The uterine scar dilemma: Outcomes of a restricted elective repeat cesarean section policy in a high‐fertility, resource‐limited setting

Introduction The global increase in cesarean section (CS) rates poses particular challenges in low‐ and middle‐income countries (LMICs). In high‐fertility, resource‐limited settings, deciding the optimal mode of delivery for women with a uterine scar is complex. Elective repeat CS (ERCS) is often preferred over trial of labor after cesarean (TOLAC), despite limited evidence on its safety and feasibility. This study aimed to describe clinical management and birth outcomes among women with prior cesarean section managed under a restricted ERCS policy and to identify prognostic factors to inform delivery decisions. Material and Methods We conducted a retrospective observational cohort study at EMERGENCY Hospital, Panjshir Province, Afghanistan, from October 2016 to December 2021. ERCS was limited to women with clear medical indications. Maternal and neonatal outcomes were described separately for women scheduled for TOLAC and those scheduled for ERCS. Within the TOLAC group, logistic regression analyses identified predictors of successful vaginal birth after cesarean (VBAC) and adverse maternal and neonatal outcomes. Results Among 2730 eligible women, 2621 (96.0%) attempted TOLAC, achieving a VBAC success rate of 88.2%. Uterine rupture occurred in 30 cases, all within the TOLAC group. Placenta accreta spectrum was the strongest predictor of adverse maternal outcomes, particularly in the ERCS group. Induction of labor with misoprostol was independently associated with neonatal mortality. Successful VBAC was associated with a single prior CS performed for indications other than obstructed labor and with spontaneous labor onset, particularly among women with a history of prior vaginal delivery. Maternal mortality was rare and unrelated to uterine scar complications. Overall, neonatal outcomes were favorable, with high rates of discharge in good condition. Conclusions Vaginal birth was achieved in the majority of women attempting TOLAC. A single prior CS performed for a non‐obstructed labor indication and spontaneous labor onset was associated with higher VBAC success and favorable neonatal outcomes. Promoting VBAC, alongside careful decision‐making regarding primary CSs, may reduce long‐term maternal and neonatal risks associated with repeat CS and help mitigate the growing burden of operative deliveries in LMICs.