Vaginal birth after caesarean: Views of women from countries with low VBAC rates

Providers' perspective on vaginal birth after cesarean birth: a qualitative systematic review

BACKGROUND

Vaginal Birth after Cesarean Birth (VBAC) is a birth mode recommended for reducing repeat cesarean which potentially contributes to adverse outcomes. However, VBAC is not normally practiced in some countries. Providers are an important part of the decision-making process on modes of birth among pregnant individuals. Providers' perspective on VBAC can influence whether they support or avoid conducting VBAC. This review aimed to explore providers' perspective on VBAC.

METHODS

The comprehensive search was conducted from six databases including PubMed, MEDLINE, Scopus, Cochrane Library, EMBASE, and Google scholar. The studies published in English between 2013 and 2023 were review. The Medical Subject Heading terms for VBAC and perspective were used to search. The eligible studies were selected by the PRISMA flow chart. The initial search yielded 558 articles. After excluding duplicates, articles not retrieved for full-text, and not meeting inclusion and exclusion criteria, eight articles were recruited. Quality appraisal of the studies was performed by the tool of the Joanna Briggs Institute. The meta-aggregation approach was applied to synthesize the findings.

RESULTS

Eight qualitative articles were included in this review, and six themes were developed including (1) different recognition of VBAC, (2) differences of willingness level of conducting Trial of Labor after Cesarean (TOLAC) (the approach attempting to have VBAC), (3) skills and resources needed when performing TOLAC, (4) protocol for recruiting candidacy and TOLAC management, (5) final decision making on VBAC, and (6) onset and duration of providing TOLAC information.

CONCLUSION

Providers play an important role in influencing individuals' decision on modes of birth. Providers' positive recognition and willingness of conducting TOLAC potentially impact successful VBAC rate. However, the lawsuit caused by adverse outcomes from TOLAC/VBAC is a main reason for choosing repeat cesarean.

TRIAL REGISTRATION

PROSPERO registration number of this systematic review: CRD42023427662.

Barriers and facilitators of choosing a vaginal birth after cesarean: A mixed-methods systematic review

BACKGROUND

Vaginal birth after cesarean is an effective way of reducing cesarean section rates and preventing a variety of short- and long-term complications associated with cesarean deliveries. Additionally, vaginal birth after cesarean can enhance breastfeeding rates, expedite postpartum recovery, and minimize hospitalization duration for women. Despite these benefits, the prevalence of vaginal birth after cesarean remains low in many countries, and only limited reviews have investigated the factors contributing to the low vaginal birth after cesarean rates.

OBJECTIVES

This review aims to explore the barriers and facilitators influencing decision-making during the process of vaginal birth after cesarean.

DESIGN

A mixed-methods systematic review.

METHODS

Ten electronic databases were systematically and comprehensively searched for qualitative, quantitative, and mixed-methods studies. Two reviewers critically appraised the eligible studies independently using the Joanna Briggs Institute Critical Appraisal Tool. We converted quantitative findings to narrative form and employed a convergent synthesis design to synthesize the data thematically.

RESULTS

This review included 55 studies published between 2002 and 2024. These studies originated from 19 countries and comprised 21 quantitative studies, 31 qualitative studies, and three mixed-methods studies. The methodological quality of the included studies was assessed as moderate to high. We divided the barriers and facilitators influencing vaginal birth after cesarean decision-making into four categories and nine subcategories: individual factors of pregnant women (sociodemographic characteristics, physiological factors, cognition, and psychological factors); interpersonal relationships (emotional support and communication); healthcare system factors (healthcare professionals' acceptance and commitment to action as well as healthcare facilities); and social factors (culture and ethnicity, along with law and policy).

CONCLUSIONS

This study broadens the understanding of the various factors that influence vaginal birth after cesarean decisions and may provide valuable insights for future modifications in vaginal birth after cesarean practices to enhance its availability for women. We conclude that successful implementation of vaginal birth after cesarean requires the concerted efforts of all stakeholders. Hospitals should improve the quality of care, enhance the capacity of the healthcare system to support vaginal birth after cesarean, and respect the preferences of pregnant women by providing support and encouraging their active participation in decision-making.

REGISTRATION

This systematic review was registered in PROSPERO on June 24, 2022 (CRD42022339434).

Identifies Current Trends in Vaginal Birth after Cesarean Section in IRAN: A Qualitative Study

Background

The growing prevalence of Cesarean Sections (CS), particularly repeated CS, is a major issue in contemporary midwifery. This study seeks to gain a comprehensive understanding of the experiences of pregnant women and specialists with vaginal delivery after CS, as well as the obstacles that may arise.

Materials and Methods

From March 2020 to May 2021, 10 women, 12 midwives, and 8 obstetricians and obstetricians affiliated with Qom University of Medical Sciences were interviewed to investigate the experiences and challenges associated with Vaginal Birth After Cesarean section (VBAC). We used the content analysis method, and the sampling was purposive. Semi-structured interviews were conducted to collect data, which were then analyzed using qualitative content analysis based on conventional content analysis.

Results

The results show that subcategories "individual aspects of VBAC" and "family-social aspects of VBAC" formed "positive aspects of VBAC." Subcategories "self-efficacy" and "decision-making participation" formed the "empowerment for the woman." Subcategories "technical team challenges" and "woman's challenges" formed the main category of "upcoming challenges."

Conclusions

Positive relationships, choice-making ability, and self-confidence impact a woman's decision to choose VBAC. Informing women of alternative delivery options after a CS and pursuing their dreams increases the likelihood of successful VBAC.

Translation and validation of the Czech Republic version of the Birth Satisfaction Scale-Revised (BSS-R)

BACKGROUND

Satisfaction with the birth experience has been established to be critical for the wellbeing of the mother. The Birth Satisfaction Scale-Revised (BSS-R) is a brief and psychometrically robust multi-dimensional self-report tool designed to assess birth experience. The current investigation sought to translate and validate a Czech Republic version of the BSS-R (CZ-BSS-R).

