The Missing Competency: How US Midwifery Programs Have Failed to Prepare Providers for VBAC Support
A Competency Gap Hidden in Plain Sight
Every year, hundreds of thousands of pregnant people in the United States carry a uterine scar into a new pregnancy. According to data from the Centers for Disease Control and Prevention, the national cesarean delivery rate has hovered above 30 percent for well over a decade. That means a substantial and growing proportion of the birthing population is eligible to consider vaginal birth after cesarean—yet the providers tasked with guiding those conversations are frequently underprepared to have them.
The problem does not begin at the bedside. It begins in the classroom.
Across accredited nurse-midwifery and direct-entry midwifery programs in the United States, VBAC education is treated less as a core clinical competency and more as a supplementary topic—something addressed in a lecture module, a readings list, or a brief clinical rotation addendum. Students may graduate with a thorough grounding in pharmacological pain management, fetal monitoring interpretation, and postpartum hemorrhage protocols, yet possess only a cursory understanding of uterine scar assessment, VBAC candidacy criteria, or the evidence-based communication strategies required to support families navigating this decision.
The consequences of this gap are not abstract. They are measurable in the repeat cesarean rate—which, despite evidence supporting VBAC safety in appropriately selected candidates, continues to rise.
What the Evidence Actually Says
The clinical literature on VBAC is neither new nor ambiguous. Research published over the past three decades consistently demonstrates that, for carefully selected candidates, a trial of labor after cesarean (TOLAC) carries a high likelihood of success and a risk profile that compares favorably to elective repeat cesarean section in many clinical scenarios.
The American College of Obstetricians and Gynecologists has repeatedly affirmed VBAC as a reasonable and appropriate option for eligible patients, noting that the risk of uterine rupture in candidates with a single low-transverse uterine incision is approximately 0.5 to 0.9 percent. That figure must be contextualized against the cumulative risks of multiple cesarean deliveries—including placenta accreta spectrum disorders, bowel and bladder injury, and increased maternal mortality with each subsequent surgery.
Yet this evidence rarely drives curriculum design. When midwifery educators are asked to account for the limited depth of VBAC content in their programs, the explanations offered tend to converge on a familiar cluster of pressures: institutional risk aversion, malpractice liability concerns, hospital credentialing restrictions, and the reality that many clinical training sites simply do not support TOLAC. The curriculum, in other words, reflects the environment rather than the evidence.
How Defensive Medicine Culture Shapes Midwifery Education
Understanding why VBAC training has been marginalized requires a candid look at the medicolegal landscape that shapes obstetric practice in the United States. The fear of litigation following uterine rupture—even when rupture occurs in a well-managed, appropriately monitored labor—has contributed to a culture of institutional restriction that cascades directly into training environments.
Many hospital-based clinical sites have adopted policies that effectively prohibit TOLAC, either outright or by imposing conditions—such as mandatory anesthesia availability and continuous in-house surgical capability—that smaller or rural facilities cannot meet. When midwifery students complete the majority of their clinical hours at institutions with such restrictions, they graduate without meaningful exposure to VBAC labor management, regardless of what their didactic curriculum covers.
Insurance dynamics compound this problem. Some malpractice carriers have historically imposed surcharges on providers who attend TOLAC, creating a financial disincentive that discourages even those with adequate training from offering this care. When program directors are aware that their graduates will face these structural barriers in practice, the implicit logic of de-emphasizing VBAC training—why teach what students may never be permitted to do?—becomes easier to understand, if not easier to defend.
The result is a self-reinforcing cycle. Providers are undertrained, which limits institutional willingness to support VBAC, which reduces clinical training opportunities, which produces another generation of undertrained providers.
What Evidence-Based VBAC Training Must Actually Include
Breaking this cycle requires more than adding a lecture to an existing module. Genuine VBAC competency demands a structured, multidimensional curriculum that addresses clinical, communicative, and advocacy dimensions of care.
Clinical risk assessment and candidacy criteria. Providers must be able to accurately evaluate VBAC eligibility, including scar type and number, interpregnancy interval, gestational age, estimated fetal weight, and the presence of prior vaginal delivery—all variables that meaningfully influence success rates and risk profiles. Validated tools such as the Maternal-Fetal Medicine Units Network VBAC calculator should be part of standard didactic instruction.
Intrapartum monitoring and uterine rupture recognition. Early identification of rupture signs—including the oft-cited but clinically nuanced finding of fetal heart rate decelerations, maternal tachycardia, and loss of uterine contraction pattern—is a life-saving competency. This content deserves simulation-based training, not a single paragraph in a textbook.
Informed consent and shared decision-making. Families pursuing VBAC frequently encounter providers who present the option with explicit or implicit bias toward repeat cesarean. Midwifery students must be trained to present balanced, evidence-based information without projecting institutional preferences onto patients. This includes understanding how to communicate absolute versus relative risk in language that is accessible to patients with varying health literacy.
Navigating institutional barriers on behalf of patients. Not every graduate will practice in a VBAC-supportive environment. Training programs have a responsibility to prepare students to advocate for patients within restrictive systems—including knowing when and how to facilitate appropriate referrals, document patient preferences, and engage with hospital policy processes.
Continuity across the care continuum. VBAC preparation is not a third-trimester conversation. It begins with prenatal counseling that addresses scar healing, birth preferences, and realistic expectations. Programs should teach students to integrate VBAC planning into longitudinal prenatal care rather than treating it as a late-pregnancy checklist item.
Rethinking What Midwifery Programs Owe Their Students
Midwifery education in the United States is built on a foundational commitment to physiologic birth—to the principle that normal labor and delivery, when supported skillfully and respectfully, produces better outcomes for most people than routine medical intervention. VBAC is not a fringe application of that principle. It is one of its most significant expressions.
When programs fail to train students in VBAC support, they are not simply omitting a clinical skill. They are communicating, implicitly, that the repeat cesarean is the default—that the uterine scar is a permanent reclassification rather than a variable in a nuanced clinical picture. That message is inconsistent with the evidence, inconsistent with patient autonomy, and inconsistent with the foundational values that midwifery education claims to uphold.
Accreditation bodies, program directors, and clinical site coordinators all bear responsibility for closing this gap. Requiring meaningful VBAC competency—not as an elective enrichment but as a graduation requirement—is a concrete and achievable step. Expanding partnerships with VBAC-supportive clinical sites, integrating simulation-based rupture recognition training, and explicitly addressing the medicolegal culture that discourages this care are equally necessary.
The families who arrive at a subsequent pregnancy carrying a cesarean scar deserve providers who are fully equipped to walk that path with them. Training programs that fail to provide that preparation are not protecting anyone from risk. They are simply transferring it—from institutions onto patients.
