Improving women's choice and control over their maternity care has been on the political agenda in the UK for over 20 years (Department of Health, 1993). An area where the issue of women's choice is regularly encountered is the choice of vaginal birth after caesarean (VBAC) (Hamilton, 2009). Key midwifery textbooks (Hamilton, 2009; Meakin, 2012) devote only a few paragraphs to VBAC, terming it ‘trial of scar’ and solely discussing success rates and risk factors. Downe (2008) describes this occurrence as the ‘primacy of risk’ in maternity care, with risk being the foremost concern—the main risk of VBAC being uterine rupture (Hamilton, 2009). However, this is a 0.21% risk (Fitzpatrick et al, 2012) and when balanced against the morbidity associated with multiple caesarean sections (Silver et al, 2006), VBAC is considered a safe and valid choice (Guise et al, 2010). Paré et al (2006) discovered that for women who want to give birth to at least two more children, VBAC is associated with better long-term outcomes, recognising the long-term reproductive consequences (including the chance of hysterectomy for uterine rupture and placenta accreta) of multiple caesarean sections.
The self-perpetuating effect of caesareans and repeat caesareans is well recognised (Thomas and Paranjothy, 2001) and the National Institute for Health and Care Excellence describes VBAC as being an important strategy to reduce the national caesarean rate to safer levels (NICE, 2004). However, in the UK there is currently no definitive national recommendation for VBAC. The Royal College of Obstetricians and Gynaecologists recommend that in a woman with one previous uncomplicated lower segment transverse caesarean section, in an otherwise uncomplicated pregnancy at term, the risks and benefits of both VBAC and elective caesarean section should be discussed and the woman supported in the choice she makes (RCOG, 2007).
The simultaneous importance and difficulty of the decision to choose a VBAC is illustrated by Knight et al (2014), who found that despite a UK average of 52.2% VBACs in NHS Trusts, there was a variation in attempted VBAC rates of 33–94% between Trusts. This variation highlights that the decision to pursue a VBAC is very emotive and complicated for women, as well as for the health professionals caring for them.
Pregnant women have to make many decisions about their own health and that of their infant. The key to understanding the reasons why only 52.2% of women, nationally, plan a VBAC (Knight et al, 2014) is to discover what influences women in their decision to choose VBAC rather than an elective caesarean section.
The aim of the literature review is to identify the factors that influence women's decision-making when choosing whether to plan for a VBAC or elective repeat caesarean section.
Method
The keywords ‘ decision-making’ and ‘vaginal birth after caesarean’ were extracted from the research question, as being the two main concepts in the aim of the literature review. Variations of the two keywords formed the search terms, with caesarean spelt as ‘c?esar?an’ to account for various English and American variations, including ‘caesarean’, ‘cesarean’ and ‘cesarian’. Truncation also increased the sensitivity of the search, ensuring no variations of the same word were missed. The search made was: (decision-making OR decision* OR decid* OR cho*) AND (vaginal birth after c?esar?an OR VBAC OR previous c?esar?an). This was entered into two database platforms: Ovid Online and EBSCOhost. The NHS evidence database platform was also initially used but then abandoned as it did not contain any databases which were not already found via the other two platforms. Within each platform, the databases searched were: Journals from Ovid, EMBASE, AMED, Global Health, Maternity and Infant care, Ovid MEDLINE and Ovid Nursing Full Text Plus, Academic Search Complete, CINAHL, EBSCOhost E-Journals, Health and Psychosocial Instruments, Medline, PsycARTICLES, Psychology and Behavioural Sciences Collection, PsycINFO and SocINDEX. Next, the inclusion criteria given in Table 1 were applied using a combination of search filters and hand sorting.
| Inclusion criteria | Justification |
|---|---|
| Primary research | To ensure originality of data |
| Peer reviewed | More likely to be rigorous method and no major flaws |
| Between dates 2000–2014 | Options and recommendations have changed drastically in the 21st Century and research conducted prior to this was considered not as applicable to modern practice |
| Specific to women's decision-making around VBAC | To remain focused on research question and aims |
| Previous caesarean section | In order to qualify for a VBAC |
| Qualitative research | Based on unique human lived experiences of women |
| English language papers | To enable comprehension |
| Any country | To widen the scope of the findings |
Results
Nine qualitative, primary research papers were found (consisting of 136 interviewed women and 311 blog entries). They were appraised using the Critical Skills Appraisal Programme (CASP, 2013) for qualitative research and none of the research studies were excluded on the grounds of quality as no fatal flaws were found and all were methodologically and ethically sound.
