Disclaimer: This content is for informational and entertainment purposes only and does not constitute medical advice. Always consult your healthcare provider about your own health and birth options.
You’ve had a cesarean. Now you’re pregnant again, staring down a whole new maze of opinions.
One provider says, “Once a C‑section, always a C‑section.”
Another says, “You’re a great VBAC candidate.”
Your friend casually mentions she had a home birth after cesarean and it “changed her life.”
If you’re here, you’re probably wondering whether a home birth after cesarean (HBAC) is even on the table, and if so, whether it’s brave, reckless, empowering, unsafe… or all of the above depending on who you ask.
This post is your deep‑dive explainer: not to tell you what to do, but to lay out what we actually know from research, what professional guidelines say, and which questions really matter when you’re thinking about HBAC.
HBAC, VBAC, TOLAC: decoding the alphabet soup
Let’s clean up the jargon first, because it’s everywhere in this conversation.
TOLAC – Trial of Labor After Cesarean: you plan to labor after a previous C‑section. No promises about how you’ll deliver; it’s about your intention to labor.
VBAC – Vaginal Birth After Cesarean: this is what you call it after the fact when a TOLAC ends in a vaginal birth.
HBAC – Home Birth After Cesarean: a planned VBAC where the intended place of birth is home (many discussions lump freestanding birth centers into a similar “community birth” bucket).
ERCS – Elective Repeat Cesarean Section: a planned C‑section in a future pregnancy, usually scheduled before labor starts.
The big idea to keep in mind:
You’re not choosing between “safe” and “dangerous” options. You’re choosing between different bundles of risk, benefit, and values: HBAC, hospital VBAC, and repeat cesarean all have trade‑offs.
Why this conversation is happening more and more
In many high‑income countries, cesarean birth rates have climbed far above the 10–15% level the World Health Organization once suggested might be “ideal” for population health. In the US, about 1 in 3 births is by cesarean.
Historically, once someone had a cesarean, they were often told they had to have repeat C‑sections. That attitude is softening:
Large studies and guidelines now support TOLAC as a reasonable option for many people with one prior low‑transverse cesarean.
Successful VBAC can mean fewer complications in this pregnancy and lower risks in future pregnancies (like dangerous placenta attachment problems) compared with multiple repeat cesareans.
At the same time, access to VBAC‑supportive hospital care is patchy. Some hospitals don’t offer TOLAC at all; others have policies that feel restrictive or coercive. That’s part of what nudges some families toward exploring HBAC.
Home and community birth are also growing
In several countries, out‑of‑hospital births (home + freestanding birth centers) have increased over the past two decades, especially among healthy, low‑risk pregnancies.
For people with a previous cesarean, HBAC is still a small minority of births but it’s growing enough that we now have:
Several large cohort studies from the UK and Canada.
A recent systematic review/meta‑analysis of VBAC in midwifery‑led settings (birth centers + home).
That means we can finally talk about HBAC with something more than vibes and horror stories.
What guidelines actually say about HBAC
Here’s where the professional bodies disagree, and where a lot of the confusion starts.
ACOG (US obstetricians): “HBAC is a no”
The American College of Obstetricians and Gynecologists (ACOG) has a 2017 Committee Opinion on planned home birth that takes a very clear stance:
ACOG considers prior cesarean an absolute contraindication to planned home birth, along with fetal malpresentation (e.g., breech) and multiple pregnancy.
At the same time, ACOG’s guidance on VBAC itself is more supportive:
They acknowledge that TOLAC is appropriate for many with one prior low‑transverse cesarean and that successful VBAC has lower maternal morbidity and fewer complications in future pregnancies than repeated cesarean.
So: VBAC in hospital = often encouraged; VBAC at home = officially no.
ACNM (US nurse‑midwives): “Informed choice, real options”
The American College of Nurse-Midwives (ACNM) takes a more nuanced approach in its 2024 position statement “Care of the Pregnant Person with a History of Cesarean Birth”:
Emphasizes shared decision‑making between pregnant person and clinician, weighing TOLAC vs elective repeat cesarean.
Notes that uterine rupture is rare (often around 0.5–0.7% with TOLAC) and that overall, vaginal birth after cesarean lowers the risks of complications in future pregnancies.
Recognizes evidence on VBAC in midwifery‑led and community settings (including HBAC in Canada and the UK).
