Birth choice following primary Caesarean section: mothers' perceptions of the influence of health professionals on decision‐making

Maternity clinician use of shared decision-making in antenatal care: A scoping review

BACKGROUND

Implementation of shared decision-making in antenatal care has had limited exploration.

OBJECTIVE

To assess what is known about shared decision-making in antenatal care.

SEARCH STRATEGY

Five databases were searched (1997-2022) limited to English language studies from OECD countries.

DATA COLLECTION AND ANALYSIS

A data collection table was constructed with findings from 32 papers. A narrative synthesis was conducted with subsequent thematic analysis of included papers.

MAIN RESULTS

Four areas of decision-making were identified with six themes revealing enablers and barriers to shared decision-making in antenatal care.

CONCLUSION

Implementation of shared decision-making requires continuity, time and personalisation of care.

Impact of no publicly accessible prenatal education programming on patients and their care providers: a descriptive qualitative study in Nova Scotia, Canada

OBJECTIVE

Patients in Nova Scotia do not have access to public prenatal education programming. This study aimed to explore whether care providers find patients are uninformed or misinformed, and the impact of that on patients and their care providers with a focus on clinical outcomes, time, resources and informed decision-making.

METHODS

Semistructured interviews were conducted with 13 care providers around Halifax and Cape Breton. An interview guide (supplemental) of open-ended questions was used for consistency. A descriptive qualitative approach was employed to describe the contents of the interviews. Each interview was audio-taped and transcribed verbatim by an interdependent transcriber. Transcripts were analysed using established techniques in qualitative descriptive research including coding, grouping, detailing and comparing the data using NVivo V.12 software. A co-coder (SS) independently coded two interviews for inter-rater reliability.

RESULTS

The study revealed six themes: (1) concern for a significant population of Nova Scotians experiencing pregnancy, birth and postpartum uninformed and misinformed, (2) consequences for patients who are uninformed and misinformed, (3) more time and resources spent on care for patients who are uninformed or misinformed, (4) patients and their care providers need a publicly available education programme, particularly vulnerable populations, (5) emphasis on programme quality and disappointment with the programme previously been in place and (6) recommendations for an effective prenatal education programme for Nova Scotians.

CONCLUSIONS

This study shows care providers believe a public prenatal education programme could improve health literacy in Nova Scotia. Patients are seeking health education, but it is not accessible to all and being uninformed or misinformed negatively impacts patients' experiences and outcomes. This study revealed excess time and resources are being spent on individualised prenatal education by care providers with high individual and system-wide cost and explored the complicated process of providing patient-centred care for people who are uninformed or misinformed.

Patient-Led Approaches to a Vaginal Birth After Cesarean Delivery Calculator

OBJECTIVE

To describe patient approaches to navigating their probability of a vaginal birth after cesarean (VBAC) within the context of prediction scores generated from the original Maternal-Fetal Medicine Units' VBAC calculator, which incorporated race and ethnicity as one of six risk factors.

METHODS

We invited a diverse group of participants with a history of prior cesarean delivery to participate in interviews and have their prenatal visits recorded. Using an open-ended iterative interview guide, we queried and observed these individuals' mode-of-birth decisions in the context of their VBAC calculator scores. We used a critical and feminist approach to analyze thematic data gleaned from interview and visit transcripts.

RESULTS

Among the 31 participants who enrolled, their self-identified racial and ethnic categories included: Asian or South Asian (2); Black (4); Hispanic (12); Indigenous (1); White (8); and mixed-Black, -Hispanic, or -Asian background (4). Predicted VBAC success probabilities ranged from 12% to 95%. Participants completed 64 interviews, and 14 prenatal visits were recorded. We identified four themes that demonstrated a range of patient-led approaches to interpreting the probability generated by the VBAC calculator: 1) rejecting the role of race and ethnicity; 2) reframing failure, finding success; 3) factoring the physical experience of labor; and 4) modifying the probability for VBAC.

CONCLUSION

Our findings demonstrate that a numeric probability for VBAC may not be highly valued or important to all patients, especially those who have strong intentions for VBAC. Black and Hispanic participants challenged the VBAC calculator's incorporation of race and ethnicity as a risk factor and resisted the implication it produced, especially that their bodies were less capable of achieving a vaginal birth. Our findings suggest that patient-led approaches to assessing and interpreting VBAC probability may be an untapped resource for achieving a more person-centered, equitable approach to counseling.

[Traumatic childbirth and trauma-sensitive obstetric support]

Childbirth can be a very happy and empowering experience for women but also one of suffering and despair. Biographical traumatic experiences, especially sexual, physical and emotional violence, are risk factors for a traumatic childbirth experience with the danger of subsequent trauma sequelae and impaired mother-child bonding; however, obstetrically indicated interventions or poor communication in the delivery room can also primarily be experienced as traumatic.In recent years, policies affecting traumatic childbirth experience have been controversially and sometimes emotionally discussed. In the clinical obstetric routine there is often a fine line between medically necessary rapid interventions and emotionally supportive trauma-sensitive and preventive obstetric care. The following article addresses the causes and prevention strategies of traumatic childbirth experiences from obstetric, midwifery and psychotherapeutic perspectives.

