Groping Through the Fog

A Metasynthesis of Women's Experiences on VBAC (Vaginal Birth After Caesarean Section)

Ingela Lundgren; Cecily Begley; Mechthild M Gross; Terese Bondas


BMC Pregnancy Childbirth. 2012;12(85) 

In This Article


This metasynthesis was based on the interpretative meta ethnography described by Noblit and Hare.[21] The synthesis is focused on creating new knowledge and it is based in interpretation, and not aggregation.[22,24,25]

The challenge is to find, classify and integrate findings from qualitative studies using multiple methods from several epistemological and theoretical perspectives.[26] Each study was characterized according to authors, discipline, method, theoretical perspective, data collection, setting, and aim (Table 1). The subject is the interpretation of findings and does not use primary datasets. The core is translation, by which is meant the interpretation of findings from different studies that share similar research questions.[21]

In the analysis process the preservation of meaning from the original text was important. The articles were independently reviewed and read through several times to get a grasp of the whole and to categorize them using the key themes, categories, metaphors, phrases, ideas, and concepts in the findings of the study. The themes were systematically juxtaposed to identify homogeneity and to note if there was discordance or dissonance between the themes. We explored the convergence of the themes across the articles. In the last phase the themes were synthesized. The findings were seen as analogous and compatible between the studies.[21]

Sampling, Inclusion and Exclusion Criteria

The inclusion criteria for the studies were peer-reviewed empirical qualitative studies in different disciplines in English from women's perspectives of VBAC. The study includes research published between the years 2002–2010. No studies were found before 2002. The exclusion criteria were studies that were quantitative in design and included mixed studies, and mixed events and time period where it was not possible to separate findings related to VBAC.

Health care related databases were searched in different disciplines and findings from different cultures with the chosen keywords. Previous literature reviews were searched, and author and ancestry search was performed to access studies not identified through the database search. The following databases were searched: CINAHL, EBSCO, Journals@OVID, Pubmed, PSYCHINFO, using the keywords VBAC, vaginal birth after caesarean section, qualitative study, experiences, qualitative and women's experiences in various combinations. In total, 1981 papers were identified; of these, 1959 were excluded after reading the title or abstract, when it became apparent that the paper did not fit the inclusion criteria. The remaining 22 papers were obtained and reviewed in full text format. Eleven were excluded at this stage, as not focusing on women's experiences, or only focusing on experiences of CS in relation to VBAC (Figure 1).

Figure 1.

Flow chart summarizing search strategy

The final 11 papers were assessed for quality, initially using the COREQ 32-item check-list.[27] However, it was noted that the COREQ tool did not include some aspects that have been identified as important in qualitative research, such as ethical issues, thorough use of the literature, quality and audit mechanisms, relevance and transferability. Accordingly, we incorporated 13 other items into the check-list (items 9, 10, 12, 13, 33–35, 40–45) and adapted four items (items 8, 26, 28, 29) relating to these aspects (Table 2), derived from the work of Walsh and Downe.[28] We found this composite grid to be useful in determining the quality of the papers and assisting the decision for inclusion or exclusion.

Two authors assessed each study and agreed its inclusion. Eight papers that were deemed to be of medium quality (positive ratings for 31–38 items) were included in this review (Table 1). No papers were marked as high quality (rated positively for 39–45 items) The remaining three papers were excluded due to an overall rating of minor quality (30 or below). The excluded papers had lower ratings in relation to all domains; research team and reflexivity, scope and purpose, study design, analysis and findings, and relevance and transferability.