The findings were synthesised into five key themes reflecting the factors influencing women's decision-making about planning a VBAC.
Theme 1: Personal beliefs about birth
In their prospective analysis of VBAC blogs, Dahlen and Homer (2011) found that the over arching concept influencing women to opt for a VBAC was their own personal internal ‘birth framework’. The authors called this the ‘motherbirth–childbirth dichotomy’ and found that mothers who chose a VBAC often came from the ‘motherbirth’ perspective: they believe birth is as much about a happy healthy mother as about a healthy baby and that the two are not mutually exclusive. The ‘childbirth’ perspective believed in only thinking of the infant, disregarding the mother and reinforcing society's expectations for a good mother to sacrifice herself for her child and opt for a caesarean. This moral concern was also echoed by Farnworth and Pearson (2007), where fear of being blamed and making the right choice guided decision-making. However, this study was set in the UK, unlike Dahlen and Homer's (2011) study from which the majority of the blog entries were by women who lived in the US so moral views of safe birth may be different due to a more anti-VBAC culture among health professionals in the US (Ridley et al, 2002; McGrath et al, 2010). Within the body of literature examined, surprisingly little influence of maternal and infant health was found. Only the ‘self-selected’ women referred to maternal and child physical health advantages, such as benefits of birth via the birth canal and better post-birth recovery (Fenwick et al, 2007). Farnworth and Pearson (2007) also found evidence of anxiety around societal perception, in terms of beliefs around vaginal birth being most ‘natural’ according to public opinion. However, some women themselves also saw a vaginal birth as a ‘significant life event’, important for themselves and their internal feelings of accomplished femininity (Fenwick et al, 2007). Some women, however, did not have strong beliefs about birth and experienced intense anxiety before, and even after, the birth due to not being certain about which choice is best (Emmett et al, 2006).
Theme 2: Previous birth experience
All studies revealed the influence of previous birth experience on women's decision on mode of birth in their current pregnancy. This theme overlaps with both ‘beliefs about birth’ and ‘control’. Although all the women in the studies had previously experienced a caesarean section, this appeared to have affected them and their current decision-making in opposing ways: complete acceptance or feelings of betrayal due to a perceived lack of support and informed choice (Fenwick et al, 2007). The latter view was more likely to influence women to opt for a VBAC due to the significance of having not yet accomplished the ‘life event’ of a vaginal birth (Fenwick et al, 2007; Meddings et al, 2007). Dahlen and Homer (2011) reinforced the view of betrayal presented by some of the cohort in Fenwick et al's (2007) study, with women perceiving their body to be ‘inadequate’ and being worried about the potential lack of control with the vaginal route, discouraging them from a VBAC. Furthermore, preferring a calm elective caesarean section rather than risking an emergency caesarean section, stemmed from women's previous ‘lived’ experiences (Moffat et al, 2007). Ridley et al's (2002) descriptive, phenomenological study shows a more pragmatic approach where women were influenced by the previous long recovery period and effect on home life, linking with the theme of ‘practicality’.
Theme 3: The need for control
Dahlen and Homer (2011) found that women motivated each other to ‘take control’, in the context of retaining the power to attempt a VBAC. However, it was also found that women saw an elective caesarean section as a more predictable option than vaginal birth, enhancing their perceptions of being ‘in control’. Likewise, Farnworth and Pearson (2007) also found paradoxical findings, with different women associating both VBAC and elective caesarean section with feelings of increased control.
The UK study by Meddings et al (2007) recognised that the majority of women wished to exercise their control over the decision-making around mode of birth due to placing great value on making an informed choice and being free to make that choice for themselves. However, the study also showed a minority of women who actively resented having full control—one of the five did not want an active part in the decision-making process.