'It will dictate how many children I will have"- Women's decision-making in pregnancy following a previous caesarean birth (CB)

Vaginal birth after caesarean (VBAC) is supported in systematic reviews (Wu et al., 2019) and national guidelines (RCOG, 2015) and women are expected to be involved in the decision-making process for either a repeat caesarean birth or planned VBAC.

AIM

To develop a Grounded Theory (GT) of women's decision making of their birth choices in pregnancy following a previous caesarean birth (CB) OBJECTIVE: To explore what determines women's birth choice and their decision making for birth following a previous CB.

DESIGN

Semi structured interviews with pregnant women were undertaken in order to develop a Glasserian Grounded Theory SETTING: Antenatal clinics and wards in a large tertiary level maternity hospital.

FINDINGS

The theory of 'Mentalizing Possibilities' is a substantive theory which explains pregnant women's decision making about their birth choices after a previous CB. Women's main concern is to achieve a positive experience. The core category of 'Mentalizing Possibilities' explains how women process their previous experience, adapt to uncertainty and deal with the decisional conflict. There are behavioural and cognitive strategies which women use to go through this process.

CONCLUSION

Women want a positive birth experience after a previous CB and require support and continuity in decision making to help them decide the optimal birth choice for their current pregnancy.

African American Women's Experiences with Birth After a Prior Cesarean Section

OBJECTIVES

Women who have had a cesarean section (C-section) and become pregnant again may choose to have a planned repeat cesarean delivery (RCD) or vaginal birth after a cesarean (VBAC). This study aimed to characterize the pregnancy and birth experiences of African American (AA) women who had a successful VBAC, failed VBAC, or RCD.

METHODS

Eligible participants (N = 25) self-identified as AA, had a C-section and a subsequent birth(s) in the past 12 years, and were educated past high school. Each participant was individually interviewed via phone call. The Sort and Sift, Think and Shift method was used to evaluate interview transcripts to minimize researcher bias and emphasize the voices of the participants.

RESULTS

The resulting themes included the impact of providers on pregnancy and childbirth satisfaction, the value of autonomy in maternal health decision-making, and the role that racism plays in AA women's birth experiences. Although some participants recalled a positive experience, the presence of limited autonomy, lack of support, and negative experiences with providers indicate that birth after a prior C-section for AA women can be improved.

CONCLUSIONS

Providers should address their own racial biases and utilize the shared decision-making approach when their patients decide between a VBAC and RCD to improve patient satisfaction.

Demographic, Socioeconomic, Health Systems, and Geographic Factors Associated with Vaginal Birth After Cesarean: An Analysis of 2017 U.S. Birth Certificate Data

OBJECTIVES

In order to better understand the current rates of vaginal birth after cesarean (VBAC) in the United States, 2017 U.S. birth certificate data were used to examine sociodemographic and geographic factors associated with the outcome of a VBAC.

METHODS

The 2017 Natality Limited Geography Dataset and block sequential logistic regression were used to examine sociodemographic and geographic factors associated with subsequent births in 2017 in the United States to women with a history of 1 or 2 cesareans (N = 540,711).

RESULTS

The adjusted odds of VBAC were 6% higher for Black women (1.06; 95% CI: 1.04, 1.08) and 18% higher for American Indian/Alaska Native women (aOR 1.18; 95% CI: 1.10, 1.27) relative to white women. Asian/Pacific Islander women were 9% less likely to have a VBAC (aOR 0.91; 95% CI: 0.88, 0.94) than similar white women with a history of cesarean delivery. Latina women had a 10% less likelihood of a VBAC (aOR 0.90; 95% CI: 0.88, 0.92) when compared with non-Latina women. Women with a high school education (aOR 0.85; 95% CI: 0.83, 0.88) or some college (aOR 0.85; 95% CI: 0.84, 0.87) were less likely to have a VBAC than women educated at a baccalaureate level or higher. Women whose births were paid for by Medicaid had a 5% increased likelihood of VBAC over women with private insurance (aOR 1.05, 95% CI: 1.03, 1.07). Women who self-pay have twice the likelihood of VBAC (aOR 1.99; 95% CI: 1.92, 2.07) compared to women with private insurance. The adjusted odds of VBAC were lowest for women giving birth in Southern states (aOR 0.72; 95% CI: 0.71, 0.74) and highest for women giving birth in the Midwest (aOR 1.19; 95% CI: 1.16, 1.22) relative to women in the Northeastern U.S. Thirteen percent (13%) of women who had a VBAC had a certified nurse-midwife (CNM) birth attendant, which is 44% higher than the national CNM-attended birth rate.

CONCLUSIONS FOR PRACTICE

Significant variation exists in VBAC rates based on a number of sociodemographic and geographic factors, likely reflecting disparities in access to vaginal birth after cesarean and differences in preference regarding mode of birth after cesarean. Further research is recommended to better understand and address these disparities to improve maternity care.

