(1118) Modifiable Clinician-Level Factors Associated with TOLAC Counseling and Management

The sample included 107 obstetric providers: 44 attendings (41.1%), 35 midwives (32.7%), and 28 residents/fellows (26.2%). Demographics were not associated with TOLAC counseling, but profession, specialty, employment setting, and delivery site were (Table 1). Midwives and those in academic centers recommended TOLAC more often across scenarios (p< 0.001); MFM more often in higher-risk scenarios (p=0.04). Stronger beliefs that birth is natural were linked to more frequent TOLAC counseling while viewing it as medical were linked to less (Table 2). Greater litigation concerns were associated with less frequent TOLAC recommendations in higher-risk scenarios. 

Overall, 24.5% managed TOLAC vignettes to VBAC. Management was similar across demographics, but hospital- or community-employed providers (30.1%) were more likely than private/self-employed (4.3%) to manage for VBAC (p=0.01). Perceived institutional support was linked to higher VBAC rates (29.4% vs. 4.8%, p=0.02). Providers were less likely to manage for VBAC when the vignette patient was Black (14.8%) vs. White (34.6%) (p=0.02). 






Conclusion:
Provider profession, beliefs, and malpractice concerns influenced TOLAC counseling, particularly in higher risk cases. Institutional context and racial bias in clinical-decision making was evident. Findings underscore the need for interventions including bias training, standardized counseling, and supportive institutional policies to improve equity and outcomes.