having a vaginal birth, they have many flaws. They should not be considered the ultimate decision-maker when deciding how to birth.
What is a good VBAC score?
Some believe that a VBAC score of 60%-70% or higher is a good score to allow a trial of labor. However, up to 80% of parents who choose to attempt a VBAC will succeed, regardless of their score.
Is VBAC considered high risk?
VBAC is generally considered safer than a repeat Cesarean and is not regarded as high risk.
Who is a good candidate for VBAC?
Most women are great candidates for VBAC. Finding a provider that is VBAC supportive will ensure you are set up for success.
If you want to learn everything you can about VBAC, so you can make informed birth decisions every step of the way, check out our VBAC Course for Parents.