Improving the organisation of maternal health service delivery and optimising childbirth by increasing vaginal birth after caesarean section through enhanced women-centred care (OptiBIRTH trial): study protocol for a randomised controlled trial (ISRCTN10612254)

Decision-making experiences and the need for decision aids in women considering vaginal birth after cesarean: A qualitative meta-synthesis

AIMS

This study aims to comprehensively explore the decision-making requirements of women contemplating vaginal birth after cesarean (VBAC).

DESIGN & METHODS

A meta-synthesis approach was employed for this study. Using an integrative methodology, we conducted a systematic assessment of women's experiences and needs related to VBAC decision-making. A comprehensive search was conducted across The Cochrane Library, PubMed, EMBASE, Ovid Medline, SCOPUS, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Wan Fang databases to identify pertinent studies between 2000 and 2022. Furthermore, the reference lists of the included studies were thoroughly examined.

RESULTS

Fifteen studies were incorporated, from which seven themes emerged: emotional changes, preference for vaginal birth, unmet information needs, influences on decision-making, decision-making autonomy, aligning information provision with decision-support needs, and the requirement for support systems. Two primary syntheses were constructed on the decision-making process and the need for decision-making aids, respectively.

CONCLUSION

Women opting for VBAC experienced emotional shifts during their decision-making process in pregnancy. There remains a need for an enhanced decision-making tool to guide them in their choice. Recommendations for implementation in VBAC decision aids include facilitating women's involvement in decision-making, satisfying their information needs, and delivering appropriate emotional support.

Educational interventions targeting pregnant women to optimise the use of caesarean section: What are the essential elements? A qualitative comparative analysis

BACKGROUND

Caesarean section (CS) rates are increasing globally, posing risks to women and babies. To reduce CS, educational interventions targeting pregnant women have been implemented globally, however, their effectiveness is varied. To optimise benefits of these interventions, it is important to understand which intervention components influence success. In this study, we aimed to identify essential intervention components that lead to successful implementation of interventions focusing on pregnant women to optimise CS use.

METHODS

We re-analysed existing systematic reviews that were used to develop and update WHO guidelines on non-clinical interventions to optimise CS. To identify if certain combinations of intervention components (e.g., how the intervention was delivered, and contextual characteristics) are associated with successful implementation, we conducted a Qualitative Comparative Analysis (QCA). We defined successful interventions as interventions that were able to reduce CS rates. We included 36 papers, comprising 17 CS intervention studies and an additional 19 sibling studies (e.g., secondary analyses, process evaluations) reporting on these interventions to identify intervention components. We conducted QCA in six stages: 1) Identifying conditions and calibrating the data; 2) Constructing truth tables, 3) Checking quality of truth tables; 4) Identifying parsimonious configurations through Boolean minimization; 5) Checking quality of the solution; 6) Interpretation of solutions. We used existing published qualitative evidence synthesis to develop potential theories driving intervention success.

RESULTS

We found successful interventions were those that leveraged social or peer support through group-based intervention delivery, provided communication materials to women, encouraged emotional support by partner or family participation, and gave women opportunities to interact with health providers. Unsuccessful interventions were characterised by the absence of at least two of these components.

CONCLUSION

We identified four key essential intervention components which can lead to successful interventions targeting women to reduce CS. These four components are 1) group-based delivery, 2) provision of IEC materials, 3) partner or family member involvement, and 4) opportunity for women to interact with health providers. Maternal health services and hospitals aiming to better prepare women for vaginal birth and reduce CS can consider including the identified components to optimise health and well-being benefits for the woman and baby.

Cesarean section rates in Turkey 2018-2023: Overview of national data by using Robson ten group classification system

Objective

Cesarean section (CS) rates continue to rise globally because of various factors. Medically unnecessary cesarean operations have no benefit to the mother or child's health. Since the World Health Organization (WHO) has determined that the acceptable CS rate should not be more than 10-15%, it also stated the use of a classification system to compare different patient groups and facilities. Turkey has the highest CS rates globally and has been rising over the years. This study aims to assess CS rates between 2018 and 2023 using National Health Data and to analyze them according to the Robson classification system and WHO reference values to discuss possible measures against increasing rates.

