“I had to fight for my VBAC”: A mixed methods exploration of women’s experiences of pregnancy and vaginal birth after cesarean in the United States

Abstract

Background Vaginal birth after cesarean (VBAC) is safe, cost‐effective, and beneficial. Despite professional recommendations supporting VBAC and high success rates, VBAC rates in the United States (US) have remained below 15% since 2002. Very little has been written about access to VBAC in the United States from the perspectives of birthing people. We describe findings from a mixed methods study examining experiences seeking a VBAC in the United States. Methods Individuals with a history of cesarean and recent subsequent birth were recruited through social media groups. Using an online questionnaire, we collected sociodemographic and birth history information, qualitative accounts of participants’ experiences, and scores on the Mothers on Respect Index, the Mothers Autonomy in Decision Making Scale, and the Generalized Self‐Efficacy Scale. Results Participants (N = 1711) representing all 50 states completed the questionnaire; 1151 provided qualitative data. Participants who planned a VBAC reported significantly greater decision‐making autonomy and respectful treatment in their maternity care compared with those who did not. The qualitative theme: “I had to fight for my VBAC” describes participants’ accounts of navigating obstacles to VBAC, including finding a supportive provider and traveling long distances to locate a clinician and/or hospital willing to provide care. Participants cited support from providers, doulas, and peers as critical to their ability to acquire the requisite knowledge and power to effectively self‐advocate. Discussion Findings highlight the difficulties individuals face accessing VBAC within the context of a complex health system and help to explain why rates of attempted VBAC remain low.

Experiences of Quality Perinatal Care During the US COVID‐19 Pandemic

“…In our study, 1 in 3 participants reported that they did not receive high‐quality perinatal care during the COVID‐19 pandemic. Participants who identified as BIPOC (racial and ethnic minorities) were less likely to experience high‐quality perinatal care than white participants, which is similar to experiences reported by BIPOC participants in other studies 31,38,39 . The quality of health care received, from preconception through postpartum care, may be a “critical lever for improving outcomes for racial and ethnic minority women.” 12 (p2) There is significant research showing that experiences of disrespectful care and mistreatment by health care providers, including racism and racial discrimination, are linked to health and specifically to negative birth outcomes for women and infants of color 40–43 …”

“…The study's focus on health equity in maternal health corresponds to the latest priorities of the US Surgeon General and Department of Health and Human Services 48,49 . Although the experiences of our participants occurred during a global health crisis, their mean scores on the MADM and MOR were slightly higher than in a comparable pre‐COVID‐19 US national sample, 39 and median scores were higher than pre‐COVID‐19 Australian and German samples 50,51 …”

Inequities in quality perinatal care in the United States during pregnancy and birth after cesarean

“…These included lacking health insurance, being unable to meet financial obligations, being unable to buy enough food, having their heat or electricity turned off, being unable to find work, housing instability, intimate partner violence, incarceration of self or partner, involvement of child protective services, and problems with drug/alcohol dependency. The full sample has been previously described in detail [ 9 ].…”

“…Participants were included irrespective of the final mode of birth for their subsequent birth. The survey design and measures, data collection, sampling, recruitment, and results related to VBAC have been previously described in detail [ 9 ]. In brief, we designed, pilot-tested, revised, and then distributed a cross-sectional, retrospective, online questionnaire via the Qualtrics (Provo, UT) platform.…”

“…Prior studies have found that women who have a hospital-based vaginal birth after cesarean (VBAC) [ 7 ] and those who decline care [ 8 ] are more likely to experience mistreatment during childbirth. Women who desired a VBAC, but were unable to plan one, were less likely to experience respectful maternity care or to have autonomy in their decision making for their maternity care than women who planned a VBAC [ 9 ]. Recent studies found that individuals who reported a difference of opinion with their providers about the right care for themselves or their baby were significantly more likely to report mistreatment or to feel disrespected and coerced by their provider [ 7 , 9 , 10 ].…”