METHODS

Following translation psychometric assessment of the CZ-BSS-R was undertaken using a cross-sectional design. A between-subjects design was incorporated in order to evaluate known-groups validity evaluation of the translated measure. Four hundred and sixty-five Czech-speaking women within the Czech Republic took part in the study. Confirmatory factor analysis was undertaken and divergent and convergent validity and internal consistency characteristics also evaluated.

RESULTS

The CZ-BSS-R was observed to have excellent psychometric properties and conceptually and measurement faithful to the original English-language measure. Consistent with previous investigations using the BSS-R significant differences were found in scores as a function of delivery type.

CONCLUSIONS

The CZ-BSS-R is a valid, robust and reliable measure of birth experience and suitable for use with Czech-speaking women in the Czech Republic. The study highlighted that instrument and emergency Caesarean section were associated with a lower level of birth satisfaction compared to vaginal delivery.

Women's experiences of birth and birth options counselling after laparoscopic or open myomectomy

There is emerging evidence that vaginal birth after open and laparoscopic myomectomy may be safe in many pregnancies, however, there are no studies examining the perspectives of women who have given birth post myomectomy and their preferences regarding mode of birth. We performed a retrospective questionnaire survey of women who had an open or laparoscopic myomectomy followed by a pregnancy within 3 maternity units in a single NHS trust in the UK over a 5-year period. Our results revealed only 53% felt actively involved in the decision making for their birth plan and 90% had not been offered a specific birth options counselling clinic. Of those who had either a successful trial of labour after myomectomy (TOLAM) or elective caesarean section (ELCS) in the index pregnancy, 95% indicated satisfaction with their mode of birth however, 80% would prefer vaginal birth in a future pregnancy. Whilst long term prospective data is required to fully establish the safety of vaginal birth after laparoscopic and open myomectomy, this study is the first to explore the subjective experiences of women who had given birth post laparoscopic or open myomectomy and has highlighted the inadequate involvement of these women in the decision-making process.IMPACT STATEMENTWhat is already known on this subject? Fibroids are the commonest female solid tumours in women of childbearing age with surgical management including open and laparoscopic excision techniques. However, the management of a subsequent pregnancy and birth remains controversial with no robust guidance on which women may be suitable for vaginal birth.What do the results of this study add? We present the first study to our knowledge which explores women's experiences of birth and birth options counselling after open and laparoscopic myomectomy.What are the implications of these findings for clinical practice and/or further research? We provide a rationale for using birth options clinics to facilitate an informed decision-making process and highlight the current inadequate guidance for clinicians on how to advise women having a pregnancy following a myomectomy. Whilst long term prospective data is required to fully establish the safety of vaginal birth after laparoscopic and open myomectomy, this needs to be carried out in a way which promotes the preferences of the women affected by this research.

Vaginal birth after cesarean section: A quantitative study exploring women's understanding and experience regarding VBAC rates in Greece

INTRODUCTION

Vaginal birth after cesarean section (VBAC) is a choice of birth that provides many advantages for women. This study presents women's VBAC experience in a Greek population. The study's aims were mainly to determine the reasons for choosing VBAC, women's feelings during pregnancy and their experience, and level of post-birth satisfaction.

METHODS

This study is sampling research which has a cross-section retrospect study design. The study was held via the internet due to a self-administered questionnaire which is comprises both open-ended and close-ended questions. Data analysis was performed in S.P.S.S. 20 and Microsoft Excel.

RESULTS

A total number of 473 women participated in this study. The findings showed that during pregnancy and childbirth over 50% of women felt very happy and satisfied, while 35% to 40% felt moderate or no fear at all. Furthermore, 96.48% of them would attempt for a VBAC birth again while 97.36% would recommend this way of delivery to other women. There was a total of 78.85% of succeeded VBAC. The main reason for women to choose VBAC for a birth option were the desire for a normal birth (23.1%), the thought of vaginal birth as the normal way of giving birth (22.4%), to avoid another surgery (14.2%) and to experience a vaginal birth (10%).

CONCLUSIONS

VBAC is an option that needs to be offered more in Greece, and needs improvement in obtaining informed consent in obstetric care services. More studies are required to draw further conclusions.

Predictors and trends of Caesarean section and breastfeeding in the Eastern Mediterranean region: Data from the cross-sectional Cyprus Women's Health Research (COHERE) Initiative

INTRODUCTION

Caesarean section (C-section) is a life-saving procedure when medically indicated but unmet need and overuse can add to avoidable morbidity and mortality. It is not clear whether C-section has a negative impact on breastfeeding and there is limited data available on rates of C-section or breastfeeding from Northern Cyprus, an emerging region in Europe. This study aimed to investigate prevalence, trends and associations of C-section and breastfeeding in this population.

METHODS

Using self-reported data from the representative Cyprus Women's Health Research (COHERE) Initiative, we used 2,836 first pregnancies to describe trends in C-section and breastfeeding between 1981 and 2017. Using modified Poisson regression, we examined the relationship between year of pregnancy and C-section and breastfeeding, as well as the association between C-section and breastfeeding prevalence and duration.

RESULTS

C-section prevalence in first pregnancies increased from 11.1% in 1981 to 72.5% in 2017 with a relative risk of 2.60 (95%CI; 2.14-2.15) of babies being delivered by C-section after 2005 compared to before 1995, after full adjustment for demographic and maternal medical and pregnancy related factors. Prevalence of ever breastfeeding remained steady throughout the years at 88.7% and there was no significant association between breastfeeding initiation and the year of pregnancy, or demographic and maternal medical and pregnancy related variables. After full adjustment, women who gave birth after 2005 were 1.24 (95%CI; 1.06-1.45) times more likely to breastfeed for >12 weeks compared to women who gave birth before 1995. There was no association between C-section and breastfeeding prevalence or length.