Materials and Methods

In this study, we assessed the rates of CSs between 2018 and 2023; the CS rate including all 5-years and analysis of CS rates for each Robson group as advocated by WHO. Also, another assessment was done of the facilities where the CSs were applied (Public, private, or university hospitals).

Results

The total number of births recorded between 2018 and2023 was 6.161.976. The overall CS rate was 57.55%. The number of total CS operations was 3.546.049. The primary CS rate was 28.83% (N:1.776.503). Significant differences were observed between the public and private centers for each Robson group.

Conclusion

The CS rates of Groups 1-4 are obviously higher than expected. The CSs of these groups cumulatively affect the rates of other groups. Nulliparous women have CSs mostly in private hospitals. There is a need for improvements in the health system in this regard for better maternal and child health.

Interventions targeting healthcare providers to optimise use of caesarean section: a qualitative comparative analysis to identify important intervention features

BACKGROUND

Rapid increases in caesarean section (CS) rates have been observed globally; however, CS rates exceeding 15% at a population-level have limited benefits for women and babies. Many interventions targeting healthcare providers have been developed to optimise use of CS, typically aiming to improve and monitor clinical decision-making. However, interventions are often complex, and effectiveness is varied. Understanding intervention and implementation features that likely lead to optimised CS use is important to optimise benefits. The aim of this study was to identify important components that lead to successful interventions to optimise CS, focusing on interventions targeting healthcare providers.  METHODS: We used Qualitative Comparative Analysis (QCA) to identify if certain combination of important intervention features (e.g. type of intervention, contextual characteristics, and how the intervention was delivered) are associated with a successful intervention as reflected in a reduction of CS. We included 21 intervention studies targeting healthcare providers to reduce CS, comprising of 34 papers reporting on these interventions. To develop potential theories driving intervention success, we used existing published qualitative evidence syntheses on healthcare providers' perspectives and experiences of interventions targeted at them to reduce CS.

RESULTS

We identified five important components that trigger successful interventions targeting healthcare providers: 1) training to improve providers' knowledge and skills, 2) active dissemination of CS indications, 3) actionable recommendations, 4) multidisciplinary collaboration, and 5) providers' willingness to change. Importantly, when one or more of these components are absent, dictated nature of intervention, where providers are enforced to adhere to the intervention, is needed to prompt successful interventions. Unsuccessful interventions were characterised by the absence of these components.

CONCLUSION

We identified five important intervention components and combinations of intervention components which can lead to successful interventions targeting healthcare providers to optimise CS use. Health facility managers, researchers, and policy-makers aiming to improve providers' clinical decision making and reduce CS may consider including the identified components to optimise benefits.

Effect of a Locally Tailored Clinical Pathway Tool on VBAC Outcomes in a Private Hospital in India

Background

Customized clinical and administrative interventions in the form of a care pathway tool can improve VBAC outcomes and reduce the alarming rise in caesarean sections globally.

Objective

To determine the effect of a locally tailored clinical pathway tool on VBAC outcomes in a private hospital in India.

Methods

A pre- and post-implementation study was conducted in a private hospital in India. All women with one previous caesarean section term pregnancy and cephalic presentation were included at baseline from January 2013 to December 2015 (Phase 1) and from January 2016 to December 2018 (Phase 2) after ongoing implementation of a clinical pathway tool by all providers. Background characteristics and clinical outcomes in both phases were reviewed retrospectively from case files.

Results

Overall 223 (13.42%) women among 1661 total births and 244 (11.62%) women among 2099 total births were included in Phase 1 and Phase 2, respectively. Total number of women who underwent trial of labour (TOLAC) increased from 36.77% to 64.34% (P < 0.001) and VBAC rate increased from 23.76% to 58.19% (P < 0.001) in Phase 2. There was no significant difference in perinatal morbidity and mortality in the two phases.