ACNM doesn’t come out with a simple “yes, HBAC for all” or “no, never HBAC.” Instead, they treat community VBAC as something that can be considered in the context of candidate selection, integrated systems, and clear transfer pathways.
First, zoom out: how safe is VBAC in general?
Before getting into HBAC specifically, it helps to understand “typical” VBAC, since almost all the big data sets are from hospitals.
VBAC success and uterine rupture
Large studies and reviews give us some consistent numbers:
VBAC success rate – usually 60–80%, higher for those who’ve had a prior vaginal birth.
Uterine rupture (when the old scar gives way in labor):
Around 0.4–0.7% (about 1 in 150–250) in people attempting TOLAC.
Much lower (around 0.02–0.07%) with planned repeat cesarean and no labor.
A famous multicenter NEJM study (Landon et al., ~18,000 TOLACs) found:
Uterine rupture: 0.7% with TOLAC vs none in the ERCS group.
About 73% of people attempting labor delivered vaginally.
So TOLAC does slightly increase certain risks compared with a planned repeat C‑section, but the absolute risk of uterine rupture is still low.
Maternal risks: VBAC vs repeat C‑section
It’s not just about the scar.
Across multiple guidelines and reviews:
Successful VBAC tends to have:
Less blood loss.
Lower infection rates.
Fewer surgical complications.
Shorter recovery.
Failed TOLAC (labor that ends in an emergency C‑section) carries higher maternal morbidity than either ERCS or successful VBAC, because now you’ve had surgery after a long/complicated labor.
Multiple repeat cesareans increase the risk of problems like placenta previa and placenta accreta in later pregnancies, which can be life‑threatening and often require complex surgery or hysterectomy.
Baby’s risks: VBAC vs repeat C‑section
When researchers compare babies born after TOLAC vs ERCS:
Serious outcomes like perinatal death are:
Lower with ERCS.
Slightly higher with TOLAC, largely driven by the small number of uterine ruptures.
Importantly, the absolute numbers are still low, and TOLAC risks are comparable to those of a first‑time labor with no previous cesarean.
So: hospital VBAC is a respectable, evidence‑supported option. The real controversy kicks in when you add “at home” to the mix.
What the research says specifically about HBAC
Here’s the awkward truth: we don’t have as much HBAC data as VBAC‑in‑hospital data. But we do have some large, decent studies to work with.
Canada: HBAC in an integrated midwifery system (Bayrampour et al. 2021)
In British Columbia, Canada, midwives are regulated and part of the provincial health system. A 2021 study looked at 4,741 people with at least one prior cesarean:
4,180 planned hospital VBAC.
561 planned home VBAC (HBAC), all attended by registered midwives.
Key findings:
Planned HBAC was associated with a 39% lower odds of cesarean birth compared with planned hospital VBAC (adjusted OR 0.61, 95% CI 0.47–0.79).
Severe adverse outcomes (serious maternal or neonatal complications) were very rare in both groups, and the study wasn’t big enough to clearly detect differences in extremely rare events like uterine rupture or neonatal death.
Take‑home: in this integrated setting, HBAC was linked to more vaginal births and no obvious spike in bad outcomes—but the sample size means we can’t rule out small differences in rare complications.
England: home VBAC in the Birthplace cohort (Rowe et al. 2015)
In the UK Birthplace study, researchers looked at people planning VBAC either at home or in an obstetric unit:
209 planned HBAC.
1,227 planned VBAC in obstetric units.
They found:
People planning HBAC were more likely to have a vaginal birth than those planning VBAC in hospital.
Transfer rates from home to hospital were high, especially for those who had only had one previous birth.
The risk of a serious adverse outcome for parent or baby was about 2–3% in both groups.
The authors explicitly said there wasn’t enough evidence to change official guidance, but they didn’t find HBAC to be wildly more dangerous within this system.
2024 systematic review: VBAC in midwifery‑led settings (Parslow et al.)
A 2024 review pulled together VBAC planned in midwifery‑led settings (birth centers and home) vs obstetric‑led care. Essentially, it combined the Canadian and English data above.
Broad conclusions:
Midwifery‑led VBAC (including HBAC) was linked to:
Higher rates of vaginal birth.
Fewer interventions (operative birth, cesarean).
Serious complications were rare across all settings, and the relative risk of uterine rupture was about 1.0, with very wide confidence intervals (meaning it could be a bit higher or lower, and we can’t say for sure).