CONCLUSION

Prevalence of C-section in this population is much higher than WHO recommendations. Public awareness campaigns surrounding choice during pregnancy and change in legal framework to allow for midwife-led continuity models of birthing care should be implemented. Further research is required to understand the reasons and drivers behind this high rate.

"Because it eases my Childbirth Plan": a qualitative study on factors contributing to preferences for caesarean section in Thailand

BACKGROUND

Although caesarean section (CS) rates have increased rapidly in Thailand, the upward trend is not supported by significant maternal or perinatal health benefits. The appropriate use of CS through QUALIty DECision-making by women and providers (QUALI-DEC project) aims to design and implement a strategy to optimize the use of CS through non-clinical interventions. This study aimed to explore the factors influencing women's and health professionals' preferences for CS delivery in Thailand.

METHODS

We conducted a formative qualitative study by using semi-structured in-depth interviews with pregnant and postpartum women, and healthcare staff. Purposive sampling was used to recruit participants from eight hospitals across four regions of Thailand. Content analysis was used to develop the main themes.

RESULTS

There were 78 participants, including 27 pregnant and 25 postpartum women, 8 administrators, 13 obstetricians, and 5 interns. We identified three main themes and seven sub-themes of women and healthcare providers' perceptions on CS: (1) avoiding the negative experiences from vaginal birth (the pain of labor and childbirth, uncertainty during the labor period); (2) CS is a safer mode of birth (guarantees the baby's safety, a protective shield for doctors); and (3) CS facilitates time management (baby's destiny at an auspicious time, family's management, manage my work/time).

CONCLUSIONS

Women mentioned negative experiences and beliefs about vaginal delivery, labor pain, and uncertain delivery outcomes as important factors influencing CS preferences. On the other hand, CS is safer for babies and facilitates multiple tasks in women's lives. From health professionals' perspectives, CS is the easier and safer method for patients and them. Interventions to reduce unnecessary CS, including QUALI-DEC, should be designed and implemented, taking into consideration the perceptions of both women and healthcare providers.

Cesarean section in Uruguay from 2008 to 2018: country analysis based on the Robson classification. An observational study

BACKGROUND

The use of caesarean section has steadily increased, with Latin America being the region with the highest rates. Multiple factors account for that increase and the Robson classification is appropriate to compare determinants at the clinical level for caesarean section rates over time. The purpose of this study is to describe the evolution of caesarean section rates by Robson groups in Uruguay from 2008 to 2018 using a country level database.

METHODS

We included the records of all women giving birth in Uruguay (pregnancies ≥22 weeks and weights ≥500 g) with valid data in the mode of childbirth recorded in the Perinatal Information System database between 2008 and 2018. Caesarean section rates were calculated by Robson groups for each of the years included, disaggregated by care sector (public/private) and by geographical area (Capital City/Non-Capital), with time trends and their significance analyzed using linear regression models.

RESULTS

Of the total 485,263 births included in this research, the overall caesarean section rate was 43,1%. In 2018, among the groups at lower risk of caesarean section (1 to 4), the highest rates were seen in women in group 2B (98,8%), followed by those in group 4B (97,9%). A significant increase in the number of caesarean sections was seen in groups 2B (97,9 to 98,8%), 3 (8,36 to 11,1%) and 4 (A (22,7 to 26,9%) and B (95,4 to 97,9%) Significant growth was also observed in groups 5 (74,3 to 78,1%), 8 (90,6 to 95,5%), and 10 (39,1 to 46,7%). The private sector had higher rates of caesarean section for all groups throughout the period, except for women in group 9. The private sector in Montevideo presented the highest rates in the groups with the lowest risk of caesarean section (1, 2A, 3 and 4A), followed by the private sector outside of the capital.

CONCLUSION

Uruguay is no exception to the increasing caesarean section trend, even in groups of women who have lower risk of requiring caesarean section. The implementation of interventions aimed at reducing caesarean section in the groups with lower obstetric risk in Uruguay is warranted.

Women's views and preferences regarding the mode of birth after cesarean section: Polish cross-sectional web-based survey

OBJECTIVE

Currently, the most common indication for cesarean section is a previous cesarean section. Some of them are performed for no medical reasons. Therefore, it is crucial to recognize the preferences and expectations of women concerning birth after cesarean section. This study's main aim was to understand the women's points of view on the mode of birth after cesarean.

STUDY DESIGN

A cross-sectional study was conducted, and data was collected using an original structured online questionnaire. The study group consisted of 733 pregnant Polish women who had previously undergone a cesarean birth.

RESULTS

Women more often preferred vaginal birth after cesarean section (73.26%) and less frequently (23.33%) chose elective cesarean section. Women preferring VBAC when making decisions were guided by the benefits, opportunities, and risks associated with each mode of birth. For women preferring elective cesarean section the only highly significant factor was the experience of previous deliveries. Women mainly use Internet sources and the support of other women giving birth after cesarean section. More than half of the women did not talk about the mode of birth with their midwife, and every fifth did not talk about it with the obstetrician.

CONCLUSION

Obstetric history and personal beliefs about birth after cesarean section, motivations, and concerns about childbirth affect women's preferences regarding the mode of birth. It is necessary to educate women, in particular, talks about the opportunities and risks associated with cesarean birth carried out by the medical staff at an early stage of pregnancy.

A Retrospective Study of the Association of Repeated Attempts at Trial of Labor After Cesarean Birth on Maternal and Neonatal Outcomes

Purpose

To assess the maternal and neonatal outcomes of repeated trials of labor after one previous cesarean section.

Materials and Methods

We identified and reviewed the records of all women who had had a trial of labor after cesarean section at a tertiary care center in Saudi Arabia between January 1, 2011, and December 30, 2018. The inclusion criteria were women with singleton vertex pregnancies between 24 and 42 weeks of gestation and a trial of labor after one cesarean section. The exclusion criteria were two or more previous cesarean sections, intrauterine fetal demise, breech presentation, labor induction, estimated fetal weight >4 kg, and classical or low vertical uterine incision. The pregnancy outcomes of these women were compared according to the number of trials of labor after cesarean section.