Factors associated with women's birth beliefs and experiences of decision-making in the context of planned birth: A survey study

OBJECTIVE

In many high-income countries, approximately half of all births are now planned regarding timing, either by elective Caesarean Section (CS) or induction of labour (IOL). To what degree this is explained by women's birth beliefs and preferences, and in turn, factors such as parity and ethnicity that may influence them, is contentious. Within a broader study on Timing of Birth by planned CS or IOL, we aimed to explore the association between demographic and pregnancy factors, with women's birth beliefs and experiences of planned birth decision-making in late pregnancy.

DESIGN

Survey study of women's birth beliefs and experiences of planned birth decision-making. Both univariate analysis and ordinal regression modelling was performed to examine the influence of; parity; cultural background; continuity of pregnancy care; CS or IOL; and whether CS was "recommended" or "requested", on women's stated birth beliefs and decision-making experience.

SETTING

8 Sydney hospitals PARTICIPANTS: Women planned to have an IOL or CS between November 2018-July 2019.

MEASUREMENT

The survey included four statements regarding birth beliefs and ten statements about experiences of decision-making on a 5-item Likert scale, as well as questions about demographic and pregnancy factors that might influence these beliefs.

FINDINGS

Of 340 included surveys, 56% regarded IOL and 44% CS. Women indicated strong belief both that they should be supported to make decisions about their birth and that their doctor/midwife knows what is best for them (over 90% agreement for both). Regarding decision-making, over 90% also agreed they had trust in the person providing information, understood it, and had sufficient time for both questions and decision-making. However only 58% were provided written information, 19% felt they "didn't really have a choice", and 9% felt pressure to make a decision. On both univariate and multivariate analysis, women having CS (versus IOL) expressed more positive views of their experience and involvement in decision-making, as did women experiencing a pregnancy continuity-of-care model. Women identifying as from a specific cultural or ethnic background expressed more negative experiences. On modelling, the studied factors accounted for only a small proportion of the variation in responses (3-19%).

CONCLUSIONS

Continuity of pregnancy care was associated with positive decision-making experiences and cultural background with more negative experiences. Women whose planned birth was IOL versus CS also reported more negative decision-making experiences.

IMPLICATIONS FOR PRACTICE

Attention to improving quality of information provision, including written information, to women having IOL and women of diverse background, is recommended to improve women's experiences of planned birth decision-making.

Making shared decisions in relation to planned caesarean sections: What are we up to?

OBJECTIVE

To map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women's experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions.

METHODS

Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018.

RESULTS

34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women.

CONCLUSION

Many women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage.

PRACTICE IMPLICATIONS

Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.

Women's Perceptions of Barriers and Facilitators to Vaginal Birth After Cesarean in the United States: An Integrative Review

INTRODUCTION

The purpose of this integrative review was to synthesize the literature on women's perceived barriers and facilitators to achieving a vaginal birth after cesarean.

METHODS

A search of Scopus and PubMed databases and relevant citations from 2000 to 2018 was conducted to identify resources meeting inclusion criteria. Conclusion drawing and verification were completed using data displays, data analysis, and comparison.

RESULTS

Sixteen resources met inclusion criteria. Factors identified by women with a history of cesarean that act as facilitators or barriers to achieving a vaginal birth after cesarean included (1) individual factors (knowledge, body, and psychological), (2) social factors (culture and social support), and (3) systemic factors (perinatal care provider, health system, and financial). Some factors related to barriers and facilitators reflected opposing aspects of the same phenomenon on a continuum.

DISCUSSION

Enhancing facilitators identified by women, while addressing perceived barriers, may increase access to labor after cesarean for women in the United States. Increasing access to labor after cesarean may subsequently improve women's experiences of care and decrease the US cesarean rate, positively affecting individual health outcomes and overall health of childbearing women in the United States.

Experience of Vaginal Birth After Cesarean: A Phenomenological Study

The international literature concerning cesarean surgeries (CSs) make it clear that many of these procedures are unnecessary. Using a phenomenological methodology, we seek to understand the experiences and decisions of women who have undergone vaginal birth after cesarean (VBAC). Various factors contribute to the choice of VBAC. Making VBAC a more regular practice would contribute to a decrease in the total number of repeat CSs. The purpose of this study is threefold: (a) to understand the process that women use to select a VBAC rather than a repeat cesarean, (b) to understand the mothers' lived experience of that VBAC, and (c) to use the aforementioned data to inform the development of new educational programs for mothers considering VBAC.

How communication about risk and role affects women's decisions about birth after caesarean

OBJECTIVE

This study investigated how health care provider communication of risk information, and women's role in decision-making, influenced women's preferences for mode of birth after a previous caesarean birth.

METHODS

Women (N = 669) were randomised to one of eight conditions in a 2 (selectivity of risk information) × 2 (format of risk information) × 2 (role in decision making) experimental design. After exposure to a hypothetical decision scenario that varied information communicated by an obstetrician to a pregnant woman with a previous caesarean birth across the three factors, women were asked to decide their preferred hypothetical childbirth preference.

