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.

Ingela Lundgren,Christina Nilsson,Susanne Grylka-Baeschlin,Andrea Matterne,Sandra Morano,Joan Lalor,Mechthild M Gross,Cecily Begley,Jane Nicoletti,Margaret Carroll,Patricia Healy

doi:10.1186/s12884-016-1144-0

Abstract

BackgroundCaesarean 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.MethodsFocus 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.ResultsThe 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.ConclusionsThe 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.

Highlights

Caesarean section (CS) rates are increasing worldwide and the most common reason is repeat CS following previous CS
Caesarean section (CS) rates are increasing in both resource-intense and resource-poor countries [1]; of concern is the variation in CS rates internationally
As the purpose of this phase of the study was to inform the development of an intervention to increase vaginal birth after a previous CS (VBAC) rates in countries with low rates, agreement was reached within the research team that the following five questions would be asked in the same order, in each site and in each country: What factors are important for VBAC? What are the barriers to VBAC? What is important to you as a professional? What are your views on shared decision making with women? How can women be supported to be confident with VBAC?

Summary

Introduction

Caesarean section (CS) rates are increasing worldwide and the most common reason is repeat CS following previous CS. In the absence of a robust justification of these increasing rates, an exploration of clinicians’ attitudes to CS as a mode of birth is required [2, 5,6,7], since an understanding of the non-medical factors associated with the decision to perform a CS are becoming more important. These factors include maternal requests [8] and provider attitudes [9]. Evidence exists that for most women a VBAC is safe, practice varies significantly, with as few as 29–36 % of women in Ireland, Italy and Germany experiencing a VBAC compared with 45–55 % of women in Finland, Sweden and the Netherlands [14]

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Results

Conclusion