Results

During the study period, 1139 women met the inclusion criteria. The number of women with previous zero, one, two, or three or more trials of labor after cesarean section were 669 (58.7%), 237 (20.8%), 132 (11.6%), and 101 (8.9%), respectively. There were statistically significant trends between the four groups in age, nationality, gravidity, and parity but not in the booking status, BMI, or the hemoglobin level before a trial of labor after cesarean section. The rate of vaginal birth after cesarean section increased significantly (p<0.001) from 72.9% with zero to 93.3% with one, 93.9% with two, and 94.1% with three or more trials of labor after cesarean section.

Conclusion

Previously successful vaginal births after cesarean delivery are associated with improved maternal and neonatal outcomes in the subsequent trials of labor after cesarean delivery.

Women's experiences of VBAC in Cyprus: a qualitative study

BACKGROUND AND AIM

In 21st century, there has been an increasing interest in vaginal birth after previous caesarean section (VBAC) in Cyprus, a country with a very high operative birth rate. Research-based evidence of women's VBAC experiences in Cyprus is non-existent, despite its significance for the well-being of mothers and families. The aim of this study is to gain insight into the women's lived experience of VBAC in Cyprus. In this study women's experiences of VBAC are explored for the first time in Cyprus.

METHOD

The study is qualitative and exploratory in nature. Data were collected through semi-structured interviews with 10 women, who experienced vaginal birth after a previous caesarean section (VBAC) in Cyprus. A descriptive phenomenological approach was employed for the analysis of data.

RESULTS

Analysis of data yielded four major themes: (a) medicalization of childbirth, (b) preparing for a VBAC, (c) birth environment, and (d) healing through VBAC. On the whole, the women interviewed described their previous experience of CS as traumatic, in contrast to vaginal childbirth. VBAC was considered an utterly positive experience that made the women feel empowered and proud of themselves.

CONCLUSION

This study offers valuable insight into a newly researched subject in Cyprus, which is necessary for advancing perinatal care in Cyprus. The findings indicate that women need evidence-based information, guidelines on birthing options, good preparation with tailored information and personalized care for a successful vaginal birth after a previous caesarean section. Proper, non-biased, consultations are a main factor that affects women's choice of mode of birth. The introduction of new, women-friendly perinatal strategies that respect and promote childbirth rights is imperative in the case of Cyprus. All women have the right to exercise informed choice and the choice to alternative birthing options.

Women's views of birth after cesarean section

BACKGROUND

Vaginal birth is a safe mode of childbirth for the majority of women after cesarean section (CS). However, data show that women who have undergone a CS are more likely to have an elective CS (ECS) than a vaginal birth after CS (VBAC) in many areas of the world.

AIM

This study aimed to review the literature about women's mode of birth preferences and attitudes and the underlying reasons for, and factors associated with, their preferences.

METHODS

This is narrative literature review. PubMed/MEDLINE and Scopus databases were searched, limiting the results to non-interventional studies published between 1990 and 2020. Twenty-one articles were included in the analysis.

RESULTS

The review found 34 different factors that influence women's preferences. Five factors influenced both VBAC and ECS preference, depending on the study. The most common factors having a dualistic effect on preference were: medical staff recommendation, doctor's opinion, and fear of pain. The most common factors were: desire to experience natural childbirth, faster/easier recovery, support from doctor's, and midwife's opinion. Among the factors influencing the preference for ECS, two were particularly prominent: predictability, controllability and comfortability of CS and the belief that CS is safer for the baby and/or mother.

CONCLUSIONS

Our review showed that there are a variety of factors that influence women's preference for the mode of delivery after CS. Some of these have a dualistic effect according to the study. The key to making an informed decision regarding the mode of delivery is communication with medical professionals.

Midwifery continuity of care and vaginal birth after caesarean section: A randomised controlled trial

PROBLEM AND BACKGROUND

Caesarean section (CS) rates in Australia and many countries worldwide are high and increasing, with elective repeat caesarean section a significant contributor.

AIM

To determine whether midwifery continuity of care for women with a previous CS increases the proportion of women who plan to attempt a vaginal birth in their current pregnancy.

METHODS

A randomised controlled design was undertaken. Women who met the inclusion criteria were randomised to one of two groups; the Community Midwifery Program (CMP) (continuity across the full spectrum - antenatal, intrapartum and postpartum) (n=110) and the Midwifery Antenatal Care (MAC) Program (antenatal continuity of care) (n=111) using a remote randomisation service. Analysis was undertaken on an intention to treat basis. The primary outcome measure was the rate of attempted vaginal birth after caesarean section and secondary outcomes included composite measures of maternal and neonatal wellbeing.

FINDINGS

The model of care did not significantly impact planned vaginal birth at 36 weeks (CMP 66.7% vs MAC 57.3%) or success rate (CMP 27.8% vs MAC 32.7%). The rate of maternal and neonatal complications was similar between the groups.

CONCLUSION

Model of care did not significantly impact the proportion of women attempting VBAC in this study. The similarity in the number of midwives seen antenatally and during labour and birth suggests that these models of care had more similarities than differences and that the model of continuity could be described as informational continuity. Future research should focus on the impact of relationship based continuity of care.

Do women prefer caesarean sections? A qualitative evidence synthesis of their views and experiences

Background

Caesarean sections (CS) continue to increase worldwide. Multiple and complex factors are contributing to the increase, including non-clinical factors related to individual women, families and their interactions with health providers. This global qualitative evidence synthesis explores women’s preferences for mode of birth and factors underlying preferences for CS.