Conclusion

A locally customized clinical care pathway tool implemented to support both mothers and care givers for TOLAC seemed to improve VBAC outcomes in a private setting in India.

"An unnecessary cut?" multilevel health systems analysis of drivers of caesarean sections rates in Italy: a systematic review

BACKGROUND

Improvements in medical technologies have seen over-medicalization of childbirth. Caesarean section (CS) is a lifesaving procedure proven effective in reducing maternal and perinatal mortality across the globe. However, as with any medical procedure, the CS intrinsically carries some risk to its beneficiaries. In recent years, CS rates have risen alarmingly in high-income countries. Many exceeding the World Health Organisation (WHO) recommendation of a 10 to 15% annual CS rate. While this situation poses an increased risk to women and their children, it also represents an excess human and financial burden on health systems. Therefore, from a health system perspective this study systematically summarizes existing evidence relevant to the factors driving the phenomenon of increasing CS rates using Italy as a case study.

METHODS

Employing the WHO Health System Framework (WHOHSF), this systematic review used the PRISMA guidelines to report findings. PubMed, SCOPUS, MEDLINE, Cochrane Library and Google Scholar databases were searched up until April 1, 2020. Findings were organised through the six dimensions of the WHOHSF framework: service delivery, health workforce, health system information; medical products vaccine and technologies, financing; and leadership and governance.

RESULTS

CS rates in Italy are affected by complex interactions among several stakeholder groups and contextual factors such as the hyper-medicalisation of delivery, differences in policy and practice across units and the national context, issues pertaining to the legal and social environment, and women's attitudes towards pregnancy and childbirth.

CONCLUSION

Mitigating the high rates of CS will require a synergistic multi-stakeholder intervention. Specifically, with processes able to attract the official endorsement of policy makers, encourage concensus between regional authorities and local governments and guide the systematic compliance of delivery units with its clinical guidelines.

'No to unnecessary caesarean sections': Evaluation of a mass-media campaign on women's knowledge, attitude and intention for mode of delivery

Introduction

Improvement of women’s knowledge and attitude toward vaginal birth is recognized as an important strategy to control caesarean sections (CS) on maternal request. This study aimed to evaluate the effectiveness of a mass-media campaign in improving knowledge, attitude and intention of women for vaginal birth.

Methods

This was a population-based study carried out in Tehran, Iran. A national ‘No to unnecessary caesarean sections’ campaign was launched in April 2016 and was televised for ten days. A random sample of pregnant women from all defined geographical areas of Tehran were recruited and assessed for knowledge about the benefits of vaginal birth and the risk of CS, attitude and intention toward mode of delivery at two points in time: before and after the campaign. A comparison was made to evaluate outcome measures among those who had seen the campaign and those who had not.

Results

In all, 37 public and private maternity care centers were selected randomly and 702 eligible pregnant women attending these centers were entered in the study. Pre- and post-intervention data for 466 women were available for analysis. Of these, 194 women indicated that they had seen the campaign and the remaining 272 women said that they had not. A comparison of the outcome measures between the two study groups showed that there were significant differences between those who had seen the campaign and those who had not. Those who had seen the campaign reported increased knowledge, had a more positive attitude and indicated increased behavioral intention toward vaginal birth.

Conclusions

In general, the findings indicated that the mass-media campaign improved pregnant women’s knowledge, attitude and intention towards vaginal birth. However, the long-term effects of such campaigns need further investigation.

Nutri-Epigenetics and Gut Microbiota: How Birth Care, Bonding and Breastfeeding Can Influence and Be Influenced?

