Abstract
BackgroundAs the birth policy has been adjusted from one-child-one-couple to universal two-child-one-couple in China, there is an increasing number of women undergoing a second pregnancy after a previous cesarean section (CS). Undertaking an elective repeat CS (ERCS) has been taken for granted and has thus become a major contributor to the increasing CS rate in China. Promoting trial of labor after CS (TOLAC) can reduce the CS rate without compromising delivery outcomes. This study aimed to investigate Chinese obstetricians’ perspectives regarding TOLAC, and the factors associated with their decision-making regarding recommending TOLAC to pregnant women with a history of CS under the two-child policy.MethodsA cross-sectional survey was carried out between May and July 2018. Binary logistic regression was used to determine the factors associated with the obstetricians’ intention to recommend TOLAC to pregnant women with a history of CS. The independent variables included sociodemographic factors and perceptions regarding TOLAC (selection criteria for TOLAC, basis underlying the selection criteria for TOLAC, and perceived challenges regarding promoting TOLAC).ResultsA total of 426 obstetricians were surveyed, with a response rate of ≥83%. The results showed that 31.0% of the obstetricians had no intention to recommend TOLAC to pregnant women with a history of CS. Their decisions were associated with the perceived lack of confidence regarding undergoing TOLAC among pregnant women with a history of CS and their families (odds ratio [OR] = 2.31; 95% CI: 1.38–1.38); obstetricians’ uncertainty about the safety of TOLAC for pregnant women with a history of CS (OR = 0.49; 95% CI: 0.27–0.96), and worries about medical lawsuits due to adverse delivery outcomes (OR = 0.14; 95% CI: 0.07–0.31). The main reported challenges regarding performing TOLAC were lack of clear guidelines for predicting or avoiding the risks associated with TOLAC (83.4%), obstetricians’ uncertainty about the safety of TOLAC for women with a history of CS (81.2%), pregnant women’s unwillingness to accept the risks associated with TOLAC (81.0%) or demand for ERCS (80.7%), and the perceived lack of confidence (77.5%) or understanding (69.7%) regarding undergoing TOLAC among pregnant women and their families.ConclusionA proportion of Chinese obstetricians did not intend to recommend TOLAC to pregnant women with a history of CS. This phenomenon was closely associated with obstetricians’ concerns about TOLAC safety and perceived attitudes of the pregnant women and their families regarding TOLAC. Effective measures are needed to help obstetricians predict and reduce the risks associated with TOLAC, clearly specify the indications for TOLAC, improve labor management, and popularize TOLAC in China. Additionally, public health education on TOLAC is necessary to improve the understanding of TOLAC among pregnant women with a history of CS and their families, and to improve their interactions with their obstetricians regarding shared decision making.
Highlights
As the birth policy has been adjusted from one-child-one-couple to universal two-child-one-couple in China, there is an increasing number of women undergoing a second pregnancy after a previous cesarean section (CS)
Selection criteria for trial of labor after CS (TOLAC) More than 70.0% of the obstetricians reported that the selection criteria for TOLAC should include the following: “Patient agrees to TOLAC and understands the advantages and risks”, “Medical institutions have the resources and capacity to deal with TOLAC complications”, “Fetus is in a cephalic dorsal position”, “Patient’s prior CS involved a transverse incision in the lower segment and no complications, and no contraindications for vaginal delivery exist in the present pregnancy”, “Parturient canal, fetus, force of labor, and patient’s mental factors are in a normal state”, “Ultrasonography shows that the muscular layer of anterior inferior uterus segment is in a normal state”, “Estimated fetal weight
56.1% of the obstetricians believed that the parturition interval should be ≥24 months rather than ≥18 months and 6.6% considered that the estimated fetal weight should be < 4000 g rather than < 3500 g; these conservative precautions were not consistent with the expert consensus in China (Table 2)
Summary
As the birth policy has been adjusted from one-child-one-couple to universal two-child-one-couple in China, there is an increasing number of women undergoing a second pregnancy after a previous cesarean section (CS). Undertaking an elective repeat CS (ERCS) has been taken for granted and has become a major contributor to the increasing CS rate in China. Since the introduction of the two-child policy, women who have become pregnant after a history of CS have been blindly encouraged to undergo an elective repeat CS (ERCS). This approach has been taken for granted and has become a major contributor to the increasing CS rate in China [3, 4]. TOLAC can fail and can lead to repeated CS, instrumental delivery, and even worse outcomes such as complications (< 1%) including, though very rarely (< 1‰), uterine rupture [10, 18,19,20,21]
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