Methods

Systematic database searches (MEDLINE, EMBASE, CINAHL, PsycINFO) were conducted in December 2016 and updated in May 2019 and February 2021. Studies conducted across all resource settings were eligible for inclusion, except those from China and Taiwan which have been reported in a companion publication. Phenomena of interest were opinions, views and perspectives of women regarding preferences for mode of birth, attributes of CS, societal and cultural beliefs about modes of birth, and right to choose mode of birth. Thematic synthesis of data was conducted. Confidence in findings was assessed using GRADE-CERQual.

Results

We included 52 studies, from 28 countries, encompassing the views and perspectives of pregnant women, non-pregnant women, women with previous CS, postpartum women, and women’s partners. Most of the studies were conducted in high-income countries and published between 2011 and 2021.

Factors underlying women preferences for CS had to do mainly with strong fear of pain and injuries to the mother and child during labour or birth (High confidence), uncertainty regarding vaginal birth (High confidence), and positive views or perceived advantages of CS (High confidence).

Women who preferred CS expressed resoluteness about it, but there were also many women who had a clear preference for vaginal birth and those who even developed strategies to keep their birth plans in environments that were not supportive of vaginal births (High confidence). The findings also identified that social, cultural and personal factors as well as attributes related to health systems impact on the reasons underlying women preferences for various modes of birth (High confidence).

Conclusions

A wide variety of factors underlie women’s preferences for CS in the absence of medical indications. Major factors contributing to perceptions of CS as preferable include fear of pain, uncertainty with vaginal birth and positive views on CS. Interventions need to address these factors to reduce unnecessary CS.

Caesarean section rates: applying the modified ten-group Robson classification in an Australian tertiary hospital

The aim of this study was to determine the main contributors to caesarean section (CS) rates at an Australian tertiary hospital. We conducted a retrospective review of women who delivered in an Australian tertiary hospital between 2014 and 2017. Women were allocated according to a modified Robson Ten-Group Classification System and CS indications were collected in nulliparous women and women with previous CS. The largest contributor to the 35.7% overall CS rate was women with a term cephalic infant and a previous CS (31.5% relative CS rate) and the most common indication was repeat CS. The group CS rate in nulliparous women with a cephalic term infant was higher when labour was induced compared to occurring spontaneously (36.6% and 18.1% respectively). The primary CS indication for these women was labour dystocia and maternal request was the most common CS indication for nulliparous women with a pre-labour CS.IMPACT STATEMENTWhat is already known on this subject? Significantly increasing caesarean section (CS) rates continue to prompt concern due to the associated neonatal and maternal risks. The World Health Organisation have endorsed the Robson Ten-Group Classification System to identify and analyse CS rate contributors.What do the results of this study add? We have used the modified Robson Ten-Group Classification System to identify that women with cephalic term infants who are nulliparous or who have had a previous CS are the largest contributors to overall CS rates. CS rates were higher in these nulliparous women if labour was induced compared to occurring spontaneously and the primary CS indication was labour dystocia. In nulliparous women with a CS prior to labour the most common CS indication was maternal request. Majority of women with a previous CS elected for a repeat CS.What are the implications of these findings for clinical practice? Future efforts should focus on minimising repeat CS in multiparous women and primary CS in nulliparous women. This may be achieved by redefining the definition of labour dystocia, exploring maternal request CS reasoning and critically evaluating induction timing and indication. Appropriately promoting a trial of labour in women with a previous CS in suitable candidates may reduce repeat CS incidence.

Factors obstetricians, family physicians and midwives consider when counselling women about a trial of labour after caesarean and planned repeat caesarean: a qualitative descriptive study

BACKGROUND

Repeat caesarean sections (CSs) are major contributors to the high rate of CS in Canada and globally. Women's decisions to have a planned repeat CS (PRCS) or a trial of labour after CS (TOLAC) are influenced by their maternity care providers. This study explored factors maternity care providers consider when counselling pregnant women with a previous CS, eligible for a TOLAC, about delivery method.

METHODS

A qualitative descriptive design was implemented. Semi-structured, one-to-one in-depth telephone interviews were conducted with 39 maternity care providers in Ontario, Canada. Participants were recruited at 2 maternity care conferences and with the use of snowball sampling. Interviews were audio recorded and transcribed verbatim. Data were uploaded into the data management software, NVIVO 10.0 and analyzed using qualitative content analysis.

RESULTS

Participants consisted of 12 obstetricians, 13 family physicians and 14 midwives. Emergent themes, reflecting the factors maternity care providers considered when counselling on mode of delivery, were organized under the categories clinical/patient factors, health system factors and provider preferences. Maternity care providers considered clinical/patient factors, including women's choice … with conditions, their assessment of women's chances of a successful TOLAC, their perception of women's risk tolerance, women's preferred delivery method, and their perception of women's beliefs and attitudes about childbirth. Additionally, providers considered health system factors which included colleague support for TOLAC and time needed to mount an emergency CS. Finally, provider factors emerged as considerations when counselling. They included provider preference for PRCS or TOLAC, provider scope of practice, financial incentives and convenience related to PRCS, past experiences with TOLAC and PRCS and providers' perspectives on risk of TOLAC.

CONCLUSION

The findings highlight the multiplicity of factors maternity care providers consider when counselling women. Effectively addressing clinical, health care system and personal factors that influence counselling may help decrease non-medically indicated PRCS.

Trial of labor after cesarean delivery (TOLAC) in Japan: rates and complications

PURPOSE

To determine the rates of trial of labor after cesarean delivery (TOLAC) and complications in Japan.

METHODS

We conducted a descriptive study of pregnant women with one prior cesarean section registered between January 2013 and December 2015 in the perinatal database of the Japan Society of Obstetrics and Gynecology. This database is a nationwide institution-based registry in Japan. This study included women who had undergone one prior cesarean delivery and who delivered a singleton by cephalic presentation between 37 and 41 weeks of gestation. We collected data on delivery method, particularly with regard to the involvement of TOLAC or elective repeated cesarean deliveries (ERCD). Rates of TOLAC were investigated by facility type, and we calculated the rates of maternal and perinatal complications including uterine rupture in TOLAC.