Maternal lifestyle is an important factor in the programming of an infant's epigenome, in particular when considered alongside the mode of birth and choice of feeding method (i.e., breastfeeding or formula feeding). Beginning in utero, and during the first two years of an infant's life, cells acquire an epigenetic memory of the neonatal exposome which can be influential across the entire lifespan. Parental lifestyle (e.g., malnutrition, alcohol intake, smoke, stress, exposure to xenobiotics and/or drugs) can modify both the maternal and paternal epigenome, leading to epigenetic inheritance in their offspring. This review aims to outline the origin of early life modulation of the epigenome, and to share this fundamental concept with all the health care professionals involved in the development and provision of care during childbirth in order to inform future parents and clinicians of the importance of the this process and the key role it plays in the programming of a child's health.

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.

Preference of birth mode and postnatal health related quality of life after one previous caesarean section in three European countries

OBJECTIVES

Women who have had a caesarean section may have a preference for birth mode during their subsequent pregnancy, either 'vaginal birth after caesarean' (VBAC) or 'elective repeat caesarean section' (ERCS). A mismatch between the preferred and actual birth mode may result in an impaired postnatal Health Related Quality of Life (HRQoL). This study examined the associations between antenatal birth mode preferences, the actual birth mode and postnatal HRQoL in women with one previous caesarean section in three European countries.

DESIGN

Prospective longitudinal survey, as a part of a cluster randomised trial (OptiBIRTH) SETTING: Fifteen maternity units in three European countries: Germany (5), Ireland (5) and Italy (5).

PARTICIPANTS

Women (≥ aged 18 years) living in Germany, Ireland and Italy with one previous caesarean section. The sample consisted of 862 women with complete antenatal and postpartum data.

MEASUREMENTS

Women's preference for birth mode after one previous caesarean section was assessed at inclusion to the trial, and HRQoL was assessed antenatally and at three months postpartum using the Short-Form Six-Dimension health survey. Based on women's preferences and actual birth mode six groups were determined: "match VBAC-VBAC" (preference for vaginal birth, actual mode of birth vaginal birth), "match ERCS-ERCS" (preference for caesarean section, actual mode of birth elective repeat caesarean section), "match ERCS-EMCS" (preference for caesarean section, actual mode of birth emergency repeat caesarean section), "mismatch VBAC-ERCS" (preference for vaginal birth, actual mode of birth elective repeat caesarean section), "mismatch VBAC-EMCS" (preference for vaginal birth, actual mode of birth emergency repeat caesarean section) and "no preference". Associations between the preferred and actual birth mode were examined using univariate and multivariate analyses.

FINDINGS

Women with preference for vaginal birth but who gave birth by elective repeat caesarean section (mismatch VBAC-ERCS) had a lower postnatal HRQoL compared to women with a preference for vaginal birth who actually had a birth vaginally (match VBAC-VBAC, p = 0.02). Poor antenatal HRQoL scores (p < 0.01) and maternal readmission postpartum (p = 0.03) are cofounding factors for poorer postnatal HRQoL scores.

KEY CONCLUSIONS

The results show that women with a preference for a vaginal birth who gave birth by an elective repeat caesarean section had a significantly lower HRQoL at three months postnatal. The long-term consequences and psychological health of women who do not achieve a vaginal birth after caesarean require further consideration and research.

IMPLICATIONS FOR PRACTICE

Attention should be given to the long-term impact of a mismatch in preferred and actual mode on the psychological health of women.

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'.

Maternal and neonatal outcomes for women giving birth after previous cesarean

INTRODUCTION

Rising rates of caesarean section (CS) is an issue of particular concern. Recently, there has been research supporting Vaginal Births After Caesarean (VBAC), which is controversial. In Greece, over half of births in the country are by CS, placing Greece among countries with the highest CS rates. The aim of this study was to investigate the prevalence and the factors associated with VBACs and to compare the maternal/neonatal outcomes with a 'non-caesarean' control group.

METHODS

The data were evaluated and retrospectively gathered on archived singleton births, from medical records of a midwifery-led team, between May 2006 and May 2013. The target group of the study included mothers with a previous CS, who had a second birth. The sample consisted of 71 VBAC women and 583 who had normal spontaneous vaginal delivery (NSVD) as the 'non-caesarean' control group.