RESULTS

Women provided with selective information (incomplete/biased toward repeat caesarean) and relative risk formats (ratio of incidence being compared e.g. 2.5 times higher), perceived lower risk for caesarean and were significantly more likely to prefer repeat caesarean birth than those provided with non-selective information (complete/unbiased) and absolute risk formats (incidence rate e.g. 0.01 per 100). Role in decision-making did not significantly influence childbirth preferences CONCLUSIONS: Modifiable aspects of healthcare provider communication may influence women's decision-making about childbirth preferences PRACTICE IMPLICATIONS: Optimised communication about risks of all options may have an impact on over-use of repeat CS.

Fear of Childbirth, Postpartum Depression, and Birth-Related Variables as Predictors of Posttraumatic Stress Disorder After Childbirth

BACKGROUND

Childbirth may be a significant cause of postpartum posttraumatic stress disorder (PTSD) in women.

AIMS

The objective of this study is to examine the effect of fear of childbirth, postpartum depression, and certain birth-related variables on postpartum PTSD.

METHODS

This study is a cross-sectional study. The study was carried out in a maternity hospital nonstress unit between December 1, 2015, and February 29, 2016. Three hundred and one pregnant women who met the criteria for inclusion in the study made up the research sample.

RESULTS

Fear of childbirth and postpartum depression significantly and positively predicted the level of posttraumatic stress after childbirth (β = 0.17, p < .01; β = 0.68, p < .001). Fear of childbirth explains 3% of the total variance in posttraumatic stress (R²  = .03, adjusted R²  = .02, F = 7.141, p < .01), while postpartum depression explains 47% of it (R²  = .47, adjusted R²  = .46, F = 196.35, p < .001). Satisfaction with the attitudes of the medical staff during childbirth, defining the childbirth experience, and the state of experiencing postpartum problems by the mother are significant predictors of postpartum posttraumatic stress (β = -0.21, p < .01; β = -0.14, p < .05; β = 0.17, p < .01). When these three variables are addressed together, they explain 14% of the total variance (R²  = .14, adjusted R²  = .13, F = 9.33, p < .001).

LINKING EVIDENCE TO ACTION

Postpartum PTSD is a situation that must be carefully emphasized in terms of maternal, baby, and family health. For this reason, it is necessary to evaluate postpartum PTSD more quickly and objectively, and healthcare providers have major duties in this respect.

Women's and communities' views of targeted educational interventions to reduce unnecessary caesarean section: a qualitative evidence synthesis

BACKGROUND

There is continued debate about the role of women and communities in influencing rising rates of caesarean section (CS). In settings where CS rates exceed recommended levels, mothers and babies are exposed to potential harms that may outweigh the potential benefits. There is therefore a need to understand how educational interventions targeted at women and communities to reduce unnecessary CS are perceived and used. This qualitative evidence synthesis aimed to explore what women and communities say about the barriers and facilitators to intervention effectiveness for these important groups.

METHOD

Seven electronic databases were searched using predefined search terms. Studies reporting qualitative data pertaining to interventions, published between 1985 and March 2017, with no language restriction were sought. Study quality was independently assessed by two authors before qualitative evidence synthesis was undertaken using an interpretive, meta-ethnography approach. Resulting Statements of Findings were assessed using GRADE-CERQual, and summarised thematically.

RESULTS

Twelve studies were included. They were published between 2001 and 2016. Eleven were from high-income countries. Twelve Summaries of Findings encompassed the data, and were graded (moderate or high) on CerQual. The Statements of Findings are reported under three final themes: 1) Mutability of women's and communities' beliefs about birth; 2) Multiplicity of individual information needs about birth; 3) Interactions with health professionals and influence of healthcare system on actual birth method. Women and communities value educational interventions that include opportunities for dialogue, are individualised (including acknowledgement of previous birth experiences), and are consistent with available clinical care and the advice of the health professional they come into contact with.

CONCLUSION

Women's values and preferences for birth, and for information format and content, vary across populations, and evolves in individual women over time. Interactions with health professionals and health system factors can partly be responsible for changes in views. Educational interventions should take into account these dynamic interactions, as well as the women's need for emotional support and dialogue with professionals alongside information about birth. Further research is required to test these findings and the utility of their practical application, particularly in medium and low income settings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2017 CRD42017059453 .

The journey from pain to power: A meta-ethnography on women's experiences of vaginal birth after caesarean

BACKGROUND

Vaginal birth after caesarean can be a safe and satisfying option for many women who have had a previous caesarean, yet rates of vaginal birth after caesarean remain low in the majority of countries. Exploring women's experiences of vaginal birth after caesarean can improve health practitioners' understanding of the factors that facilitate or hinder women in the journey to have a vaginal birth after caesarean.

METHODS

This paper reports on a meta-ethnographic review of 20 research papers exploring women's experience of vaginal birth after caesarean in a variety of birth locations. Meta-ethnography utilises a seven-stage process to synthesise qualitative research.

RESULTS

The overarching theme was 'the journey from pain to power'. The theme 'the hurt me' describes the previous caesarean experience and resulting feelings. Women experience a journey of 'peaks and troughs' moving from their previous caesarean to their vaginal birth after caesarean. Achieving a vaginal birth after caesarean was seen in the theme 'the powerful me,' and the resultant benefits are described in the theme 'the ongoing journey'.

