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

Disclosures

BMC Pregnancy Childbirth. 2012;12(85) 

In This Article

Discussion

This metasynthesis offers qualitative evidence from the women's perspectives on VBAC to complement and deepen the empirical studies in the field. Women's experiences were studied from different disciplinary perspectives but qualitative research on VBAC seems to be limited to a few countries, notably in an Anglo-American context. There is always a tension between combining studies and retaining the uniqueness of each study. However, we tried to preserve the significance by remaining close to them, going back and forth in the interpretation in order to not lose sight of the primary study, and use citations.[24,26] The researchers had different cultural and ontological perspectives that enabled a reflective and critical attitude.[26]

The main results from our study shows that experiences of VBAC is like groping through the fog, where decision-making and information from the health care system and professionals, both during pregnancy and the birth, is unclear and contrasting. These findings are in line with Endozien's[8] statement that there is an unmet need for clinicians to provide sufficient information to women, so that the woman's choice can be an informed one. Further, our metasynthesis shows that women's experiences of VBAC are only studied in an Anglo-American context, as the studies were from US, UK and Australia. This is an interesting finding since the high CS-rate occurs world-wide, and the question about women's experiences should be of interest for other maternity care settings and countries. For example, no studies were found from the Netherlands or Scandinavian countries, which in comparison with other high-income countries, have high rates of VBAC.[4] It would be of interest to interview women from these countries about their experiences of VBAC.

Our metasynthesis shows that women's experiences were studied in relation to decision-making whether to give birth vaginally or with CS during the subsequent birth,[2,13,20] experiences of the influence of health professionals on decision-making,[30] and reason for trying a vaginal birth after a previous CS.[18,20,31] These aspects must be related to a maternity care where women have informed choice, and access to high quality care.[32] Further research is needed to see if informed choice is a problem for women when the information given is unclear. In this study, to be involved in decision-making about mode of delivery was found to be difficult but important. According to Cox,[14] Changing Childbirth in 1993 in UK gave women more choice over their maternity care, and it may be that this has led to many women making a 'choice' to have a repeat CS instead of VBAC,[14] as has happened in other countries, with a resulting steep increase in CS-rate.[32] One could question why do women choose CS when VBAC is the best option, from an empirical evidence-base.[10,11] One answer according to our study is that women are groping in the fog in a context where vaginal birth is seen as a risky project and positive aspects of vaginal birth are mainly described by women and not the health care system.

The women had to confront serious risks mediated by health-professionals, and lack of information about the benefits of vaginal birth. These findings may be related to the provision of maternity care with a risk focus.[33,34] Our study shows that women experienced risk mediated by different percentages (20–70%) in relation to their individual risks,[18,30] and as 'odds' being against them.[18] Information given to women should be derived from the most recent evidence. A woman with no other risk factors who was told that she might have a chance of 50/50 for a successful vaginal birth after CS had not been informed appropriately.[30] References from various studies conclude that women have a 74% chance for a successful VBAC if no further risk is obvious.[7] The risks that the women are informed about are uterine rupture,[2,13] death of the child or mother or both,[13,19] and the risk of ending up having another CS,[2,13] and of being irresponsible and putting the baby at risk.[19,30] These results indicate that the women were well informed about potential risks, but perhaps not always accurately, and are not informed about the benefits of vaginal birth.

The results show that vaginal birth has several positive aspects, mainly described by the women. They felt they had their 'own strong responsibility for giving birth vaginally'. Vaginal birth is experienced by women as good for the baby and the relationship and as a meaningful experience for them as women in line with birth as a life event described by Larkin et al.,[35] and birth as an opportunity for women to gain an understanding of their strengths.[36]

Limitations of the study are that three studies referred to the same group of data. All metasynthesis studies are in themselves three times removed from the participants' lives.[24] We tried, however, to preserve the significance of the primary findings in the studies, and to remain close to them. This metasynthesis may complement the individual studies but they cannot replace them.[23,26]

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