RESULTS

During the study period, 647,098 births were registered. Among the 34,460 women who met the inclusion criteria, 1730 (5.0%) and 32,730 (95.0%) underwent TOLAC and ERCD, respectively. In total, 76.4% of hospitals did not perform TOLAC at all. Generally in perinatal medical centers, which are better equipped with facilities, 58.7% women did not perform TOLAC. With regard to complications, we identified eight cases (0.46%) of uterine rupture with TOLAC. TOLAC births did not include maternal death and perinatal death. Among women attempting TOLAC, 1532 (88.6%) had successful vaginal births.

CONCLUSION

The TOLAC rate in Japan was considerably lower than that reported in other countries, despite comparable complication rates.

OptiBIRTH: a cluster randomised trial of a complex intervention to increase vaginal birth after caesarean section

BACKGROUND

Despite evidence supporting the safety of vaginal birth after caesarean section (VBAC), rates are low in many countries.

METHODS

OptiBIRTH investigated the effects of a woman-centred intervention designed to increase VBAC rates through an unblinded cluster randomised trial in 15 maternity units with VBAC rates < 35% in Germany, Ireland and Italy. Sites were matched in pairs or triplets based on annual birth numbers and VBAC rate, and randomised, 1:1 or 2:1, intervention versus control, following trial registration. The intervention involved evidence-based education of clinicians and women with one previous caesarean section (CS), appointment of opinion leaders, audit/peer review, and joint discussions by women and clinicians. Control sites provided usual care. Primary outcome was annual hospital-level VBAC rates before the trial (2012) versus final year of the trial (2016). Between April 2014 and October 2015, 2002 women were recruited (intervention 1195, control 807), with mode-of-birth data available for 1940 women.

RESULTS

The OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was no statistically significant difference in the change in the proportion of women having a VBAC between intervention sites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences between intervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI: 0.67, 1.14, p = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited women with birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782 in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000.

CONCLUSIONS

Changing clinical practice takes time. As elective repeat CS is the most common reason for CS in multiparous women, interventions that are feasible and safe and that have been shown to lead to decreasing repeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. This may best be done using an implementation science approach that can modify evidence-based interventions in response to changing clinical circumstances.

TRIAL REGISTRATION

The OptiBIRTH trial was registered on 3/4/2013. Trial registration number ISRCTN10612254.

Understanding Factors Leading to Primary Cesarean Section and Vaginal Birth After Cesarean Delivery in the Friuli-Venezia Giulia Region (North-Eastern Italy), 2005-2015

Although there is no evidence that elevated rates of cesarean sections (CS) translate into reduced maternal/child perinatal morbidity or mortality, CS have been increasingly overused almost everywhere, both in high and low-income countries. The primary cesarean section (PCS) has become a major driver of the overall CS (OCS) rate, since it carries intrinsic risk of repeat CS (RCS) in future pregnancies. In our study we examined patterns of PCS, pl compared with planned TOLAC anned PCS (PPCS), vaginal birth after 1 previous CS (VBAC-1) and associated factors in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy, collecting data from its 11 maternity centres (coded from A to K) during 2005-2015. By fitting three multiple logistic regression models (one for each delivery mode), we calculated the adjusted rates of PCS and PPCS among women without history of CS, whilst the calculation of the VBAC rate was restricted to women with just one previous CS (VBAC-1). Results, expressed as odds ratio (OR) with 95% confidence interval (95%CI), were controlled for the effect of hospital, calendar year as well as several factors related to the clinical and obstetric conditions of the mothers and the newborn, the obstetric history and socio-demographic background. In FVG during 2005-2015 there were 24,467 OCS (rate of 24.2%), 19,565 PCS (19.6%), 7,736 PPCS (7.7%) and 2,303 VBAC-1 (28.4%). We found high variability of delivery mode (DM) at hospital level, especially for PCS and PPCS. Breech presentation was the strongest determinant for PCS as well as PPCS. Leaving aside placenta previa/abuptio placenta/ante-partum hemorrhage, further significant factors, more importantly associated with PCS than PPCS were non-reassuring fetal status and obstructed labour, followed by (in order of statistical significance): multiple birth; eclampsia/pre-eclampsia; maternal age 40-44 years; placental weight  600-99 g; oligohydramios; pre-delivery LoS 3-5 days; maternal age 35-39 years; placenta weight 1,000-1,500 g; birthweight < 2,000 g; maternal age ≥ 45 years; pre-delivery LoS ≥ 6 days; mother's age 30-34 years; low birthweight (2,000-2,500 g); polyhydramnions; cord prolaspe; ≥6 US scas performed during pregnancy and pre-term gestations (33-36 weeks). Significant factors for PPCS were (in order of statistical significance): breech presentation; placenta previa/abruptio placenta/ante-partum haemorrhage; multiple birth; pre-delivery LoS ≥ 3 days; placental weight ≥ 600 g; maternal age  40-44 years; ≥6 US scans performed in pregnancy; maternal age ≥ 45 and 35-39 years; oligohydramnios; eclampsia/pre-eclampsia; mother's age 30-34 years; birthweight <2,000 g; polyhydramnios and pre-term gestation (33-36 weeks). VBAC-1 were more likely with gestation ≥ 41 weeks, placental weight <500 g and especially labour analgesia. During 2005-2015 the overall rate of PCS in FVG (19.6%) was substantially lower than the corresponding figure reported in 2010 for the entire Italy (29%) and still slightly under the most recent national PCS rate for 2017 (22.2%). The VBAC-1 rate on women with history of one previous CS in FVG was 28.4% (25.3% considering VBAC on all women with at least 1 previous CS), roughly three times the Italian national rate of 9% reported for 2017. The discrepancy between the OCS rate at country level (38.1%) and FVG's (24.2%) is therefore mainly attributable to RCS. Although there was a marginal decrease of PCS and PPCS crudes rates over time in the whole region, accompained by a progressive enhancement of the crude VBAC rate, we found remarkable variability of DM across hospitals. To further contain the number of unnecessary PCS and promote VBAC where appropriate, standardized obstetric protocols should be introduced and enforced at hospital level. Decision-making on PCS should be carefully scrutinized, introducing a diagnostic second opinion for all PCS, particularly for term singleton pregancies with cephalic presentation and in case of obstructed labour as well as non-reassuring fetal status, grey areas potentially affected by subjective clinical assessment. This process of change could be facilitated with education of staff/patients by opinion leaders and prenatal counseling for women and partners, although clinical audits, financial penalties and rewards to efficient maternity centres could also be considered.