CONCLUSION

Women undergo a journey from their previous caesarean with different positive and negative experiences as they move towards their goal of achieving a vaginal birth after caesarean. This 'journey from pain to power' is strongly influenced by both negative and positive support provided by health care practitioners. Positive support from a health care professional is more common in confident practitioners and continuity of care with a midwife.

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

PROBLEM AND BACKGROUND

Vaginal birth after caesarean section is a safe option for the majority of women. Seeking women's views can be of help in understanding factors of importance for achieving vaginal birth in countries where the vaginal birth rates after caesarean is low.

AIM

To investigate women's views on important factors to improve the rate of vaginal birth after caesareanin countries where vaginal birth rates after previous caesarean are low.

METHODS

A qualitative study using content analysis. Data were gathered through focus groups and individual interviews with 51 women, in their native languages, in Germany, Ireland and Italy. The women were asked five questions about vaginal birth after caesarean. Data were translated to English, analysed together and finally validated in each country.

FINDINGS

Important factors for the women were that all involved in caring for them were of the same opinion about vaginal birth after caesarean, that they experience shared decision-making with clinicians supportive of vaginal birth, receive correct information, are sufficiently prepared for a vaginal birth, and experience a culture that supports vaginal birth after caesarean.

DISCUSSION AND CONCLUSION

Women's decision-making about vaginal birth after caesarean in these countries involves a complex, multidimensional interplay of medical, psychosocial, cultural, personal and practical considerations. Further research is needed to explore if the information deficit women report negatively affects their ability to make informed choices, and to understand what matters most to women when making decisions about vaginal birth after a previous caesarean as a mode of birth.

Breastfeeding Initiation in Mothers with Repeat Cesarean Section: The Impact of Marital Status

BACKGROUND

Approximately 90% of mothers with a primary C-section have a subsequent C-section. To date, research has demonstrated that primary C-sections are associated with breastfeeding noninitiation. However, it is unknown if this association persists after the primary C-section. Furthermore, literature has shown a differing relationship between breastfeeding initiations by marital status. Due to the high proportion of women who give birth while unmarried, investigating differences by marital status will add a significant contribution to breastfeeding literature. This study investigates the association between repeat C-section and breastfeeding initiation within marital status groups using a nationally representative cross-sectional survey.

MATERIALS AND METHODS

Data from the 2004 to 2011 Pregnancy Risk Assessment Monitoring System were analyzed. The sample was restricted to women with a previous singleton live birth who had C-section and whose infant was alive at the time of interview (N = 34,854). Multiple logistic regression analyses were conducted to obtain crude and adjusted odds ratio (AOR) and 95% confidence intervals (CIs).

RESULTS

After adjusting for potential confounders, married women who had a repeat C-section were 2.2 times (AOR = 2.16, 95% CI = 1.69-2.77) more likely to never breastfeed compared to women with vaginal birth after caesarean section (VBAC). Similarly, the odds of breastfeeding noninitiation were 76% (AOR = 1.76, 95% CI = 1.47-2.12) higher among women with a repeat C-section compared to women with VBAC. No significant associations were exhibited among nonmarried women.

CONCLUSIONS

Enhanced educational programs and counseling support may be needed to help families cope with delivery challenges and resulting stressors that may reduce their desire to initiate breastfeeding in the postpartum period.

Vaginal Birth After Cesarean: Views of Women From Countries With High VBAC Rates

Despite the consequences for women's health, a repeat cesarean section (CS) birth after a previous CS is common in Western countries. Vaginal Birth After Cesarean (VBAC) is recommended for most women, yet VBAC rates are decreasing and vary across maternity organizations and countries. We investigated women's views on factors of importance for improving the rate of VBAC in countries where VBAC rates are high. We interviewed 22 women who had experienced VBAC in Finland, the Netherlands, and Sweden. We used content analysis, which revealed five categories: receiving information from supportive clinicians, receiving professional support from a calm and confident midwife/obstetrician during childbirth, knowing the advantages of VBAC, letting go of the previous childbirth in preparation for the new birth, and viewing VBAC as the first alternative for all involved when no complications are present. These findings reflect not only women's needs but also sociocultural factors influencing their views on VBAC.

Clinicians' views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates

BACKGROUND

Caesarean section (CS) rates are increasing worldwide and the most common reason is repeat CS following previous CS. For most women a vaginal birth after a previous CS (VBAC) is a safe option. However, the rate of VBAC differs in an international perspective. Obtaining deeper knowledge of clinicians' views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Focus group interviews with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of "OptiBIRTH", an ongoing research project. The study reported here aims to explore the views of clinicians from countries with low VBAC rates on factors of importance for improving VBAC rates.

METHODS

Focus group interviews were held in Ireland, Italy and Germany. In total 71 clinicians participated in nine focus group interviews. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country.

RESULTS

The findings are presented in four main categories with several sub-categories: 1) "prameters for VBAC", including the importance of the obstetric history, present obstetric factors, a positive attitude among those who are centrally involved, early follow-up after CS and antenatal classes; 2) "organisational support and resources for women undergoing a VBAC", meaning a successful VBAC requires clinical expertise and resources during labour; 3) "fear as a key inhibitor of successful VBAC", including understanding women's fear of childbirth, clinicians' fear of VBAC and the ways that clinicians' fear can be transferred to women; and 4) "shared decision making - rapport, knowledge and confidence", meaning ensuring consistent, realistic and unbiased information and developing trust within the clinician-woman relationship.