RESULTS

The duration of labour was longer for the VBACs compared with first-time mothers who gave birth naturally (for duration 481-720 min, 27% vs 10.3%, respectively), episiotomy was more common for VBAC (20.7% vs 7.9%), and epidural analgesia was more often for VBAC (68.4% vs 10%). The percentage of 1-min Apgar score in the range 0-7 in the VBAC group was 5%, and there was no significant difference in women who had NSVD (3.6%). The Apgar score in the 5th minute was always above 8 for both groups.

CONCLUSIONS

Severe maternal and neonatal complications are infrequent, and therefore the necessity arises for further continuous studies to ascertain the safety of VBAC.

Health economic analysis of a cluster-randomised trial (OptiBIRTH) designed to increase rates of vaginal birth after caesarean section

OBJECTIVE

To perform a health economic analysis of an intervention designed to increase rates of vaginal birth after caesarean, compared with usual care.

DESIGN

Economic analysis alongside the cluster-randomised OptiBIRTH trial (Optimising childbirth by increasing vaginal birth after caesarean section (VBAC) through enhanced women-centred care).

SETTING

Fifteen maternity units in three European countries - Germany (five), Ireland (five), and Italy (five) - with relatively low VBAC rates.

POPULATION

Pregnant women with a history of one previous lower-segment caesarean section; sites were randomised (3:2) to intervention or control.

METHODS

A cost-utility analysis from both societal and health-services perspectives, using a decision tree.

MAIN OUTCOME MEASURES

Costs and resource use per woman and infant were compared between the control and intervention group by country, from pregnancy recognition until 3 months postpartum. Based on the caesarean section rates, and maternal and neonatal morbidities and mortality, the incremental cost-utility ratios were calculated per country.

RESULTS

The mean difference in costs per quality-adjusted life years (QALYs) gained from a societal perspective between the intervention and the control group, using a probabilistic sensitivity analysis, was: €263 (95% CI €258-268) and 0.008 QALYs (95% CI 0.008-0.009 QALYs) for Germany, €456 (95% CI €448-464) and 0.052 QALYs (95% CI 0.051-0.053 QALYs) for Ireland, and €1174 (95% CI €1170-1178) and 0.006 QALYs (95% CI 0.005-0.007 QALYs) for Italy. The incremental cost-utility ratios were €33,741/QALY for Germany, €8785/QALY for Ireland, and €214,318/QALY for Italy, with a 51% probability of being cost-effective for Germany, 92% for Ireland, and 15% for Italy.

CONCLUSION

The OptiBIRTH intervention was likely to be cost-effective in Ireland and Germany.

TWEETABLE ABSTRACT

The OptiBIRTH intervention (to increase VBAC rates) is likely to be cost-effective in Germany and Ireland.

Labour characteristics of women achieving successful vaginal birth after caesarean section in three European countries

OBJECTIVE

Knowledge about labour characteristics of women achieving successful vaginal birth after caesarean section (VBAC) might be used to improve labour and birth management. This study examined sociodemographic and labour process-related factors regarding a) differences between countries, b) the comparison of successful VBAC with unplanned caesarean section, and c) predictors for the success of planned VBAC in three European countries.

DESIGN

We analysed observational data collected within the OptiBIRTH trial, a cluster-randomised controlled trial.

SETTING

Fifteen study sites in Ireland, Italy and Germany, five in each country.

PARTICIPANTS

790 participants going into labour for planned VBAC.

MEASUREMENTS

Descriptive statistics and random-effects logistic regression models were applied.

FINDINGS

The pooled successful VBAC-rate was 74.6%. Italy had the highest proportion of women receiving none of the four intrapartum interventions amniotomy (ARM), oxytocin, epidural or opioids (42.5% vs Ireland: 26.8% and Germany: 25.3%, p < 0.001). Earlier performance of ARM was associated with successful VBAC (3.50 hrs vs 6.08 hrs, p = 0.004). A positive predictor for successful vaginal birth was a previous vaginal birth (OR=3.73, 95% CI [2.17, 6.44], p < 0.001). The effect of ARM increased with longer labour duration (OR for interaction term=1.06, 95% CI [1.004, 1.12], p = 0.035). Higher infant birthweight (OR per kg=0.34, 95% CI [0.23, 0.50], p < 0.001), ARM (reference spontaneous rupture of membranes (SROM), OR=0.20, 95% CI [0.11, 0.37], p < 0.001) and a longer labour duration (OR per hour=0.93, 95% CI [0.90, 0.97], p < 0.001) decreased the odds of a vaginal birth.