To challenge oneself as a childbearing woman-the lived experience of vaginal birth after caesarean section in Sweden

PURPOSE

There is a need to gain deeper knowledge about women's experience of vaginal birth after caesarean section (VBAC). Considerable research has been conducted on VBAC; however, only a few qualitative studies focus on women's experiences. Therefore, the aim of this study was to describe the lived experiences of VBAC among women resident in Sweden, a country with a high VBAC rate.

METHOD

This studywas performed in accordance with a phenomenological reflective lifeworld approach. Interviews were conducted with nine women in an urban region of Sweden one year after their VBAC birth.

RESULTS

The essential meaning of the studied phenomenon is "to challenge oneself as a childbearing woman", which is further described by its four constituents: "striving for support from professionals", "desiring the experience", "contrasting and comparing memories of two different births" and "being part of the birthing culture".

CONCLUSIONS

The experience of VBAC meant regained trust in the ability to give birth vaginally. The women lacked follow-up and support after the caesarean section (CS), during the subsequent pregnancy and the forthcoming VBAC. Enhanced support could be a key factor in helping women meeting the challenge and feel confident about giving birth vaginally despite their previous experiences of CS.

ABBREVIATIONS

VBAC: vaginal birth after caesarean section; CS: caesarean section.

Patients at the centre of care: debriefing patients after caesarean section

Empowering patients and working collaboratively to improve healthcare is a focus for current healthcare development strategies. In obstetric practice, working in collaboration with women to discuss mode of delivery after caesarean section has been shown to impact women’s choice. A preliminary survey in our tertiary maternity unit showed 20% of women gained ‘full clarity’ with the information they received after caesarean-section regarding indication, complications and impact on future delivery. Focus groups identified what information patients required about their surgery. General practitioners (GP) highlighted a lack of communication between secondary and primary care. Junior obstetricians surveyed felt uncertain about debriefing. The aim was to improve monthly ‘full clarity’ scores to 30% in 6 months. Our team introduced a debrief form, filled by the operator and kept in maternity notes. The operator verbally debriefed as part of their current standard practice. Junior doctors postoperatively debriefed the patient using the form. The triplicate form ensured both patients and primary care received a copy. It was anticipated that in the long term, this would provide consistent information and aid informed decision making in subsequent pregnancies. Review of the forms’ use was undertaken weekly. Multidisciplinary input identified barriers to uptake. Plan, Do, Study, Act cycles promoted the project, disseminated results, evidenced growing participation and rewarded consistent form use. Patient groups critiqued the form layout. Teaching aimed to improve junior doctor confidence in debriefing discussions. Sustained participation resulted in effective form uptake. Patient ‘full clarity’ scores improved to 60% with minimal impact on workload. Teaching successfully improved junior doctor confidence as evidenced by increased documented debrief discussions. GP focus groups felt empowered to counsel women consistently about their surgery increasing clarity for everyone. This project highlights that patient satisfaction improves when we listen to their views and commit to change.

Questionnaire survey on women's views after a first caesarean delivery in two tertiary centres in Ireland and their preference for involvement in a future randomised trial on mode of birth

OBJECTIVE

To assess the views of women after a first caesarean section (CS) on their birth experience, preference for future mode of birth and willingness to participate in a randomised controlled trial on mode of birth in a future pregnancy.

DESIGN

Questionnaire survey.

SETTING

Two tertiary maternity centres Ireland, Galway University Hospital, Galwayand the National Maternity Hospital, Dublin.

PARTICIPANTS

Women with one previous CS.

METHODS

Eligible women consented to participate, and postal surveys were forwarded. Results were collected and analysed. Results were compared between women who had elective operations and women who had emergency operations.

PRIMARY OUTCOME MEASURES

The satisfaction levels of women after a first caesarean, their preference for mode of birth in a future pregnancy and their willingness to participate in a randomised trial on mode of birth.

RESULTS

There were 347 completed surveys of 633 women who consented to participate (54.8%), of whom 285 and 62 had emergency and elective caesarean deliveries, respectively. In general, satisfaction ratings with the delivery were greater than 90%, with similar levels of satisfaction with the care received from doctors and midwives. Women who an emergency procedure expressed lower satisfaction levels with the information about the caesarean and the debriefing received afterwards than women who had a planned operation (p<0.05). For future mode of birth, 39.5% expressed a preference for vaginal birth after caesarean (VBAC) in a subsequent pregnancy, and 80% said they would consider involvement in a randomised trial in a future pregnancy.

CONCLUSION

Debriefing and counselling women after a CS is an important part of pregnancy care and can significantly impact on a woman's overall birth experience. A significant proportion of this cohort considered VBAC as a future birth option. These data indicate that a randomised trial on mode of birth after caesarean would be viewed positively by women in our population.

Women's decision-making processes and experiences of vaginal birth after caesarean birth: A phenomenological study

AIM

To discover, identify, and interpret the decision-making processes and experiences of women on vaginal birth after caesarean section.

METHODS

This Husserlian phenomenological qualitative study was conducted using semistructured individual interviews with 12 women who experienced vaginal birth after caesarean section between August and December 2017. Colaizzi's qualitative analysis method was used.