CONCLUSIONS

The findings indicate that increasing the VBAC rate depends on organisational factors, the care offered during pregnancy and childbirth, the decision-making process and the strategies employed to reduce fear in all involved.

Influences on vaginal birth after caesarean section: A qualitative study of Taiwanese women

BACKGROUND

Vaginal birth is a safe mode of birth for most women who have had a prior caesarean with a transverse incision. Despite the evidence, most Taiwanese women who have had a previous caesarean are rarely offered the opportunity to consider any possibility other than a repeat caesarean.

AIM

This study explored factors affecting Taiwanese women's decisionmaking regarding vaginal birth after cesarean.

METHODS

Ajzen's Theory of Planned Behaviour provided the theoretical framework to underpin the study, which adopted an interpretive descriptive methodology. Sequential semi-structured interviews were conducted with 29 women who had a previous caesarean and were pregnant between 34 and 38 weeks gestation, ten women who attempted vaginal birth in the third to fifth day postpartum, and 25 women in the fourth week postpartum. Boyatzis' method of thematic analysis was used to identify themes and codes.

FINDINGS

This paper reports the findings of the prenatal interviews with 29 participants. The major factor influencing women's decision-making was to avoid negative outcomes for themselves and their babies. Three thematic codes describe influences on the women's decisions: 'past experience of childbirth', 'anticipating the next experience of normal birth' and 'contemplation on the process of childbirth'.

CONCLUSIONS

Women who have had a previous caesarean section are prepared to have a vaginal birth but are not always supported to carry out this decision. Changing the models of antenatal care is recommended as a strategy to overcome this difficulty therefore empowering women to make a meaningful choice about VBAC after a CS.

The Turkish version of perceived support and control in birth scale

OBJECTIVE

This is a methodological study carried out to evaluate the validity and reliability of the Turkish version of the Support and Control in Birth Scale (SCIB).

METHODS

This study included 339 post-partum women. The validity of the Turkish version of the scale was assessed in terms of content and construct validity. Reliability was evaluated using the internal consistency coefficient, the test-retest correlation coefficient and the item correlation between the subscales.

RESULTS

The internal consistency coefficient of the scale was 0.84 (p < 0.01). There were significant correlations between sub-scales (rho = 0.122, 0.129, 0.263, p < 0.05), and the test-retest correlation coefficient of the scale was also significant (rho = 0.86, α = 0.000). As in the original scale, a three-factor structure was examined, which explained 42.85% of the total variance. The model was verified by a confirmatory factor analysis.

CONCLUSION

The Turkish version of the SCIB is a reliable and valid instrument for measuring the perceived support and control during birth among Turkish women.

Maternal and perinatal outcomes in women planning vaginal birth after caesarean (VBAC) at home in England: secondary analysis of the Birthplace national prospective cohort study

OBJECTIVE

To compare vaginal birth rates in women planning vaginal birth after caesarean (VBAC) at home versus in an obstetric unit (OU) and explore transfer rates in women planning home VBAC.

DESIGN

Prospective cohort study.

SETTING

OUs and planned home births in England.

POPULATION

1436 women planning VBAC in the Birthplace cohort, including 209 planning home VBAC.

METHODS

We used Poisson regression to calculate relative risks adjusted for maternal characteristics.

MAIN OUTCOME MEASURES

MAIN OUTCOMES

(i) vaginal birth and (ii) transfer from planned home birth to OU during labour or immediately after birth.

SECONDARY OUTCOMES

(i) composite of maternal blood transfusion or admission to higher level care, (ii) stillbirth or Apgar score <7 at 5 minutes, (iii) neonatal unit admission.

RESULTS

Planned VBAC at home was associated with a statistically significant increase in the chances of having a vaginal birth compared with planned VBAC in an OU (adjusted relative risk 1.15, 95% confidence interval 1.06-1.24). The risk of an adverse maternal outcome was around 2-3% in both settings, with a similar risk of an adverse neonatal outcome. Transfer rates were high (37%) and varied markedly by parity (para 1, 56.7% versus para 2+, 24.6%).

CONCLUSION

Women in the cohort who planned VBAC at home had an increased chance of a vaginal birth compared with those planning VBAC in an OU, but transfer rates were high, particularly for women with only one previous birth, and the risk of an adverse maternal or perinatal outcome was around 2-3%. No change in guidance can be recommended.

TWEETABLE ABSTRACT

Higher vaginal birth rates in planned VBAC at home versus in OU but 2-3% adverse outcomes and high transfer rate.

Choosing an out-of-hospital birth centre: Exploring women's decision-making experiences

OBJECTIVE

the primary objective for this study was to explore women's experiences of choosing to plan a birth at an out-of-hospital birth centre. We sought to understand how women make the choice to plan for an out-of-hospital birth and the meaning that women ascribe to this decision-making process.