KEY CONCLUSION

Women with a previous vaginal birth, an infant with a lower birth weight, SROM and a shorter labour duration were most likely to have a successful vaginal birth. If SROM did not occur, an earlier ARM increased the odds of a vaginal birth.

IMPLICATION FOR PRACTICE

Labour progress should be accelerated by fostering endogenous uterine contractions. With slow labour progress and intact membranes, ARM might increase the chance of a vaginal birth.

Maternity care experiences and health needs of migrant women from female genital mutilation-practicing countries in high-income contexts: A systematic review and meta-synthesis

BACKGROUND

Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for nontherapeutic indications. Due to changing patterns of migration, clinicians in high-income countries are seeing more women from countries where the practice is prevalent. This review aims to understand the sociocultural and health needs of these women and identify opportunities to improve the quality of maternity care for women with FGM.

METHODS

We undertook a systematic review and meta-synthesis of peer-reviewed primary qualitative research to explore the experience and needs of migrant women with FGM receiving maternity care. A structured search of nine databases was undertaken, screened papers appraised, and a thematic analysis undertaken on data extracted from the findings and discussion sections of included papers.

RESULTS

Sixteen peer-reviewed studies were included in the systematic review. Four major themes were revealed: Living with fear, stigma, and anxiety; Feelings of vulnerability, distrust, and discrimination; Dealing with past and present ways of life after resettlement; and Seeking support and involvement in health care.

CONCLUSIONS

The findings suggest that future actions for improving maternity care quality should be focused on woman-centered practice, demonstrating cultural safety and developing mutual trust between a woman and her care providers. Meaningful consultation with women affected by FGM in high-income settings requires cultural sensitivity and acknowledgment of their specific circumstances. This can be achieved by engaging women affected by FGM in service design to provide quality care and ensure woman-focused policy is developed and implemented.

Interventions to reduce unnecessary caesarean sections in healthy women and babies

Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women's and health professionals' concerns, as well as health system and financial factors.

Non-clinical interventions for reducing unnecessary caesarean section

BACKGROUND

Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline.

OBJECTIVES

To evaluate the effectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane. We narratively described results of individual studies (drawing summarised evidence from single studies assessing distinct interventions).

