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

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.

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

“…A survey on 44 doctors from countries with VBAC rate > 45% outlined that their confidence with VBAC, working in a united obstetric team positively interacting with each other and with women on defined targets (discussed with the parturients) and following structured strategies contributed to enhanced the VBAC rate 83 . This was confirmed by another survey on 71 doctors from countries with VBAC rates < 36%, stressing the importance of a shared informed decision between women and obstetricians, supported by inter-personal trustfulness, adequate clinical skill/confidence of the obstetric team and clinical decisions sustained by scientific evidence 84 . In another qualitative study based upon focus groups on 22 and 51 women from countries with high 85 and low 86 VBAC rates, women expressed desire for correct information on VBAC from doctors and to share with them the decision-making on DM.…”

“…A number of interventions may be adopted to facilitate this process of change: education of staff/patients by opinion leaders; introduction of a second opinion for all CS; prenatal counselling for women and partners [82][83][84][85]112 . Although, clinical audits, financial penalties and rewards to maternity centres could also be considered.…”

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

“…Sites randomised to the intervention group received a complex, innovative programme of evidence-based antenatal strategies, developed following three systematic reviews [17,20,21], and four qualitative studies with clinicians and women in both high and low VBAC countries [18,19,24,25]. Technology-assisted learning resources were also developed using motivational systems and instructional design theory [26].…”

“…Findings from a recent systematic review of clinicianfocussed interventions showed that the only strategy that significantly increased VBAC rates was an educational intervention provided by an opinion leader [17]. A study of 44 clinicians practising in three countries with high VBAC rates (> 45%) [18], and a similar study based on 71 clinicians from countries with low VBAC rates [19] showed comparable findings related to trust in the clinician-woman relationship, a positive attitude of all centrally involved, early follow-up and fear reduction. However, differences shown related to the decisionmaking process, parameters for VBAC, organisational support and resources, and clinical expertise, which indicate different attitudes and views among clinicians in countries with high and low VBAC rates.…”

The Clinical Analysis of Vaginal Delivery After Cesarean Section, and Favorable factors for Vaginal Delivery

“…In other hand, Susan found most women hadn't enough counseled about delivery and it was affected by many factors [29]. All things considered, give them more supports and encouragements, strengthen the confidence of vaginal delivery, increase care and decrease the fear [30].…”