DESIGN, SETTING, AND PARTICIPANTS

a qualitative phenomenological study was conducted in Winnipeg, Canada with a sample of seventeen post partum women who represent the socio-demographic characteristics of the actual users of the Birth Centre in Winnipeg. The women participated in semistructured interviews. Through a feminist perspective and using interpretative phenomenological analysis (IPA), each participant's experience of birthplace decision-making was explored.

FINDINGS

six themes emerged through the analysis: (1) Making the decision in the context of relationships; (2) Exercising personal agency; (3) An expression of one's ideology; (4) Really thinking it through; (5) Fitting into the eligibility criteria; and (6) The psychology of the space. The findings suggested that a woman's sense of safety was related to each of these themes.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the birth centre decision-making experience has many similarities to the homebirth decision-making process. The visceral impact of the physical design of the facility plays an important role and differentiates the birth centre decision from other birth setting options. The concept of relational autonomy was emphasised in this study, in that women make the decision in the context of their relationships with their midwives and partners. The study has implications for midwifery practice and health-care policy related to: client education on birth settings, design of birth environments, validation of the birth centre concept, and upholding the women-centred midwifery model of care. The study highlighted the importance of increasing access to out-of-hospital birth centres.

Vaginal birth after caesarean section: why is uptake so low? Insights from a meta-ethnographic synthesis of women's accounts of their birth choices

OBJECTIVE

To identify what women report influences their preferred mode of birth after caesarean section.

DESIGN

Systematic review of qualitative literature using meta-ethnography.

DATA SOURCES

Medline, EMBASE, ASSIA, CINAHL and PsycINFO (1996 until April 2013; updated September 2015). Hand-searched journals, reference lists and abstract authors.

STUDY SELECTION

Primary qualitative studies reporting women's accounts of what influenced their preferred mode of birth after caesarean section.

DATA EXTRACTION AND SYNTHESIS

Primary data (quotations from study participants) and authors' interpretations of these were extracted, compared and contrasted between studies, and grouped into themes to support the development of a 'line of argument' synthesis.

RESULTS

20 papers reporting the views of 507 women from four countries were included. Distinctive clusters of influences were identified for each of three groups of women. Women who confidently sought vaginal birth after a caesarean section were typically driven by a long-standing anticipation of vaginal birth. Women who sought a repeat caesarean section were strongly influenced by distressing previous birth experiences, and at times, by encouragement from social contacts. Women who were more open to information and professional guidance had fewer strong preconceptions and concerns, and viewed a range of considerations as potentially important.

CONCLUSIONS

Women's attitudes towards birth after caesarean section appear to be shaped by distinct clusters of influences, suggesting that opportunities exist for clinicians to stratify and personalise decision support by addressing relevant ideas, concerns and experiences from the first caesarean section birth onwards.

Factors associated with caesarean section among primiparous adolescents in Brazil, 2011-2012

This paper presents the factors associated with caesarean section in primiparous adolescents in Brazil using data from a national hospital-based survey conducted between 2011 and 2012. Information was obtained from postpartum women through face-to-face and telephone interviews and a theoretical model with three levels of hierarchy was used to analyze associations with the dependent variable mode of delivery (caesarean or vaginal). The results show that the caesarean section rate among primiparous teenagers is high (40%). The most significant contributing factors for caesarean section were: considering this mode of delivery safer (OR=7.0; 95%CI: 4.3-11.4); giving birth under the private health system (OR=4.3; 95%CI: 2.3-9.0); being attended by the same health care professional throughout prenatal care and delivery (OR=5.7; 95%CI: 3.3-9.0) and clinical history of risk and complications during pregnancy (OR=10.8; 95%CI: 8.5-13.7). Adolescent pregnancy continues to be an important concern on the reproductive health agenda and the rates observed by this study are worrying given the effects of early exposure to caesarean section.

What Makes for Good Collaboration and Communication in Maternity Care? A Scoping Study

BACKGROUND: Good communication and collaboration are critical to safe care for mothers and babies.

OBJECTIVE: To identify factors associated with good collaboration and communication among maternity care professionals and between both professionals and parents.

METHOD: Scoping study. We searched PubMed and Web of Science for peer reviewed, quantitative and qualitative, original, primary research in Western societies on communication and collaboration in maternity care among professionals (Search 1) and between professionals and parents (Search 2).

FINDINGS: The 40 studies (14 in Search 1; 26 in Search 2) that met our selection criteria highlighted several factors associated with good communication and collaboration. We grouped these factors into 6 categories: Expertise, Partnership, Context, Attitude, Trust, and Communication style. Studies of communication and collaboration among professionals foregrounded work-related aspects, whereas studies examining collaboration between professionals and parents paid more attention to interpersonal aspects. Before 2012, few studies covered positive aspects of communication and collaboration. We also found an underrepresentation of parents in study populations.

CONCLUSION: Our study is part of a growing trend of identifying the positive aspects of communication and collaboration in maternity care. As the study of collaboration in practice continues, researchers need to be sure to involve all stakeholders, including parents.