Theme 4: Health professionals
The influence of health professionals was identified as a major theme. Dahlen and Homer's (2011) prospective analysis of blogs, given that the majority of the blogs were written by women living in the US, was set in a context where more health professionals were considered resistant to VBAC than in the UK. The women found they were influenced not only by their own fears when making a decision, but also by those of the health professionals. The differing risk perspectives and a fear of litigation was picked up mainly from obstetricians, but also from midwives within the medicalised system (McGrath et al, 2010). In the UK, Emmett et al (2006) and Farnworth and Pearson (2007) found that the ‘experts’ were perceived as pro-VBAC by the women and despite non-directive counselling methods, their influence was perceived. In the US, ‘physician encouragement’ was also identified as a key influencing factor (Ridley et al, 2002), which may be a factor in decision-making in favour of elective caesarean section. Goodall et al (2009: 8) identify this phenomenon as ‘latent communication’—health professionals gave the statistics in a non-biased manner, but followed this with personal views, resulting in women feeling unsupported when they disagreed.
All the studies identified a need for better quality information, as women did not feel supported by the current general advice given and wanted more individualised details. There were also those who felt uncomfortable with non-directive counselling and felt distress at this ‘inappropriate’ responsibility given to them. Moffat et al (2007) found a broad range of information requirements and recommended a change in counselling technique based on this, emphasising that not all women felt comfortable in being responsible for the ultimate choice.
Theme 5: Practical considerations
The influence of the practical consequences of birth was a major theme for women in the UK study by Farnworth and Pearson (2007). A range of issues were identified, such as the reduction of expected mobility and independence if an elective caesarean was chosen, as well as influences on body image, which varied widely. The influence of family tasks was also prominent (Meddings et al, 2007; Moffat et al, 2007), as well as the effect on breastfeeding (Farnworth and Pearson, 2007). All the studies that acknowledged ‘practical considerations’ as a main influence were set in the UK, where health professionals showed a ‘consumerist’ approach and some women were overwhelmed by the choice offered (Moffat et al, 2007).
For some women, the importance of knowing the date and planning ahead confirmed their choice of elective caesarean section—this also links to perceived control over this mode of birth, in contrast with the unpredictable nature of labour. For other women the moral implications of knowing that their only reason for choosing elective caesarean section would be ‘convenience’, prompted them to desire to go through labour.
Discussion
The findings drawn from the nine research papers found were fairly consistent, with the only major cause of unbalance in the arguments appearing to be the beliefs held by health professionals with regards to the safety of VBAC versus elective caesarean sections and women's private preferences. The Australian and US maternity settings appear to be more anti-VBAC (Ridley et al, 2002; McGrath et al, 2010) and the UK more pro-VBAC, even to the extent of women reporting feeling coerced into this direction (Moffat et al, 2007).
The main factors influencing women's choice on mode of birth were ‘personal beliefs about birth’ and ‘health professionals’. Firstly, the concept of ‘birth frameworks’ through which decisions are processed was revealed in each paper. A metasynthesis of VBAC experiences also shows beliefs about birth to be the main theme (Lundgren et al, 2012).
In all nine research studies, concern about maternal physical health did not significantly impact on the decision of mode of birth, apart from when this concerned the prolonged recovery time associated with elective caesarean section in the context of fulfilling family obligations. The only women who described this as an influencing factor were mainly the self-selected cohort (Fenwick et al, 2007); however, these women only discussed the health risks of caesarean section (e.g. bleeding, potential organ damage, anaesthetic risks, and increased risk of future reproductive complications) and not the potential risks associated with VBAC, where women were most concerned with failing to achieve a vaginal birth.
