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.

Interinstitutional variations in mode of birth after a previous caesarean section: a cross-sectional study in six German hospitals.

AIMS: Regional and interinstitutional variations have been recognized in the increasing incidence of caesarean section. Modes of birth after previous caesarean section vary widely, ranging from elective repeat caesarean section (ERCS) and unplanned repeat caesarean section (URCS) after trial of labour to vaginal birth after caesarean section (VBAC). This study describes interinstitutional variations in mode of birth after previous caesarean section in relation to regional indicators in Germany. MATERIAL AND METHODS: A cross-sectional study using the birth registers of six maternity units (n=12,060) in five different German states (n=370,209). Indicators were tested by χ2 and relative deviations from regional values were expressed as relative risks and 95% confidence intervals. RESULTS: The percentages of women in the six units with previous caesarean section ranged from 11.9% to 15.9% (P=0.002). VBAC was planned for 36.0% to 49.8% (P=0.003) of these women, but actually completed in only 26.2% to 32.8% (P=0.66). Depending on the indicator, the units studied deviated from the regional data by up to 32% [relative risk 0.68 (0.47-0.97)] in respect of completed VBAC among all initiated VBAC. CONCLUSIONS: There is substantial interinstitutional variation in mode of birth following previous caesarean section. This variation is in addition to regional patterns.

Does the way that women experience the onset of labour influence the duration of labour?

OBJECTIVE: To assess whether the way in which women experience the onset of their labour influences the duration of their labour. DESIGN: Longitudinal study on a convenient sample of women in spontaneous labour with a singleton pregnancy in cephalic presentation at term. SETTING: University hospital in Germany. POPULATION/SAMPLE: Six hundred and fifty-one women (347 primiparae and 304 parae). METHODS: Women recorded how and when labour had started. Responses were subjected to structured content analysis. Two investigators independently subdivided women's reported signs and symptoms into eight predefined categories. These data were related to maternal characteristics and to the course and outcome of labour as documented in the perinatal record. MAIN OUTCOME MEASURES: Women's perception of how labour had started, interval between onset of labour and rupture of the membranes and duration of first stage labour and overall duration of labour. RESULTS: Only 60% of women reported contractions as a sign of the onset of their labour. These women had a longer interval between the onset of labour and rupture of the membranes but a similar duration of labour when compared with women who did not report contractions as a sign of the onset of labour. Self-reported loss of amniotic fluid was the only sign that showed a consistent relationship with the duration of labour. Other patterns of labour onset had no effect on the duration of labour. CONCLUSION: Irrespective of whether they have given birth before, women experience their onset of labour in a variety of ways. A large proportion of these experiences bear no resemblance to the classical diagnosis of labour and most are unrelated to the duration of labour.