VBAC and VBA2C: Reclaiming a natural birth after caesarean
Vaginal Birth After Caesarean (VBAC) and Vaginal Birth After Two Caesareans (VBA2C) are no longer fringe conversations in maternity care. Increasingly, women are seeking balanced, evidence-based information about their options following a previous caesarean section. Central to this shift in understanding is the work of Australian midwife and researcher Dr Hazel Keedle, whose qualitative and mixed-methods research has significantly advanced how we understand women’s experiences of planning and achieving birth after caesarean.
Her book, Birth After Caesarean, alongside her academic publications, challenges the narrow risk-focused framing that has traditionally dominated VBAC discussions. Instead, her work places women’s autonomy, continuity of care, and respectful maternity systems at the centre of the conversation.
Understanding VBAC and VBA2C
A VBAC refers to a vaginal birth following one previous caesarean. A VBA2C refers to vaginal birth following two previous caesareans. In Australia and many other high-income countries, caesarean rates have risen substantially over the past two decades. As a result, more women are entering subsequent pregnancies with uterine scars and facing decisions about mode of birth.
The dominant medical narrative often emphasises uterine rupture risk. While uterine rupture is a serious complication, large cohort studies consistently demonstrate that for women with a low transverse uterine incision, the absolute risk remains low — typically cited at around 0.2–0.7%. Planned repeat caesarean also carries its own risks, including surgical complications, infection, placenta accreta spectrum in future pregnancies, and longer recovery times.
Dr Keedle’s research reframes the discussion. Rather than presenting VBAC as a risky deviation from surgical repeat birth, she highlights that planned repeat caesarean is also an intervention with cumulative consequences. The question becomes not “Is VBAC safe?” but rather “What are the relative risks and benefits of each pathway in this woman’s context?”
What the evidence says about natural birth success rates
International evidence shows that approximately 60–80% of women who plan a VBAC will achieve a vaginal birth. Factors associated with higher success include:
- Prior vaginal birth
- Spontaneous onset of labour
- Supportive care environments
- Continuity of midwifery care
For VBA2C, data is more limited but increasingly supportive. Studies suggest success rates comparable to VBAC in carefully selected populations, with uterine rupture risk only marginally increased compared to one previous caesarean.
Dr Keedle’s work is particularly important because it moves beyond raw statistics. Her doctoral research explored women’s lived experiences of planning a VBAC in Australia. She identified that system-level barriers — not just clinical risk — strongly influenced outcomes.
The impact of maternity systems
One of Dr Keedle’s key findings is that women planning VBAC often encounter resistance within hospital systems. They report feeling pressured toward repeat caesarean, experiencing inconsistent information, and having difficulty accessing supportive clinicians.
Her research identified that women who achieved VBAC frequently described:
- Continuity of midwifery care
- Respectful communication
- Clinicians who framed VBAC as achievable
- Shared decision-making processes
Conversely, women who experienced repeat caesareans often described subtle coercion, risk amplification, and limited support for physiological labour.
This distinction matters. VBAC success is not determined solely by uterine integrity; it is profoundly shaped by the culture of care.
Psychological dimensions of natural birth after caesarean
Dr Keedle’s qualitative findings show that planning a VBAC is rarely only about mode of birth. Many women describe a desire for healing after a previous traumatic or unexpected caesarean. Some seek physical recovery advantages. Others seek a sense of agency.
Importantly, her research highlights that women often feel their previous caesarean experiences were not fully acknowledged. When maternity care focuses narrowly on surgical scheduling, these deeper emotional dimensions remain unaddressed.
VBAC, therefore, becomes not simply a clinical pathway but a restoration of confidence.
Risk: Relative and contextual
In discussions of VBAC and VBA2C, risk must be contextualised. Uterine rupture, though serious, is uncommon. Repeat caesarean carries increasing surgical complexity with each subsequent operation, including:
- Adhesions
- Bladder injury
- Increased haemorrhage risk
- Placenta previa and accreta in future pregnancies
For women planning larger families, cumulative caesareans pose escalating risks. Dr Keedle’s work encourages clinicians to present balanced information rather than presenting surgery as the “safe default.”
Furthermore, evidence indicates that induction methods, continuous electronic fetal monitoring, and restricted mobility may influence VBAC outcomes. Care models that support spontaneous labour and physiological movement tend to show higher success rates.
VBA2C: Expanding the conversation
Historically, women with two previous caesareans were routinely advised to undergo repeat surgery. However, emerging research — including international cohort data — indicates that planned VBA2C can be a reasonable option for selected women.
Dr Keedle advocates for informed choice rather than blanket exclusion policies. Her work emphasises that women are capable of understanding nuanced risk profiles when provided with clear, non-directive counselling.
Policies that prohibit VBA2C outright may not reflect current evidence and may undermine informed consent principles.
Continuity of Care as a Protective Factor
One of the strongest themes in Dr Keedle’s research is the importance of continuity of midwifery care. Women who had access to a known midwife throughout pregnancy reported:
- Increased confidence
- Greater understanding of labour physiology
- Reduced fear
- Improved satisfaction regardless of outcome
Continuity appears to influence not only experience but also birth outcomes. Women who feel supported are more likely to labour spontaneously and less likely to request early intervention.
This suggests that VBAC success is relational as much as clinical.
Informed decision-making
True informed consent requires balanced discussion of:
- Absolute versus relative risk
- Personal obstetric history
- Future reproductive plans
- Emotional priorities
- System capabilities
Dr Keedle argues that women deserve transparent discussions rather than directive counselling. When women feel heard, their decision — whether VBAC or repeat caesarean — is more likely to be experienced positively.
Cultural change in maternity care
Dr Keedle’s broader contribution lies in challenging risk-dominant maternity discourse. She calls for:
- Shared decision-making frameworks
- Respectful language
- Recognition of systemic bias
- Expansion of continuity models
Her work aligns with international calls to reduce unnecessary surgical birth and support physiological processes when clinically appropriate.
Final reflections
VBAC and VBA2C are not reckless undertakings. Nor are they universally appropriate. They exist within a spectrum of risk that must be weighed against the cumulative risks of repeat surgery.
The evidence suggests that for many women, VBAC is a safe and achievable option. Success is strongly influenced by care environment, communication, and continuity.
Dr Hazel Keedle’s research reminds us that birth outcomes are not determined by scars alone. They are shaped by systems, beliefs, language, and support.
In the end, the most important outcome is not simply vaginal birth versus surgical birth. It is whether a woman feels informed, respected, and supported in her choice.
That is the real measure of safe maternity care.
Podcast Great Birth Rebellion
In this episode Melanie interviews Dr Hazel Keedle and they discuss the strategies that you can apply to increase your chances of VBAC and also the risks and benefits of a repeat caesarean and the option of vaginal birth.
In this episode Melanie interviews Dr Hazel Keedle and they discuss the strategies that you can apply to increase your chances of VBAC and also the risks and benefits of a repeat caesarean and the option of vaginal birth.
- Instagram: @hazelkeedle
- Facebook: @VBACmatters
- Twitter: @HazelKeedle
Purchase Hazel’s book ‘Birth After Caesarean’
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