RESULTS

Four themes emerged: "finding a way to have vaginal birth after caesarean section," "healing by giving birth," "advantageous birth," and "being at the centre of the care," with 13 subthemes. Women defined vaginal birth after caesarean section as an important aspect of their femininity and a sense of motherhood. The women noted that traumatic experiences in caesarean section birth had been removed with vaginal birth and regarded this as an important spiritual experience and life event. The women reported that the important advantage of vaginal birth after caesarean section was not being in need of others in the post-partum period. However, women described negative experiences where health care professionals did not respect their birth preference or provide adequate information and support.

CONCLUSIONS

Continuing professional development training is recommended in order to improve health care professionals' caring consciousness about the importance of shared decision making for women's birth type.

Socio-cultural and clinician determinants in the maternal decision-making process in the choice for trial of labor vs. elective repeated cesarean section: a questionnaire comparison between Italian settings

Objective To identify socio-cultural and clinician determinants in the decision-making process in the choice for trial of labor after cesarean (TOLAC) or elective repeat cesarean section (ERCS) in delivering women. Methods A tailored questionnaire focused on epidemiological, socio-cultural and obstetric data was administered to 133 patients; of these, 95 were admitted for assistance at birth at Fondazione Policlinico Universitario "A. Gemelli" (FPG) IRCCS, Rome, and 38 at S. Chiara Hospital (SCH), Trento, Italy. Descriptive analysis and logistic regression modeling were performed. Results Vaginal birth after cesarean (VBAC) rates were higher at SCH than at FPG (68.4% vs. 23.2%; P < 0.05). Maternal age in the TOLAC/VBAC group was significantly higher at SCH than at FPG (37.1 vs. 34.9 years, P < 0.05). High levels of education and no-working condition corresponded to a lower rate of VBAC. Proposal on delivery mode after a previous CS was missed in the majority of cases. Participation in prenatal course was significantly less among women in the ERCS groups. Using logistic regression, the following determinants were found to be statistically significant in the decision-making process: maternal age [odds ratio (OR) = 0.968 (95% confidence interval [CI] 0.941-0.999); P = 0.019], education level [OR = 0.618 (95% CI 0.419-0.995); P = 0.043], information received after the previous CS [OR = 0.401 (95% CI 0.195-1.252); P = 0.029], participation in antenatal courses [OR = 0.534 (95% CI 0.407-1.223); P = 0.045] and self-determination in attempting TOLAC [OR = 0.756 (95% CI 0.522-1.077); P = 0.037]. Conclusion In the attempt to promote person-centered care, increases in TOLAC/VBAC rates could be achieved by focusing on individual maternal needs. An ad hoc strategy for making birth safer should begin from accurate information at the time of the previous CS.

Cultural perspectives on vaginal birth after previous caesarean section in countries with high and low rates - A hermeneutic study

BACKGROUND

Caesarean section (CS) rates are increasing worldwide, an increase that is multifactorial and not well understood. There is considerable variation in the rates of vaginal birth after previous Caesarean section (VBAC). Cultural differences could be one explanation of the varying rates.

OBJECTIVE

To interpret cultural perspectives on VBAC.

METHODS

A hermeneutic approach for analysing findings from four published qualitative studies that were part of the OptiBIRTH study, focusing on clinicians and women's views of important factors for improving the rate of VBAC. 115 clinicians and 73 women participated in individual interviews and focus group interviews in countries with low rates (Germany, Italy and Ireland) and countries with high rates (Sweden, Finland and the Netherlands), in the original studies.

RESULTS

Three themes demonstrated how the culture differs between the high and low VBAC rate countries; from being an obvious first alternative to an issue dependent on many factors; from something included in the ordinary care to something special; and from obstetrician making the final decision to a choice by the woman. The fourth theme, preparing for a new birth by early follow-up and leaving the last birth behind, reflects coherence between the cultures.

DISCUSSION

The findings deepen our understanding of why the VBAC rates vary across countries and healthcare settings, and can be used for improving the care for women.

CONCLUSION

In order to improve VBAC rates both maternity care settings and individual professionals need to reflect on their VBAC culture, and make make changes to develop a 'pro-VBAC culture'.

Process evaluation for OptiBIRTH, a randomised controlled trial of a complex intervention designed to increase rates of vaginal birth after caesarean section

BACKGROUND

Complex interventions encompassing several interconnecting and interacting components can be challenging to evaluate. Examining the underlying trial processes while an intervention is being tested can assist in explaining why an intervention was effective (or not). This paper describes a process evaluation of a pan-European cluster randomised controlled trial, OptiBIRTH (undertaken in Ireland, Italy and Germany), that successfully used both quantitative and qualitative methods to enhance understanding of the underlying trial mechanisms and their effect on the trial outcome.

METHODS

We carried out a mixed methods process evaluation. Quantitative and qualitative data were collected from observation of the implementation of the intervention in practice to determine whether it was delivered according to the original protocol. Data were examined to assess the delivery of the various components of the intervention and the receipt of the intervention by key stakeholders (pregnant women, midwives, obstetricians). Using ethnography, an exploration of perceived experiences from a range of recipients was conducted to understand the perspective of both those delivering and those receiving the intervention.

RESULTS

Engagement by stakeholders with the different components of the intervention varied from minimal intensity of women's engagement with antenatal classes, to moderate intensity of engagement with online resources, to high intensity of clinicians' exposure to the education sessions provided. The ethnography determined that, although the overall culture in the intervention site did not change, smaller, more individual cultural changes were observed. The fidelity of the delivery of the intervention scored average quality marks of 80% and above on repeat assessments.

CONCLUSION

Nesting a process evaluation within the trial enabled the observation of the mode of action of the intervention in its practice context and ensured that the intervention was delivered with a good level of consistency. Implementation problems were identified as they arose and were addressed accordingly. When dealing with a complex intervention, collecting and analysing both quantitative and qualitative data, as we did, can greatly enhance the process evaluation.

TRIAL REGISTRATION

Current Controlled Trials Register, ISRCTN10612254 . Registered on 3 April 2013.