Abstract / Summary
Abstract Background. Women with one previous caesarean drive caesarean rates in Kazakhstan and elsewhere, yet whether they labour again depends more on local practice than on case mix. Research on this population predicts who succeeds once labour has been chosen, which presupposes the offer. We asked the prior question, then whether the trials a service supports reach the right women. Methods. Retrospective cohort of 1020 consecutive women with one previous lower-segment caesarean delivering a term singleton cephalic pregnancy in Karaganda region, 2017–2022, classified by intended mode of birth as trial of labour after caesarean (TOLAC) or planned repeat caesarean (PRCD). Determinants of the offer were modelled on the full cohort using only pre-decision variables, and the same covariates fitted to vaginal birth among women who laboured, the two sets of weights then being compared by bootstrap. Women were stratified by an unweighted count of four guideline-derived antenatal factors, and stratum-specific vaginal birth rates applied to alternative allocations holding trials, or failed trials, fixed. Results. Of 1020 women, 224 (22.0%) laboured; 161 delivered vaginally, a cohort caesarean rate of 84.2%. Conclusions. Uptake was low and the trials offered were poorly targeted. The failed trials this service already tolerates would have supported two thirds more labouring women and nearly twice the vaginal births. The constraint is neither safety nor the success rate, but where the offer points.