So far, so cautiously encouraging—in these particular health systems.
US registry data: out‑of‑hospital VBAC outcomes
Things look more worrying in some US data. A national cohort (using birth certificates) compared babies born after VBAC in hospital vs out of hospital (home + freestanding birth centers).
It found higher rates of certain serious outcomes for out‑of‑hospital VBAC babies, including:
Higher rates of low Apgar scores.
Higher rates of neonatal seizures.
And the increased risk seemed strongest among people having their second baby with no prior vaginal birth.
Why might this differ from Canada/UK?
The US has a patchwork system: different midwifery credentials, variable integration with hospitals, and sometimes strained transfer relationships.
Where midwives are well integrated and regulated, outcomes appear more similar to hospital care. Where they’re not, the safety net is weaker.
That “system context” piece turns out to matter a lot.
So… is HBAC safe?
Short, honest answer:
HBAC is neither guaranteed safe nor automatically reckless.
In integrated midwifery systems (like parts of Canada and the UK), HBAC for carefully chosen candidates appears to have:
Similar rates of severe complications as hospital VBAC.
Higher odds of vaginal birth and fewer interventions.
In uneven systems (like much of the US), out‑of‑hospital VBAC is associated with higher rates of serious neonatal complications compared with in‑hospital VBAC, particularly for people without a prior vaginal birth.
That’s why different organizations come down in different places: they’re looking at the same small pool of data, but through different lenses of liability, values, and acceptable risk.
Who might be a lower‑risk HBAC candidate?
No blog can tell you definitively “yes, you’re a candidate.” That’s a conversation with a clinician who knows your history.
But research and guidelines do point to patterns. People more likely to have a safer and successful VBAC—whether at home or in hospital—often have:
One prior low‑transverse cesarean (the most common type).
At least one prior vaginal birth, especially a prior VBAC (this lowers uterine rupture risk and increases VBAC success).
A healthy, singleton baby in head‑down position at term.
Spontaneous labor (rather than induction or strong augmentation). Induction—especially with certain medications—has been linked to higher uterine rupture risk in TOLAC.
No major medical issues that make urgent surgery especially risky.
Reasonable proximity to a hospital with an operating theatre and blood bank, plus a clear plan for transfer.
In the Canadian HBAC study and UK Birthplace data, people who looked a lot like this group did relatively well in either setting.
Who is usually not a good HBAC candidate?
Again, this is educational, not bespoke medical advice—but most guidelines consider HBAC especially high‑risk (or outright contraindicated) if you have:
A prior classical, T‑shaped, or high vertical uterine incision.
A history of prior uterine rupture.
Placenta previa or suspected placenta accreta.
Significant medical conditions where quick surgical access is crucial.
Twins or more, or a breech baby (these alone are considered contraindications to home birth by ACOG, even without a scar).
No prior vaginal birth, especially if this is your second baby and your previous cesarean was for “labor not progressing” or “baby wouldn’t fit.”
Many midwives who do support HBAC will be especially cautious—or say no altogether—if:
You’re far from a hospital with surgical capacity.
Your local system has poor transfer relationships (e.g., hospitals routinely refuse handover or delay care for midwifery clients).
You need induction/strong augmentation and don’t have access to safe, evidence‑based protocols in a home setting.
Why some people still choose HBAC anyway
If hospital VBAC is generally safer and more supported by guidelines, why do some people still plan HBAC?
From qualitative studies and HBAC‑specific resources, common themes include:
Previous traumatic hospital experiences
– Feeling ignored, pressured, or coerced into a cesarean or interventions.
– Experiencing obstetric violence or racism.Lack of local VBAC access
– Hospital bans on VBAC.
– Policies requiring “immediately available” anesthesia or surgery that hospitals use to say “no” to TOLAC, even for good candidates.Desire for continuity and control
– Wanting to know who will be at the birth.
– Wanting more freedom of movement, fewer routine interventions, and a quieter environment.Deep trust in a known midwife
– Some people feel safer with a midwife they know intimately, even knowing the transfer risks, than with a rotating cast of hospital staff.
From a systems point of view, it’s not that these people don’t understand risk. It’s that they’re looking at a broader definition of safety that includes emotional, psychological, and cultural safety, not just surgical response time.
Questions to ask if you’re exploring HBAC
If HBAC is on your radar, here are some concrete questions that can turn vague feelings into clearer decisions:
About your own health and history
What type of uterine incision did you have?