Giving birth with epidural analgesia: the experience of first-time mothers

The purpose of our qualitative descriptive study was to describe the birth experiences of women using epidural analgesia for pain management. We interviewed nine primiparas who experienced vaginal births. Five themes emerged: (a) coping with pain, (b) finding epidural administration uneventful, (c) feeling relief having an epidural, (d) experiencing joy, and (e) having unsettled feelings of ambivalence. Although epidural analgesia was found to be effective for pain relief and may contribute to some women's satisfaction with the birth experience, it does not guarantee a quality birth experience. In order to support and promote childbearing women's decision making, we recommend improved education on the variety of available pain management options, including their risks and benefits. Fostering a sense of caring, connection, and control in women is a key factor to ensure positive birth experiences, regardless of pain management method.

The cesarean decision survey

A descriptive study design was used to describe the decision of women having a cesarean surgery. The Cesarean Birth Decision Survey was used to collect data from 101 postpartum women who underwent a cesarean. Most of the surgeries were to primipara women who reported doctor recommendation and increased safety for the baby as the main reasons for the cesarean. Those women who had repeat cesarean surgery all cited their previous cesarean as the main reason for the current surgery. Women's knowledge of cesarean surgery needs to be assessed early in pregnancy so that appropriate education may be provided. Accurate and ongoing information may decrease the number of women choosing a cesarean surgery.

'Groping through the fog': a metasynthesis of women's experiences on VBAC (Vaginal birth after Caesarean section)

BACKGROUND

Vaginal birth after Caesarean section (VBAC) is a relevant question for a large number of women due to the internationally rising Caesarean section (CS) rate. There is a great deal of research based on quantitative studies but few qualitative studies about women's experiences.

METHOD

A metasynthesis based on the interpretative meta ethnography method was conducted. The inclusion criterion was peer-review qualitative articles from different disciplines about women's experiences of VBAC. Eleven articles were checked for quality, and eight articles were included in the synthesis.

RESULTS

The included studies were from Australia (four), UK (three), and US (one), and studied women's experience in relation to different aspects of VBAC; decision-making whether to give birth vaginally, the influence of health professionals on decision-making, reason for trying a vaginal birth, experiences when choosing VBAC, experiences of giving birth vaginally, and giving birth with CS when preferring VBAC. The main results are presented with the metaphor groping through the fog; for the women the issue of VBAC is like being in a fog, where decision-making and information from the health care system and professionals, both during pregnancy and the birth, is unclear and contrasting. The results are further presented with four themes: 'to be involved in decision about mode of delivery is difficult but important,' 'vaginal birth has several positive aspects mainly described by women,' 'vaginal birth after CS is a risky project,' and 'own strong responsibility for giving birth vaginally'.

CONCLUSION

In order to promote VBAC, more studies are needed from different maternity settings and countries about women's experiences. Women need evidence-based information not only about the risks involved but also positive aspects of VBAC.

Womens' attitudes and beliefs of childbirth and association with birth preference: a comparison of a Swedish and an Australian sample in mid-pregnancy

BACKGROUND

the rate of caesarean in Australia is twice that of Sweden. Little is known about women's attitudes towards birth in countries where the caesarean rate is high compared to those where normal birth is a more common event.

OBJECTIVES

to compare attitudes and beliefs towards birth in a sample of Australian and Swedish women in mid-pregnancy.

PARTICIPANTS

women from rural towns in mid Sweden (n=386) and north-eastern Victoria in Australia (n=123).

METHODS

questionnaire data was collected from 2007 to 2009. Levels of agreement or disagreement were indicated on sixteen attitude and belief statements regarding birth. Principal components analysis (PCA) identified the presence of subscales within the attitudes inventory. Using these subscales, attitudes associated with preferred mode of birth were determined. Odds ratios were calculated at 95% CI by country of care.

RESULTS

the Australian sample was less likely than the Swedish sample to agree that they would like a birth that: 'is as pain free as possible' OR 0.4 (95% CI: 0.2-0.7), 'will reduce my chance of stress incontinence' OR 0.2 (95% CI: 0.1-0.8), 'will least affect my future sex life' OR 0.3 (95% CI: 0.2-0.6), 'will allow me to plan the date when my baby is born' OR 0.4 (95% CI: 0.2-0.7) and 'is as natural as possible' OR 0.4 (95% CI: 0.2-0.9). They were also less likely to agree that: 'if a woman wants to have a caesarean she should be able to have one under any circumstances' OR 0.4 (95% CI: 0.2-0.7) and 'giving birth is a natural process that should not be interfered with unless necessary' OR 0.3 (95% CI: 0.1-0.7). Four attitudinal subscales were found: 'Personal Impact of Birth', 'Birth as Natural Event', 'Freedom of Choice' and 'Safety Concerns'. Women who preferred a caesarean, compared to those who preferred a vaginal birth, across both countries were less likely to think of 'Birth as a natural event'.

KEY CONCLUSIONS

the Australian women were less likely than the Swedish women to hold attitudes and beliefs regarding the impact of pregnancy and birth on their body, the right to determine the type of birth they want and to value the natural process of birth. Women from both countries who preferred caesarean were less likely to agree with attitudes related to birth as a natural event.