Women-centred interventions to increase vaginal birth after caesarean section (VBAC): A systematic review

Highlights

• We searched for randomised studies on women-centred interventions designed to improve VBAC rates.

• There were only three studies that evaluated interventions in pregnancy, none during the birth.

• There were no studies showing any effect on VBAC rates.

• Decision-aids and information programmes can help women make decisions on mode of birth.

• There is an urgent need to develop women-centred interventions for improving VBAC rates.

Abstract

Objective

to evaluate the effectiveness of women-centred interventions during pregnancy and birth to increase rates of vaginal birth after caesarean.

Design

we searched bibliographic databases for randomised trials or cluster randomised trials on women-centred interventions during pregnancy and birth designed to increase VBAC rates in women with at least one previous caesarean section. Comparator groups included standard or usual care or an alternative treatment aimed at increasing VBAC rates. The methodological quality of included studies was assessed independently by two authors using the Effective Public Health Practice Project quality assessment tool. Outcome data were extracted independently from each included study by two review authors.

Findings

in total, 821 citations were identified and screened by title and abstract; 806 were excluded and full text of 15 assessed. Of these, 12 were excluded leaving three papers included in the review. Two studies evaluated the effectiveness of decision aids for mode of birth and one evaluated the effectiveness of an antenatal education programme. The findings demonstrate that neither the use of decision aids nor information/education of women have a significant effect on VBAC rates. Nevertheless, decision-aids significantly decrease women׳s decisional conflict about mode of birth, and information programmes significantly increase their knowledge about the risks and benefits of possible modes of birth.

Key conclusions

few studies evaluated women-centred interventions designed to improve VBAC rates, and all interventions were applied in pregnancy only, none during the birth. There is an urgent need to develop and evaluate the effectiveness of all types of women-centred interventions during pregnancy and birth, designed to improve VBAC rates.

Implications for practice

decision-aids and information programmes during pregnancy should be provided for women as, even though they do not affect the rate of VBAC, they decrease women׳s decisional conflict and increase their knowledge about possible modes of birth.

Introduction

Rising rates of caesarean section (CS) is an issue of particular concern in the global maternity care field (EURO-PERISTAT, 2013), due to the increased adverse maternal and neonatal outcomes associated with CS (Morrison et al., 1995, Guise et al., 2010, Marshall et al., 2011). If rates continue to rise at the same pace as in recent years, the overall CS rate is projected to be 56% by 2020 (Solheim et al., 2011). A key factor contributing to increasing rates is the tendency for women who have had a previous CS to have a repeat CS rather than a subsequent vaginal birth (Cheng et al., 2011). Given the higher incidence of placenta praevia, placenta accreta, hysterectomy, and composite maternal morbidity in women who have increasing numbers of CS births (Marshall et al., 2011), the potential effects this trend will have on women׳s health in the future warrants immediate attention.

Vaginal birth after CS (VBAC) has favourable outcomes compared with planned elective repeat CS. Maternal mortality has been shown, through a systematic review and meta-analysis of 203 research reports (Guise et al., 2010), to be significantly increased with elective repeat CS (ERCS) compared with elective VBAC (1.34 versus 0.38 per 10,000). Planned VBAC, however, significantly increases perinatal mortality (13 per 10,000) compared with ERCS (5 per 10,000), though it should be noted that absolute rates of both mortalities are low (Guise et al., 2010).

CS performed without a medically indicated reason i.e., for maternal request, is a frequently cited reason for increasing CS rates, with current rates ranging from 2.6% to 26.8% of all CSs (Quinlivan et al., 1999, Jacquemyn et al., 2003). In particular, one Australian study found that the foremost primary indication for elective caesarean section was woman׳s choice, mostly due to women refusing to agree to a planned VBAC or to agree an attempt at vaginal breech birth (Quinlivan et al., 1999). In Sweden, the rate of CS without a medical indication increased threefold during the period 1997–2006; the most frequently stated reasons for an elective CS, in conjunction with no medical indication, were previous caesarean sections (28%) and childbirth-related fear (13%) (Karlström et al., 2010). Maternal request for CS, both primary and repeat, is strongly associated with fear of childbirth and previous negative birth experience (Karlström et al., 2010, Stjernholm et al., 2010, Nilsson et al., 2012, Størksen et al., 2013).

One qualitative study (Emmett et al., 2006) explored women׳s views of decision-making around mode of birth following a previous CS. Women׳s experiences varied, with some making firm decisions and setting goals for themselves and others remaining uncertain about choosing between repeat CS and VBAC. Information given to women was most commonly provided by doctors and related mostly to procedural matters rather than focusing on the risks and benefits linked with VBAC. Women described that information was not provided routinely and they had to seek it actively, which is disappointing given the number of studies showing that education of all women in the antenatal period (including those with a previous CS) improves birth outcome (Maimburg et al., 2010) and is appreciated and requested by nulliparous and multiparous women alike (Mungrue et al., 2010). For example, relaxation and birth preparation classes, which have led to a reduction in CS rates in nulliparous women (Khunpradit et al., 2011), and psycho-educational group sessions for women experiencing an intense fear of childbirth (Salmela-Aro et al., 2012) could also be tried with women following previous CS.

Despite the knowledge that women respond to educational interventions, a recent metasynthesis of eight qualitative studies (Lundgren et al., 2012) found that women with previous CS felt they were ‘groping through the fog’ when it came to trying to access information on VBAC. The authors of this metasynthesis recommend that clinicians should provide women with evidence-based information on both the risks and benefits of VBAC, to assist in their decision-making. A recent Cochrane Review examined randomised trials of interventions designed to support decision-making about VBAC, the acceptability of any such interventions to women and their partners and how feasible their implementation would be (Horey et al., 2013). Their findings, based on three studies involving 2270 women, were that the decision support interventions used had no effect on the women׳s mode of birth, or their preferences for mode of birth. However, the review was limited to interventions designed to support decision-making only and did not seek information on any other types of intervention designed to assist women to achieve VBAC, nor did it include interventions during birth. In addition, although women liked the decision support there was concern among health professionals about the impact on their time and workload.

Accordingly, a systematic review evaluating all types of women-centred interventions during birth as well as pregnancy, for increasing VBAC rates, was proposed. The aim of this paper is to report the conduct and findings of this systematic review.