Why was your prior cesarean done? Has anything changed since then?
Have you had any vaginal births (before or after the cesarean)?
Do you have any medical issues (bleeding disorders, high blood pressure, etc.) that could matter in an emergency?
About your local system
Are midwives in your area licensed/regulated and part of an integrated system?
How far are you, in real‑life traffic and weather, from a hospital that can do an emergency C‑section 24/7?
How do transfers usually work? Are there stories of collaboration… or hostility?
About the midwife/team offering HBAC
How many HBACs have they attended?
What are their transfer rates and reasons for transfer?
What equipment and medications do they carry (e.g., for postpartum hemorrhage, neonatal resuscitation)?
How do they monitor labor progress and fetal well‑being?
How quickly can they activate a transfer if something looks off?
A good midwife or obstetric provider should welcome these questions. If you feel shamed just for asking, that’s useful data about your care environment.
Building a safer plan, whatever you choose
Even if you ultimately decide “no, HBAC is not right for me,” exploring it can help you clarify what you do want—and advocate for that in a hospital VBAC or planned repeat C‑section.
Helpful steps:
Ask for a copy of your prior op note
– This tells you what type of uterine incision you had and whether there were complications that might affect future births.Request a truly balanced VBAC vs ERCS conversation
– Bring someone with you, bring notes, and ask your provider to talk through short‑ and long‑term risks for both you and the baby. Guidelines like the ACNM statement explicitly frame this as a shared decision, not a one‑way decree.Clarify your non‑negotiables
– Continuous support? Freedom to move? Hydrotherapy? Intermittent monitoring? Delayed cord clamping?
– Many of the things people seek in HBAC can, in some settings, be negotiated in hospital too.Have a “Plan B” and “Plan C” in writing
– If you’re pursuing HBAC, spell out circumstances in which you want to move to the hospital.
– If you’re planning hospital VBAC, discuss what happens if induction becomes recommended or labor stalls—so decisions under stress aren’t made in a panic.
Putting HBAC in perspective
When you strip away the drama, here’s where the evidence tends to land:
VBAC in general
– Often safer for the birthing person in the long run than multiple repeat cesareans, especially if successful.
– Carries a small but real risk of uterine rupture and slightly higher perinatal risk compared with planned repeat cesarean.HBAC in integrated midwifery systems
– For carefully selected candidates, appears to have similar severe outcome rates as hospital VBAC, more spontaneous vaginal births, and fewer interventions—but the data are limited, and rare bad outcomes are hard to measure.Out‑of‑hospital VBAC in fragmented systems (like much of the US)
– Linked with higher rates of serious neonatal complications than hospital VBAC, especially for people without a prior vaginal birth.
Overlay all of that with:
Your own medical history and scar type.
How far you live from a hospital.
How midwives and hospitals work together (or don’t) where you live.
Your values, trauma history, fears, and hopes for this birth.
That mix is what turns research findings into a personal decision.
Final thoughts: informed choice in a messy world
HBAC isn’t just about “how many minutes to an operating room.” It’s about how you want to give birth while carrying the reality of risk honestly.
The research, limited as it is, tells us a few important truths:
HBAC is not uniformly catastrophic. In some systems, with regulated midwives and clear transfer plans, outcomes look a lot like hospital VBAC.
On the other hand, out‑of‑hospital VBAC without strong system support can carry higher risks for babies, and professional bodies like ACOG are not making up their concerns out of thin air.
Most importantly, no option is perfectly safe. Planned repeat cesarean, hospital VBAC, and HBAC all have different risk profiles and emotional landscapes.
Your job isn’t to find the zero‑risk path (it doesn’t exist). It’s to find the path where you:
Understand the evidence as well as you reasonably can.
Have care providers who respect your autonomy and tell you the truth.
Feel as physically, emotionally, and culturally safe as possible within your real‑world context.
If reading about HBAC pushes you toward a hospital VBAC with a midwife you trust, that’s a win. If it equips you to push back against blanket “once a C‑section, always a C‑section” messages, also a win. And if, in a well‑supported setting, it helps you plan a thoughtful HBAC with clear backup, that’s another way informed choice can look.
The real goal isn’t “HBAC for everyone” or “HBAC for no one.” It’s better information, kinder systems, and genuine respect for birthing people’s decisions—wherever those decisions lead.