MAIN RESULTS

We included 29 studies in this review (19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies). Most of the studies (20 studies) were conducted in high-income countries and none took place in low-income countries. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.Overall, we found low-, moderate- or high-certainty evidence that the following interventions have a beneficial effect on at least one primary outcome measure and no moderate- or high-certainty evidence of adverse effects.Interventions targeted at women or familiesChildbirth training workshops for mothers alone may reduce caesarean section (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.33 to 0.89) and may increase spontaneous vaginal birth (RR 2.25, 95% CI 1.16 to 4.36). Childbirth training workshops for couples may reduce caesarean section (RR 0.59, 95% CI 0.37 to 0.94) and may increase spontaneous vaginal birth (RR 2.13, 95% CI 1.09 to 4.16). We judged this one study with 60 participants to have low-certainty evidence for the outcomes above.Nurse-led applied relaxation training programmes (RR 0.22, 95% CI 0.11 to 0.43; 104 participants, low-certainty evidence) and psychosocial couple-based prevention programmes (RR 0.53, 95% CI 0.32 to 0.90; 147 participants, low-certainty evidence) may reduce caesarean section. Psychoeducation may increase spontaneous vaginal birth (RR 1.33, 95% CI 1.11 to 1.61; 371 participants, low-certainty evidence). The control group received routine maternity care in all studies.There were insufficient data on the effect of the four interventions on maternal and neonatal mortality or morbidity.Interventions targeted at healthcare professionalsImplementation of clinical practice guidelines combined with mandatory second opinion for caesarean section indication slightly reduces the risk of overall caesarean section (mean difference in rate change -1.9%, 95% CI -3.8 to -0.1; 149,223 participants). Implementation of clinical practice guidelines combined with audit and feedback also slightly reduces the risk of caesarean section (risk difference (RD) -1.8%, 95% CI -3.8 to -0.2; 105,351 participants). Physician education by local opinion leader (obstetrician-gynaecologist) reduced the risk of elective caesarean section to 53.7% from 66.8% (opinion leader education: 53.7%, 95% CI 46.5 to 61.0%; control: 66.8%, 95% CI 61.7 to 72.0%; 2496 participants). Healthcare professionals in the control groups received routine care in the studies. There was little or no difference in maternal and neonatal mortality or morbidity between study groups. We judged the certainty of evidence to be high.Interventions targeted at healthcare organisations or facilitiesCollaborative midwifery-labourist care (in which the obstetrician provides in-house labour and delivery coverage, 24 hours a day, without competing clinical duties), versus a private practice model of care, may reduce the primary caesarean section rate. In one interrupted time series study, the caesarean section rate decreased by 7% in the year after the intervention, and by 1.7% per year thereafter (1722 participants); the vaginal birth rate after caesarean section increased from 13.3% before to 22.4% after the intervention (684 participants). Maternal and neonatal mortality were not reported. We judged the certainty of evidence to be low.We studied the following interventions, and they either made little or no difference to caesarean section rates or had uncertain effects.Moderate-certainty evidence suggests little or no difference in caesarean section rates between usual care and: antenatal education programmes for physiologic childbirth; antenatal education on natural childbirth preparation with training in breathing and relaxation techniques; computer-based decision aids; individualised prenatal education and support programmes (versus written information in pamphlet).Low-certainty evidence suggests little or no difference in caesarean section rates between usual care and: psychoeducation; pelvic floor muscle training exercises with telephone follow-up (versus pelvic floor muscle training without telephone follow-up); intensive group therapy (cognitive behavioural therapy and childbirth psychotherapy); education of public health nurses on childbirth classes; role play (versus standard education using lectures); interactive decision aids (versus educational brochures); labourist model of obstetric care (versus traditional model of obstetric care).We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

We evaluated a wide range of non-clinical interventions to reduce unnecessary caesarean section, mostly in high-income settings. Few interventions with moderate- or high-certainty evidence, mainly targeting healthcare professionals (implementation of guidelines combined with mandatory second opinion, implementation of guidelines combined with audit and feedback, physician education by local opinion leader) have been shown to safely reduce caesarean section rates. There are uncertainties in existing evidence related to very-low or low-certainty evidence, applicability of interventions and lack of studies, particularly around interventions targeted at women or families and healthcare organisations or facilities.

Mode of birth and postnatal health-related quality of life after one previous cesarean in three European countries

BACKGROUND

How a woman gives birth can affect her health-related quality of life (HRQoL). This study explored HRQoL at 3 months postpartum in women with a history of one previous cesarean in three European countries.

METHODS

A prospective longitudinal survey, embedded within a cluster randomized trial in three countries, exploring women's postnatal HRQoL up to 3 months postpartum. The Short-Form Six-Dimensions (SF-6D) was used to measure HRQoL, and multivariate analyses were used to examine the relationship with mode of birth.

RESULTS

Complete data were available from 880 women. Women with a spontaneous vaginal birth had the highest HRQoL scores, whereas women with an emergency repeat cesarean (P = .01) had the lowest. Postnatal readmission of the mother (P = .03), having public health insurance (P = .04), and a low antenatal HRQoL score (P < .01) contributes to poorer HRQoL scores. More specifically, women with a spontaneous vaginal birth had significantly higher HRQoL scores on the vitality dimension compared with women with an emergency repeat cesarean (P = .04).