The strong influence of health professionals emerged in the findings, encompassing information giving, control and choice. However, it must be remembered that two of the studies specifically focused on this influence, perhaps inflating its importance. Baxter and Davies (2010) commented on the vague nature of the guidance given to women, emphasising that health professionals were expected to facilitate ‘informed choice’ and be unbiased, with some women perceiving ‘non-directive’ counselling to be unhelpful. Statistic-based guidelines for VBAC counselling from the Royal College of Obstetricians and Gynaecologists (RCOG, 2007) appeared inadequate and women reiterated their desire for ‘support’ (Farnworth and Pearson, 2007; Goodall et al, 2009). However, it must be noted that not all of the concerns that health professionals had (e.g. uterine rupture risk) were shared by the women. Indeed, in the study by Moffat et al (2007), notably only one woman reported the risk of uterine rupture as being a reason for her to choose elective caesarean section over VBAC. In the UK setting, VBAC is currently positively promoted in NHS Trusts by obstetricians and midwives as part a nationwide strategy for lowering the caesarean rate, but in the context of the RCOG guideline (2007), which maintains a cautious position of only recommending it if the pregnancy is otherwise low-risk.
‘ In the UK, just over 50% of women with a previous caesarean section opt for a VBAC. ’
The support required can vary depending on individual needs and circumstances of the woman and manner and empathetic approach of the clinician. A study that qualitatively analysed telephone calls by women to a VBAC clinic supported this view—it found that women most appreciated the opportunity to talk about their individual experiences and needs in a non-biased way (David et al, 2010). A larger literature review by Flannagan and Reid (2012) examined influences on women's choice on mode of birth and reinforced the importance of ‘health professionals’ as one of their key themes influencing decision-making.
It has been found that women like to use social media to explore their emotions about their previous caesarean in an empathetic environment (Bainbridge, 2002; Dahlen and Homer, 2011). In the wider literature, a peer reviewed article linking social media with positive VBAC outcomes (Romano et al, 2010) reinforced this view, emphasising the helpful effect that social media can have in a ‘hostile environment’, as some women perceive maternity services. Romano et al (2010) also describe how an online community can provide women with the information and support that they require, challenging the traditional ‘top-down’ approach of information coming from ‘medical experts’ and perhaps adding another dimension to the array of factors affecting women's decision-making.
It is important for midwives to be aware of working in a woman-orientated way, so female psychology and emotions during the childbearing continuum need to be thoroughly researched, especially in the context of this review pointing to the increased importance of psychosocial factors in decision-making.
In some areas of the UK, VBAC clinics are run by midwives and consultant obstetricians; however, there are an increasing number of VBAC clinic schemes run by consultant midwives, which show promising signs of effectiveness by increasing VBAC rates (Hardwick et al, 2012); perhaps the incorporation of continuity of care will further increase VBAC rates. A research study exploring the effect of continuity of care on VBAC uptake is currently in progress (Homer et al, 2013). VBAC is becoming an important way of increasing normality in birth, while also providing cost-efficient care, particularly for those women undecided about mode of birth and willing to consider the pros and cons of both VBAC and elective caesarean section (Cluett and Bluff, 2006).
The influence of the previous birth experience on VBAC decision-making was strong throughout the literature review. A difference can be made by supporting women during their first labour and caesarean section in such a way as to help maximise feelings of control over the situation. If the midwife remains proactive and does not take a passive approach to the emergency caesarean section, and acknowledges the woman's feelings at the time, women will have less sense of failure and loss of control, which in turn may encourage future VBACs.
Limitations
The findings in this review are based on inductive qualitative research, a quantitative study with measurable outcomes would further build on the findings of this review by testing some of the following suggestions and their effectiveness in increasing VBAC uptake. This literature review was based on qualitative studies, which limited generalisation but provided maximum insight into women's unique subjective feelings. In addition, the research papers which were reviewed were conducted in a mixture of UK, US and Australian settings, which means that perhaps not all the findings are indicative of what factors influence women accessing maternity care in a UK setting.
Recommendations
Conclusion
The multidimensional nature of the influences on women's VBAC decision-making has been shown, with personal beliefs and the influence of health professionals highlighted as the main factors. The VBAC decision is one of many choices faced by an increasing number of women as a result of the increase in the primary caesarean rate in the UK. In the clinical arena, decisions are often seen as a straightforward matter of information and choice, but reflecting on this process provides an opportunity for both midwives and obstetricians to consider their own practice in terms of facilitating this and ensure that their influence is not used negatively to disempower women, but rather to support each woman, her priorities and decisions as individual and unique.