CONCLUSIONS

In women with low-risk factors, repeat cesareans result in a poorer HRQoL compared with vaginal birth. When there are no contraindications for vaginal birth, women with a history of one previous cesarean should be encouraged to give birth vaginally rather than have an elective repeat cesarean.

Vaginal birth after caesarean versus elective repeat caesarean delivery after one previous caesarean section: a cost-effectiveness analysis in four European countries

BACKGROUND

The OptiBIRTH study incorporates a multicentre cluster randomised trial in 15 hospital sites across three European countries. The trial was designed to test a complex intervention aimed at improving vaginal birth after caesarean section (VBAC) rates through increasing women's involvement in their care. Prior to developing a robust standardised model to conduct the health economic analysis, an analysis of a hypothetical cohort was performed to estimate the costs and health effects of VBAC compared to elective repeat caesarean delivery (ERCD) for low-risk women in four European countries.

METHODS

A decision-analytic model was developed to estimate the costs and the health effects, measured using Quality Adjusted Life Years (QALYs), of VBAC compared with ERCD. A cost-effectiveness analysis for the period from confirmation of pregnancy to 6 weeks postpartum was performed for short-term consequences and during lifetime for long-term consequences, based on a hypothetical cohort of 100,000 pregnant women in each of four different countries; Belgium, Germany, Ireland and Italy. A societal perspective was adopted. Where possible, transition probabilities, costs and health effects were adapted from national data obtained from the respective countries. Country-specific thresholds were used to determine the cost-effectiveness of VBAC compared to ERCD. Deterministic and probabilistic sensitivity analyses were conducted to examine the uncertainty of model assumptions.

RESULTS

Within a 6-week time horizon, VBAC resulted in a reduction in costs, ranging from €3,334,052 (Germany) to €66,162,379 (Ireland), and gains in QALYs ranging from 6399 (Italy) to 7561 (Germany) per 100,000 women birthing in each country. Compared to ERCD, VBAC is the dominant strategy in all four countries. Applying a lifetime horizon, VBAC is dominant compared to ERCD in all countries except for Germany (probabilistic analysis, ICER: €8609/QALY). In conclusion, compared to ERCD, VBAC remains cost-effective when using a lifetime time.

CONCLUSIONS

In all four countries, VBAC was cost-effective compared to ERCD for low-risk women. This is important for health service managers, economists and policy makers concerned with maximising health benefits within limited and constrained resources.

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.

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.

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.

Patterns and Associated Factors of Caesarean Delivery Intention among Expectant Mothers in China: Implications from the Implementation of China's New National Two-Child Policy

OBJECTIVE

This study explores the basic demographic characteristics of expectant mothers in the context of their intentions regarding mode of delivery, in particular, the preference for caesarean delivery, and analyzes the social and psychological factors that influence delivery preference.

METHOD

A cross-sectional survey of pregnant women was conducted during June to August in 2015. This study adopted a stratified sampling method, and 16 representative hospitals in five provinces of China were included.

RESULTS

1755 and 590 of expectant mothers in their first and second pregnancies, respectively, were enrolled in this study. 354 (15.10%) intended to deliver by caesarean section and 585 (24.95%) participants were uncertain prior to delivery. 156 (8.89%) of expectant mothers in their first pregnancy and 198 (33.56%) expectant mothers in their second pregnancy intended to deliver by caesarean section. Ordinal logistic regression analysis found that nationality, parity, trimester of pregnancy, and advanced maternal age were factors associated with intention to deliver by caesarean (ordered logistic regression/three-level caesarean delivery intention criterion; odds ratios p < 0.05).

CONCLUSIONS

8.89% of first pregnancy expectant mothers and 33.56% of second pregnancy expectant mothers intended to deliver by caesarean section. Any intervention program to reduce the rate of Caesarean delivery should focus on the Han population, older pregnant women, and expectant mothers in their second pregnancy, at an early gestation.